How to determine whether your project is really Audit

Audits compare performance with a standard set within the Trust or by a regulatory body, they do not compare different categories of patient, staff, etc; except in the case of re-audits, when one is seeking to ensure maintenance or improvement in performance from one period to another, perhaps after a separately approved change of practice.  

Two explanatory documents created by RDSU

Research, Audit or Service Evaluation 
 
Research and Audit Ethical Approval Checklist 
 
Both copied from RDSU website on 05Oct2007, the first was subsequently modified after discussion with NRES (National Research Ethics Service of the National Patient Safety Agency) from which it originated. 
 
RSDU (Research and Development Support Unit) deals with research and service evaluations
PPI (Patient and Public Involvement) deals with service evaluations involving patient surveys

Even if your audit does not appear to have any ethics issues, if you are planning to publish your results, then you should check the advisory information for that journal to see whether an approval letter from the Trust's ethics committee is necessary.  If so, contact them (Mark Walker, manager of RDSU x5463 at GRH and x2508 at CGH) with a description of your project and a copy of the proposed data collection proforma.

In all cases, the approval of the clinical director of the specialty must be obtained before publication.