# Improvement Checklist — Document Review Reports (27 May 2026)

> **Source:** Live Document Review Report PDFs generated 27 May 2026
> **Note:** These are a snapshot. Re-run reviews to refresh and track progress

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## 🚨 Priority Issues (Across All Documents)

### 1. Processes With No Audit Configured

By far the most widespread issue. Many VOPs and audits have significant numbers of linked sub-processes with no audit assigned.

#### VOPs — No Audit Counts

| VOP | Linked Processes | No Audit | % Missing |
|-----|-----------------|----------|-----------|
| VOP 13 — Process Monitoring / PMS | 117 | **48** | **41%** |
| VOP 07 — Stock Control | 44 | **15** | **34%** |
| VOP 03 — Contract Review | 67 | **14** | **21%** |
| VOP 11 — Equipment Control | 20 | **13** | **65%** |
| VOP 16 — H&S | 23 | **18** | **78%** |
| VOP 04 — Accounts | 58 | **12** | **21%** |
| VOP 02 — Personnel | 23 | **12** | **52%** |
| VOP 25 — Sales & Marketing | 24 | **12** | **50%** |
| VOP 05 — Supplier Control | 19 | **8** | **42%** |
| VOP 01 — Documentation | 19 | **8** | **42%** |
| VOP 19 (Viamed) — Complaints/Vigilance | 14 | **13** | **93%** |
| VOP 22 — Picking & Packing | 7 | **2** | 29% |
| VOP 08 — Production | 6 | **2** | 33% |
| VOP 06 — Calibration | 4 | **1** | 25% |
| VOP 09 — Repairs | 18 | **3** | 17% |
| VOP 10 — Non-Conformance | 3 | **1** | 33% |
| VOP 12 — Training | 5 | **4** | 80% |
| VOP 15 — Data Analysis | 1 | **1** | **100%** |
| VOP 18 — Maintenance | 18 | **4** | 22% |
| VOP 20 — Goods In | 5 | **1** | 20% |
| VOP 21 — Risk Management | — | — | (no data extracted) |
| VOP 24 — External Parties | 1 | 0 | 0% |
| VOP 27 — Software Validation | 21 | **3** | 14% |
| VOP 28 — Distribution | — | — | (newer, no data) |

#### Audits — No Audit Counts (Viamed shown; VST similar)

| Audit | Linked Processes | No Audit |
|-------|-----------------|----------|
| Audit 19 — H&S | 56 | **32** |
| Audit 16 — Sales & Marketing | 37 | **20** |
| Audit 04 — Accounts | 70 | **15** |
| Audit 02 — Contract Review | 58 | **14** |
| Audit 05 — Purchasing | 38 | **14** |
| Audit 10 — Documentation | 39 | **12** |
| Audit 20 — Process Verification | 31 | **12** |
| Audit 09 — Goods Inward | 26 | **8** |
| Audit 22 — Post Market Surveillance | 12 | **8** |
| Audit 23 — Analysis of Data | 21 | **8** |
| Audit 14 — Complaints/CA | 15 | **7** |
| Audit 11 — Repairs | 24 | **5** |
| Audit 07 — Handling & Storage (VST) | 23 | **6** |
| Audit 03 — Design Control | 4 | **1** |
| Audit 17 — Internal Audits | 3 | **1** |
| Audit 01 — Picking & Packing | 9 | **1** |
| Audit 12 — CE Files | 3 | 0 |
| Audit 06 — Calibration | 5 | 0 |
| Audit 24 — Service Logs | 4 | 0 |

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### 2. Single Points of Failure — Dependency Risks

**🚨 Derek Lamb** — flagged in most VOPs at >70% threshold:
- VOP 27 — 100% (21 of 21 processes)
- VOP 10 — 100% (3 of 3)
- VOP 06 — 100% (4 of 4)
- VOP 13 — 99% (116 of 117)
- VOP 09 — 89% (16 of 18)
- VOP 01 — 89% (17 of 19)
- VOP 07 — 86% (38 of 44)
- VOP 11 — 85% (17 of 20)
- VOP 05 — 84% (16 of 19)
- VOP 08 — 83% (5 of 6)
- VOP 12 — 80% (4 of 5)
- VOP 02 — 70% (16 of 23)
- VOP 16 — 70% (16 of 23)

**🚨 Helen Lamb** — also heavily depended upon:
- VOP 04 — 98% (57 of 58)
- VOP 16 — 91% (21 of 23)
- VOP 02 — 83% (19 of 23)
- VOP 12 — 100% (5 of 5)
- VOP 01 — 74% (14 of 19)

**⚠️ Others flagged:**
- VOP 22 — Catherine Spence 100% (7 of 7), Emma Clark 86% (6 of 7)
- VOP 22 — Jonathan Connor 71% (5 of 7)
- VOP 20 — Robert Connor 80% (4 of 5)
- VOP 25 — Catrin Hird 75% (18 of 24)
- Audit 22 — Steve Nixon 83% (10 of 12)
- Audit 24 — Steve Hardaker 75% (3 of 4)

**Action:** Cross-train backup personnel for all flagged individuals.

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### 3. Processes With Only One Trained User (No Backup)

| VOP | Affected Processes |
|-----|-------------------|
| VOP 13 — Process Monitoring | **27** processes |
| VOP 02 — Personnel | **4** |
| VOP 01 — Documentation | **3** |
| VOP 05 — Supplier Control | **4** |
| VOP 11 — Equipment | **4** |
| VOP 19 (Viamed) — Complaints | **3** |
| VOP 16 — H&S | **2** |
| VOP 25 — Sales | **4** |
| VOP 27 — Software Validation | **2** |
| VOP 03 — Contract Review | **2** |
| VOP 08 — Production | **1** |
| VOP 22 — Picking | **0** (but dependency issues) |
| VOP 09 — Repairs | **0** |
| VOP 07 — Stock | **0** (but heavy Derek dep) |

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### 4. Processes Not Reviewed >24 Months

| VOP | Count | Oldest Review |
|-----|-------|---------------|
| VOP 03 — Contract Review | **15** | (multiple old) |
| VOP 07 — Stock Control | **4** | 09 Jun 2021 (Acorn) |
| VOP 04 — Accounts | **3** | 22 Jul 2024 |
| VOP 02 — Personnel | **3** | |
| VOP 19 — Complaints/Vigilance | **2** | |
| VOP 16 — H&S | **2** | |
| VOP 25 — Sales & Marketing | **2** | |
| VOP 05 — Supplier Control | **1** | |
| VOP 11 — Equipment | **1** | |
| VOP 12 — Training | **1** | |
| VOP 15 — Data Analysis | **1** | 26 Jan 2024 |
| VOP 18 — Maintenance | **1** | |

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### 5. Overdue Rolling Tasks / Audits

| Document | Overdue Count |
|----------|--------------|
| VOP 03 — Contract Review | **6** overdue |
| VOP 13 — Process Monitoring | **3** overdue |
| VOP 02 — Personnel | **1** overdue |
| VOP 04 — Accounts | **1** overdue |
| VOP 07 — Stock Control | **1** overdue |
| VOP 22 — Picking & Packing | **1** overdue |
| VOP 25 — Sales & Marketing | **1** overdue |
| VOP 18 — Maintenance | **1** overdue |
| Audit 02 — Contract Review | **9** overdue |
| Audit 11 — Repairs | **2** overdue |
| Audit 19 — H&S | **2** overdue |
| Audit 01 — Picking & Packing | **1** overdue |
| Audit 04 — Accounts | **1** overdue |
| Audit 09 — Goods Inward | **1** overdue |
| Audit 10 — Documentation | **1** overdue |
| Audit 14 — Complaints/CA | **1** overdue |
| Audit 07 — Handling & Storage | **1** overdue |

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### 6. Processes Missing Measurable Objectives

| Document | Count |
|----------|-------|
| VOP 13 — Process Monitoring | **24** |
| VOP 03 — Contract Review | **4** |
| VOP 05 — Supplier Control | **1** |
| VOP 07 — Stock Control | **1** |
| VOP 15 — Data Analysis | **1** |
| VOP 22 — Picking & Packing | **1** |
| Audit 02 — Contract Review | **3** |
| Audit 20 — Process Verification | **2** |
| Audit 01 — Picking & Packing | **1** |
| Audit 04 — Accounts | **1** |
| Audit 05 — Purchasing | **1** |
| Audit 10 — Documentation | **1** |
| Audit 21 — Audit of Audit | **1** |
| Audit 22 — PMS | **1** |

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### 7. Processes With No Risk Assessment At All

| Document | Count |
|----------|-------|
| VOP 05 — Supplier Control | **1** |
| VOP 13 — Process Monitoring | **2** |
| VOP 15 — Data Analysis | **1** |
| Audit 05 — Purchasing | **1** |
| Audit 10 — Documentation | **1** |

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### 8. Processes With No Trained Staff

**Critical:** These processes exist in the system but have **zero** trained personnel assigned.

- VOP 05 — Supplier Control: **1 process** with NO trained staff
- VOP 13 — Process Monitoring: **1 process** with NO trained staff
- Audit 05 — Purchasing: **1 process** with NO trained staff

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## 📋 Action Summary (By Priority)

### 🔴 Do This Week

1. **Audit 19 — H&S (32 processes no audit)** — highest volume. Configure mini-audits for each linked process
2. **VOP 19 — Complaints/Vigilance (13/14 processes no audit)** — this will be checked by NB auditors. Configure audits immediately
3. **VOP 13 — Process Monitoring (48 no audit, 27 single-trained)** — the backbone of the system. Huge gap.
4. **Assign trained staff to 0-staff processes** in VOP 05, VOP 13, Audit 05
5. **Clear 9 overdue tasks in Audit 02** (Contract Review — biggest overdue pileup)

### 🟡 Do This Month

6. **Set measurable objectives** on VOP 13 (24 missing), VOP 03 (4 missing)
7. **Cross-train backup** for VOP 01 (3 processes), VOP 02 (4), VOP 05 (4), VOP 11 (4) single-user processes
8. **Run reviews** for processes >24 months old (VOP 03 has 15 — tackle the oldest first)
9. **Configure audits** for VOP 11 (13 missing), VOP 16 (18 missing), VOP 07 (15 missing)
10. **Add risk assessments** to VOP 05, VOP 13, VOP 15, Audit 05, Audit 10

### 🟠 Ongoing

11. **Reduce Derek dependency** — cross-train on key processes across all VOPs
12. **Reduce Helen dependency** — especially Accounts (98%) and H&S (91%)
13. **Reduce Catherine Spence dependency** — Picking (100%)
14. **Review VOP 07 (Stock) — process maturity only 33%** — needs audits, objectives, backup, recent review

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## 🔄 How to Refresh

1. Run Document Review Reports from Intrastats
2. Export PDFs and place in the relevant VOP / AUDIT folders
3. Tell me you've updated them — I'll extract the new findings and produce an updated checklist comparing to this baseline

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*Generated: 27 May 2026 from 27 May 2026 Document Review PDFs*