Skill mix on a stroke unit: when cover becomes unsafe delegation

Start from the principle, not the person. A task can be delegated when it is within the delegate's trained, assessed and recorded competence, there is a clear escalation route, and accountability for the overall decision sits with the clinician qualified to make it. Competence must be demonstrated, not assumed from grade.

• Swallow screen by a band 5 physiotherapist: not acceptable. Swallow assessment after stroke is a specialist clinical judgement about aspiration risk, not a task transferable by asking. A screen done without the training and without a pathway for abnormal findings gives false reassurance, and 'screening clear' may be read as 'safe to feed'.
• 4AT by the healthcare assistant: potentially acceptable. The tool is designed to be used by trained non-specialists. The problem is the absence of competency sign-off, supervision and a rule for what happens to a positive score, not the task itself.
• Nurse practitioner signing 'not for CPR' forms: not acceptable as described. This is a significant clinical and legal decision requiring a clinician who has assessed the patient, discussed it and holds the authority. Retrospective countersigning means the signatory did not make the decision.

The unit is running three extended roles with no governance behind any of them.

Separate what is safe this weekend from what should be commissioned over the next quarter.

For the weekend: the safe default is that patients who are nil by mouth stay nil by mouth, with intravenous fluids, mouth care and a documented review plan. Deferring an upgrade by 48 hours is usually a much smaller harm than an aspiration pneumonia. In parallel, mobilise legitimate options: an on-call or telemedicine speech and language therapy opinion; a nurse-led screening protocol, but only for staff with recorded competency and only with an explicit rule that a failed or equivocal screen keeps the patient nil by mouth; and clear consultant escalation for anyone the team is worried about.

For the quarter: a competency framework naming each extended role, who assesses it, how it is recorded and revalidated, and the escalation route. Record the decision you gave the matron and the reasoning, so that the Friday judgement is auditable if it is later questioned.

Stop the practice first, then review what already exists, because an invalid form may be sitting at the front of a patient's notes right now.

For each form: confirm the decision was made by someone with the authority and the clinical assessment to make it; confirm the patient had capacity and was involved, or that a best-interests process with family and colleagues took place; confirm the form reflects the discussion, not just a signature. Where any of this is absent, re-open the decision with an appropriate clinician, document it properly, and tell the nursing team so that the bedside record matches the notes.

Escalate as an incident: this is a potential deprivation of care decision made without authority, and it needs to go to the medical director and the safeguarding or governance route, not be quietly corrected.

Then fix the cause: a policy stating who may make the decision, mandatory documentation fields, senior review within 24 hours for decisions made out of hours, and teaching on the legal framework for capacity and best interests.