Sudan Gurung, Registered Nurse

Leading an elective orthopaedic ward, he successfully managed its transformation into a trauma ward post-COVID, navigating significant service changes and high staff turnover.

In 2023, the ward faced a serious incident involving a hospital-acquired Category 4 pressure injury, leading to an inquest and a Prevention of Future Deaths (PFD) report in June 2024.

The team also faced challenges with staffing levels, training gaps, and adapting to digital patient record systems.

Sudan

• Demonstrated courage and authenticity by providing a transparent statement in the coroner’s court and taking ownership of the learning outcomes.

• Remained calm and composed, driving improvements in patient care and team performance.

• Led the ‘Stop the Pressure’ quality improvement initiative on Ward F6. (Project certified by Frimley Excellence Team).

• Educated, supervised, and audited staff performance in timely completion of skin care assessment (now Purpose T), implementation of risk-reducing measures, and collating pressure ulcer data to track progress.

• Used Epic dashboard data to monitor compliance with timely skin risk assessments and implement risk-reducing measures. Utilized digital service and maximized its efficiency.

• Introduced PU education boards for team debriefs, focused on fundamental nursing care, and provided weekly reports to HON/Matron-led PU meetings.

• Owned each PDSA cycle for continuous improvement projects.

This has led to the following impacts:

• Significant reduction in pressure ulcer incidents since April 2024, with improvement continuing to date.

• Improved compliance with digital documentation and risk assessments.

• Enhanced staff confidence, staff retention and competence through education and supervision.

• Positive feedback on Sudan’s visibility, approachability, and leadership during challenging times.

Sudan personifies courage and transformational leadership. His ability to remain composed under scrutiny and relentlessly pursue quality improvement has created measurable impact on patient safety and care standards.

Sudan Gurung exemplifies how reflective learning and feedback can drive meaningful change.

Following a serious incident and subsequent PFD report, Sudan demonstrated courage and authenticity by openly engaging with the review process, providing a transparent statement in court, and using the findings as a catalyst for improvement.

He implemented systemic changes through the Stop the Pressure initiative, certified by the Frimley Excellence Team, and adopted digital tools like Epic dashboards to monitor compliance and improve care standards.

Sudan’s leadership fostered a culture of openness and shared learning, inspiring his team to embrace continuous improvement.

The measurable impact—significant reduction in pressure ulcers, improved documentation compliance, and enhanced staff confidence—shows how Sudan turned the PFD into an opportunity for growth, embodying the essence of learning under the spotlight.

Further demonstrating his commitment, Sudan continued to champion quality improvement post-PFD, ensuring practices were embedded into daily care.

He proactively recognised pressure injuries during patient transfers to F6 in real time, reinforcing safety measures.

His leadership extended beyond his ward, sharing the PI audit tool across Trauma & Orthopaedics to promote best practice.

Sudan’s responsiveness and initiative were evident when he became the first Band 7 in the Directorate to chair PI meetings in the absence of senior leadership—an outstanding example of accountability and dedication to sustaining improvements.