Executive summary
The review panel is thankful to the Trust for accommodating this review and for facilitating good attendance at each of the sessions.
The review panel was pleased to note a general feeling amongst resident doctors that managerial and educational leads for acute medicine were demonstrating leadership, responding to feedback and making improvements to the learning environment.
It was noted that the presence of acute internal medicine consultants on the ‘shop floor’ had improved since previous education quality reviews and resident doctors’ experiences of educational and clinical supervision were generally positive. Resident doctors found acute internal medicine consultants to be consistently accessible and approachable, and generally felt well supported whilst on acute take shifts, with some citing a strong sense of teamwork.
However, several areas for improvement remained. The review panel was particularly concerned to hear that induction to the acute take was inadequate at every training grade (including foundation level), which posed a patient safety and learner wellbeing issue.
Although consultants were rostered to various acute take shifts each day, there continued to be a lack of clarity on the part of both resident doctors and supervisors about who had overall responsibility for patients admitted on the acute take on a daily basis.
The review panel was concerned to hear of non-collegiate interactions and poor behaviour towards resident doctors on the acute take by emergency medicine and surgical staff. Both the review panel and resident doctors were also apprehensive about the impact of an upcoming change to the way the emergency department will refer patients to the acute medicine team; only by telephone, rather by both telephone and an electronic system, CareFlow.
Resident doctors were concerned that due to tagging errors, patients on the acute medical take might not be seen by a doctor on the acute take rota for 24 hours. They also reported significant difficulties processing phlebotomy and imaging requests for take patients.
Specialty level resident doctors received minimal bedside teaching from consultants and core level resident doctors had limited training opportunities during acute take shifts. Foundation doctors also reported being unable to attend core teaching sessions.
Inefficient systems, operations, logistics and processes within the department and across the Trust were cited as having a negative impact upon resident doctors’ duties, overall satisfaction with their placements and patient care.
Whilst the review panel was encouraged to hear of positive changes being implemented across the acute medicine learning environment, the specialty remains under General Medical Council (GMC) Enhanced Monitoring with conditions attached to GMC approval of posts in Acute Internal Medicine at the Trust until further sustained improvements have been evidenced in relation to outstanding concerns and those identified during this review.
This report includes specific requirements for the Trust to take forward, which will be reviewed by NHS England – London as part of the three-monthly action planning timeline. NHS England – London intends to conduct a follow-up learner and educator review in spring 2025.
Review overview
Background to the review
This learner and educator review was arranged in follow-up to an urgent concern learner review in January 2024, a senior leader engagement visit in February 2024 and a learner and educator review in May 2024, all pertaining to the training experience of resident doctors in training on the acute medical take rota at Queen’s Hospital.
These aforementioned reviews were initiated as a result of concerns raised about training in medicine via email from an internal medicine training (IMT) resident doctor, which aligned with information from internal focus groups elicited by the Director of Medical Education (DME). The concerns raised related to workload, clinical supervision, supervision out of hours and patient safety on the acute medical take.
There have been long-term issues with the acute medicine pathway at Queen’s Hospital and acute internal medicine remains under GMC Enhanced Monitoring (Trust-wide) since April 2019. Although a Work Programme Meeting had already been arranged in early 2024 to discuss some of open actions pertaining to acute internal medicine, NHS England – London decided a learner review followed by a senior leader engagement visit would be more effective at addressing these serious concerns.
The reviews in January and February 2024 revealed that although work was being undertaken by the Trust to address concerns relating to the acute medical take, there was still much improvement to be made. The GMC informed the Trust that various conditions were to be attached to their Enhanced Monitoring Status which should be reviewed and actioned urgently. NHS England – London then arranged a follow-up visit in May 2024 to hear from resident doctors, clinical supervisors and the senior leadership team. Overall, the review panel was pleased to note improvements made to the acute internal medicine learning environment since the previous reviews and the ongoing work being undertaken by the department to drive positive change.However, as concerns remained in a number of areas, NHS England – London arranged this follow-up learner and educator review in October 2024 to obtain further feedback from resident doctors, clinical supervisors and the leadership team on the acute medical take training experience and updates on the open actions assigned to this area.
The following evidence provided by the Trust was used by the review panel to formulate the key lines of enquiry for the review. The content of the review report and its conclusions are based solely on feedback received from review attendees.
- Resident doctor work schedules for acute medicine, cardiology, endocrinology and diabetes mellitus, gastroenterology, geriatrics, haematology, renal medicine, respiratory medicine, rheumatology – 2024
- General internal medicine rota patterns – 2024
- Acute Assessment Unit (AAU) Local Faculty Group (LFG) meeting minutes – January, March, April, May, June, July, September 2024
- Medicine educational and clinical supervisor allocations – undated
- Acute medicine education summaries – undated
- Acute medicine teaching attendance registers – 2024
- Acute medicine quality improvement project and audit summaries – 2024
- Acute medicine teaching rota – 2024
Who we met with
Learners
- 32 foundation, IMT, general practice vocational training scheme (GPVTS) and specialty level resident doctors in training on the acute take rota
Educators
- Eight clinical supervisors on the acute take rota
Education team
- Directors of Medical Education
- Deputy Director of Medical Education
- Head of Undergraduate Medical Education and NHS England Quality Lead
- Head of Postgraduate Medical Education
- Chief Medical Officer
- Clinical Lead
- Educational leads
- Clinical Group Director
- IMT Training Programme Director
- Workforce Hub Manager
- Acute Medicine Consultants
Review panel
- Education Quality Review Lead: Dr Louise Schofield, System Dean – North East London, NHS England – London
- Specialty School of Medicine Representative: Dr Clifford Lisk, Deputy Head of the London Specialty School of Medicine, NHS England – London
- Foundation School Representative: Dr Alice Carter, Associate Dean for Foundation Training (Pan-London), NHS England – London
- Learner Representative: Dr Callum Jennings, Learner Representative
- General Medical Council Representative: Will Henderson, Education Quality Assurance Programme Manager (London), General Medical Council
- Lay Representative: Sarah-Jane Pluckrose, Lay Representative
- Education Quality Representative: Gemma Berry, Education Quality Coordinator, NHS England – London
Review findings
Clinical supervisors confirmed that all resident doctors and locally employed doctors on the acute take rota received an induction to the take, either during the Trust induction programme or via other sessions. However, the review panel was concerned to hear from resident doctors at every training grade that their induction to the acute take was inadequate. They usually relied upon fellow resident doctors to show them what to do during their first few take shifts, including where to find essential resources. They suggested shadowing colleagues before starting full take duties would be very helpful, or at least having a face-to-face session with a doctor who had worked in the department for a long time; not necessarily a consultant. It took two weeks from Trust induction for some resident doctors to receive log-in details for clinical systems.
Resident doctors’ experiences of educational and clinical supervision during their placements in acute internal medicine and other medical specialties were generally positive. Acute internal medicine consultants were rostered to various acute take shifts each day, with care of the elderly consultants rostered to treat patients aged 65 and over on weekdays only. The presence of acute internal medicine consultants on the ‘shop floor’, particularly in the emergency department, appeared to have improved since previous education quality reviews and resident doctors found these consultants to be consistently accessible and approachable. Resident doctors generally felt well supported whilst on acute take shifts, either by fellow resident doctors or consultants.
Nevertheless, some resident doctors said it was not always clear which consultant they should approach for advice and some consultants did not support them with decision-making. Some acute medicine consultants also reportedly refused to see unstable patients. For medical emergencies, doctors at core level tended to approach relevant specialty medical consultants for advice initially, to streamline the process and save time. They approached acute medical consultants about surgical patients in the first instance though. Foundation and core level resident doctors were particularly grateful to senior level resident doctors for their support and encouragement during take shifts.
There continued to be a lack of clarity on the part of both resident doctors and supervisors about who had overall responsibility for the acute take on a daily basis. There used to be a ‘long day’ consultant model, but this was no longer the case. The review panel heard that specialty level doctors generally led and managed the acute take and ambulatory care, with no one consultant having oversight of the take on any given day. Resident doctors felt there was a lack of leadership amongst individual consultants on the ‘shop floor’ in this regard.
Clinical supervisors confirmed they now had two hours per week set aside in their job plans for conducting assessments, but this had only been implemented this week. Foundation doctors said they received good teaching from consultants whilst on acute take shifts and usually saw all their patients with the same consultant whilst on duty, which helped them to complete case-based discussions. They felt able to approach more senior clinical colleagues for advice as needed; they would usually consult a specialty level resident doctor first before approaching a consultant.
The review panel heard that core level resident doctors had limited consultant-led teaching and assessment opportunities during acute take shifts. This was mainly because consultants prioritised supervision of foundation level doctors and there was a lack of continuity around which consultants core resident doctors were rostered with. Core level doctors said they received the majority of teaching and advice from specialty level doctors. Some core level doctors also found the high volume of calls they took impeded upon their ability to see patients. They found that some referring doctors had not made sufficient enquiries before calling them and wondered whether doctors should be of a minimum grade to be able to refer to the acute medical team.
Although specialty level resident doctors had exposure to a wide variety of pathology, they received minimal bedside teaching from consultants and found the high volume of calls they took restricted their training. They said they had to be proactive to complete workplace-based assessments, case-based discussions and acute care assessment tools (ACATs) during take shifts, but that consultants were supportive in this regard. Supervisors said specialty level resident doctors had been consulted on a proposal to implement automatic referrals from the emergency department, to limit the number of calls they received, but 100 per cent of respondents had voted against this. The review panel heard that a trial at King George Hospital to divert all GP referrals to the rostered ambulatory consultant was underway and would be evaluated to decide if it might be an effective option for alleviating the workload of the specialty level resident doctors on the acute take rota at Queen’s Hospital. The Trust had also launched a GP medical advice line on 30 October 2024, with calls going straight to consultants.
Resident doctors said the current ambulatory service at Queen’s Hospital was understaffed and the clinical space was not fit for purpose, so patients got diverted to the acute medicine team instead. The leadership team confirmed that a new same day emergency care (SDEC) service was being introduced to both Trust sites in the coming months to resolve this issue.
Foundation doctors reported being unable to attend core teaching sessions due to clashes with medical specialty ward rounds or service provision on acute take shifts. These teaching sessions were usually held at King George Hospital, despite most foundation doctors being based at Queen’s Hospital. Foundation doctors had to book these teaching sessions as study leave at least two weeks in advance. These requests were usually approved, unless they were rostered to be on the acute take. Otherwise, resident doctors’ leave requests were generally approved in a timely manner and they commended the Trust’s medical staffing and PGME teams for their efficiency.
Resident doctors advised that the daily 8.00am acute take handover was functioning well, allowing the night team to brief the day team on the most unwell patients. The daily 8.00pm handover had also improved in terms of coordinating who would see which patients, but consultant attendance was still reportedly inconsistent. Although clinical supervisors said that a ‘3.00pm huddle’ took place each day and had been incorporated into a recent quality improvement project around handovers and huddles, resident doctors said this huddle did not happen, neither did they think it was required.
Staffing and rota management for the acute take were said to be better than they had been in recent years, although weekends were still felt to be understaffed at all levels, particularly as patient numbers were sometimes higher than on weekdays and yet fewer doctors were on duty. The acute medicine department was trying to secure care of the elderly consultant cover for the take at weekends, as this was only currently in place on weekdays.
Clinical supervisors and the leadership team acknowledged that there were some ongoing issues with the acute take tagging system. However, they said that team members were flexible about seeing any patients requiring review during post-take shifts, regardless of their tag, and there was clear ownership of patients amongst those on duty. Supervisors believed incorrect tagging and losing patients only happened very rarely and the system generally worked well. They also believed that patients were sometimes inaccurately reported as missing, due to being retagged incorrectly.
Resident doctors said they received training on the tagging system, but only around three weeks after starting acute take shifts. They reported that patients on the acute medical take might not be seen by a doctor on the acute take rota for 24 hours due to tagging errors. They received regular calls about patients still waiting in the emergency department after post-take for up to 48 hours because the system was not working properly. This placed a high workload burden on senior level resident doctors seeing these patients when they had become more unwell during their wait. The review panel heard that a tag could remain assigned to a patient after discharge, so if they were re-admitted, those on the take may incorrectly think they had already been seen. Resident doctors found the system confusing and said it was often unclear which patients were waiting to be seen. They said they did not always have the time to report missing patients to consultants or via Datix, which may explain why supervisors felt the system was operating more effectively than resident doctors did.
Resident doctors thought the new acute medicine electronic clerking proforma was a good idea, but poor IT systems and reliance on paper patient records made the document ineffective after its initial use. They were also unable to find standard operating procedures on the Trust intranet, or unable to access them due to software issues. The leadership team said they would upload these to the Trust’s medical education application.
Medical staffing had reportedly circulated information to resident doctors about the use of cordless phones, but this did not align with reality. Resident doctors found the phones did not have batteries and despite being told switchboard had spares, this was not the case.
Resident doctors reported significant difficulties processing phlebotomy and imaging requests for legacy take patients, particularly overnight. They had to take bloods and deliver samples to laboratories themselves, which could take around 40 minutes, and they could not request additional blood tests by telephone, but rather had to transport additional forms to laboratories in person. They also faced resistance when trying to arrange urgent scans. They perceived there was a two-tier system in place where the emergency department could request any investigations at any time, but once patients were seen by acute medicine their access was more restricted.
The review panel and resident doctors were apprehensive about the impact of an upcoming change to the way the emergency department will refer patients to the acute medicine team from 1 December 2024; only by telephone, rather than by both telephone and CareFlow. Resident doctors said they had not been consulted on this change by the emergency department and yet it would likely create more work for them, and they were concerned about patients being missed.
The review panel was also concerned to hear of non-collegiate interactions and poor behaviour towards resident doctors on the acute take by emergency medicine and surgical staff, although relations with the emergency department had reportedly improved. Resident doctors described how those covering the acute medical take often felt bullied into accepting patients, even when the referral was inappropriate. They spoke of instances where they were subject to, or had witnessed, forceful behaviour from colleagues in other departments which had sometimes led resident doctors to question their clinical understanding, particularly as they found it difficult to access standard operating procedures to refer to. Some resident doctors felt able to involve consultants in these challenging interactions and found it useful to observe consultants pushing back to other departments. Others felt consultants did not support them enough around rejecting referrals and that that inappropriate referrals were often accepted on the take anyway.
The leadership team advised that work was underway across the Trust to ensure specialties took more ownership of their patients. Consultant engagement with this had apparently been improving. Work around culture change was also in progress to improve interactions and teamworking between emergency medicine and acute internal medicine.
Resident doctors felt able to raise concerns with the acute medicine team and generally thought that issues were addressed by the department. They commended the receptiveness and responsiveness of departmental leads and the leadership they were demonstrating to drive improvements. However, some resident doctors had been reluctant to make Datix submissions because they were not convinced they would receive any feedback or an outcome. Some resident doctors found the exception reporting process too onerous to be worth completing. Those who had submitted exception reports received payment for additional time worked, rather than time off in lieu which was too challenging to accommodate in rotas. Medical specialty teams reportedly offered particularly good support and pastoral care to resident doctors.
Resident doctors found their office, teaching and rest spaces in acute medicine areas to be inadequate. There were minimal private spaces to have confidential discussions. The layout of the acute medical unit also meant that resident doctors were continually interrupted by visitors asking for directions. The leadership team acknowledged that space at Queen’s Hospital was limited, but that a Trust committee had been established to address estates issues, there was a long-term plan to reconfigure the ground floor, and the new SDEC area and some additional space being created in the emergency department would provide facilities for teaching.
There were variable responses from resident doctors when asked whether they would recommend their training posts to peers. Foundation doctors were particularly satisfied with their placements, citing support from colleagues, teaching and development of clinical skills as reasons. However, inefficient systems, logistics and processes (including referral processes) were cited as having a very negative impact upon all resident doctors’ duties and overall satisfaction with their placements. Such factors made their workloads feel unmanageable at times and impeded the quality and efficiency of care they wanted to deliver, thus affecting their morale and wellbeing. Core level resident doctors also felt there was not enough protected time in their rotas for breaks and rest.
Whilst resident doctors believed that clinicians did their best to carry out their duties under challenging circumstances and recognised that the acute medicine department was improving, the majority would not recommend the Trust to family and friends due to poor operations, information systems and logistics. They felt these systemic inefficiencies caused delays to treatment and compounded issues related to corridor care on the acute take. They perceived that patient care was currently reliant upon clinicians’ recall of cases rather than records, and care would significantly improve with the introduction of an electronic patient records system.
Areas that are working well
| Description | Reference number and/or domain(s) and standard(s) |
|---|---|
| Medical specialty teams reportedly offered particularly good support and pastoral care to resident doctors. Resident doctors generally felt well supported whilst on acute take shifts. | AIM1.3 / 1.6 / 3.5 / 3.8 |
| Resident doctors found acute internal medicine consultants to be consistently accessible and approachable. | AIM1.3 / 3.5 |
| Staffing for the acute take was reportedly better than it had been in recent years, although weekends were still felt to be understaffed. | AIM1.5 / 1.6 |
| Resident doctors recognised that the managerial and educational leads for acute medicine were demonstrating leadership and making improvements to the learning environment. | AIM2.1 |
| The presence of acute internal medicine consultants on the ‘shop floor’ appeared to have improved since previous education quality reviews. | AIM3.5 |
| Resident doctors’ experiences of educational and clinical supervision were generally positive. | AIM3.5 / 3.6 |
| Foundation doctors received teaching whilst on acute take shifts. | AIM5.1 |
| Resident doctors’ leave requests were approved in a timely manner. | AIM5.6 |
Good practice
Not applicable
Areas for improvement
Immediate mandatory requirements
Not applicable
Mandatory requirements
| Review findings | Required action | Reference number and/or domain(s) and standard(s) |
|---|---|---|
| The review panel was concerned to hear of non-collegiate interactions and poor behaviour towards resident doctors on the acute take by emergency medicine and surgical staff. | Please provide an update on the work being undertaken by the Trust to improve interactions and teamworking between emergency medicine and acute internal medicine, with evidence that resident doctors have been involved in the culture change project. Please submit this evidence by 1 March 2025, in line with NHS England – London’s action planning timeline. | AIM1.3 (applies to all of the acute medical take) |
| Although consultants were rostered to various acute take shifts each day, there continued to be a lack of clarity on the part of both resident doctors and supervisors about who had overall responsibility for the acute take on a daily basis. | There should be a named on-call consultant with overall responsibility for the take each day, to minimise risk for the organisation and provide clarity for those on shift. Please provide evidence that this has been established and feedback from resident doctors on its implementation. Please submit this evidence by 1 March 2025, in line with NHS England – London’s action planning timeline. | AIM1.5a (applies to all of the acute medical take) |
| Whilst the acute take morning handover was functioning well and the evening handover had improved, consultant attendance for the latter was still inconsistent. Resident doctors reported that the daily ‘3.00pm huddle’ did not take place. | There should be a consultant presence at 8pm handover meetings. Please provide evidence via attendance registers, feedback from resident doctors and/or other information to demonstrate that consultant attendance is consistent. Please also provide evidence that the form, purpose and organisation of 3.00pm huddles have been explored in collaboration with resident doctors, to determine whether they are worthwhile and if so, how they will take place going forward. Please submit this evidence by 1 March 2025, in line with NHS England – London’s action planning timeline. | AIM1.5b (applies to all of the acute medical take) |
| Resident doctors were concerned that due to tagging errors, patients on the acute medical take might not be seen by a doctor on the acute take rota for 24 hours. This posed a patient safety risk and placed a high workload burden on senior level resident doctors seeing these patients when they had become more unwell during their wait. | The complexity of the acute medical take tagging system should be addressed to make the overall experience easier and more straightforward for consultants, resident doctors and patients. Please provide evidence of the activities undertaken by the department, in collaboration with resident doctors and consultants, to simplify and clarify the tagging process, including how any changes have been communicated to all staff on the acute medical take rota. Please also provide feedback from resident doctors on any changes implemented. Please submit this evidence by 1 March 2025, in line with NHS England – London’s action planning timeline. | AIM1.5c (applies to all of the acute medical take) – Please note that an action (4807) already exists regarding this issue and will be linked. |
| The review panel and resident doctors were apprehensive about the impact of an upcoming change to the way the emergency department will refer patients to the acute medicine team from 1 December 2024; only by telephone, rather than by both telephone and CareFlow. | The review panel would like to know the outcomes of this change, as well the impact of the new Trust-wide GP advice line (managed by consultants), the pilot at King George Hospital around GP referrals going straight to the rostered ambulatory consultant, and the introduction of new SDEC services at both hospital sites. Please provide this information by 1 March 2025, in line with NHS England – London’s action planning timeline. | AIM1.5d (applies to all of the acute medical take) |
| Resident doctors reported significant difficulties processing phlebotomy and imaging requests for legacy take patients. | Please provide evidence that the acute internal medicine leadership team has discussed these issues with resident doctors, and details of the action being taken to address them. Please submit this evidence by 1 March 2025, in line with NHS England – London’s action planning timeline. | AIM1.5e (applies to all of the acute medical take) |
| Resident doctors felt able to raise concerns with the acute medicine team, but were not always sure how these were addressed. They were reluctant to make Datix submissions because they were not convinced they would receive any feedback or an outcome. | Please provide evidence to demonstrate that resident doctors on the acute medical take rota have been informed about how the acute internal medicine department handles Datix submissions and provide feedback from resident doctors that they have received the outcomes of datix submissions. Please submit this evidence by 1 March 2025, in line with NHS England – London’s action planning timeline. | AIM1.7a (applies to all of the acute medical take) |
| Resident doctors found the exception reporting process too onerous to be worth completing. | Exception reporting should be encouraged and facilitated. Please provide evidence that this topic has been discussed with resident doctors on the acute medical take rota to better understand the reasons for under-reporting, and details of how the Trust will make this process more efficient. please provide evidence that the Guardian of Safe Working Hours is addressing issues raised in exception reporting. Please submit this evidence by 1 March 2025, in line with NHS England – London’s action planning timeline. | AIM1.7b (applies to all of the acute medical take) |
| Resident doctors were unable to find standard operating procedures on the Trust intranet, or were unable to access them due to software issues. | As mentioned at the review, please provide evidence that standard operating procedures have been added to the Trust’s medical education application and that resident doctors have been notified. Please submit this evidence by 1 March 2025, in line with NHS England – London’s action planning timeline. | AIM1.11a (applies to all of the acute medical take) |
| Resident doctors found their office, teaching and rest spaces in acute medicine areas to be inadequate. | Please provide an update on the Trust’s short- and long-term plans to address these issues, as well as feedback from resident doctors on the seminar space being created by the new SDEC area. Please provide this information by 1 March 2025, in line with NHS England – London’s action planning timeline. | AIM3.1(applies to all of the acute medical take) – Please note that an action (4811) already exists regarding this issue and will be linked. |
| Induction to the acute take is inadequate at every training grade (including foundation level) and poses a patient safety and learner wellbeing issue. | The department should seek input from senior level resident doctors to design inductions that include useful, accurate information about acute take processes, logistics and standard operating procedures. Please provide information about changes made to induction programmes to ensure the above points are covered. Please also provide feedback from resident doctors at all grades regarding their inductions to the acute medical take. Please submit this evidence by 1 March 2025, in line with NHS England – London’s action planning timeline. | AIM3.9 (applies to all of the acute medical take) – Please note that an action (4813) already exists regarding this issue and will be linked. |
| Specialty level resident doctors received minimal bedside teaching from consultants and core level resident doctors had limited training opportunities during acute take shifts. | The Trust must ensure that during acute take shifts, all resident doctors receive on the job teaching and experiential learning opportunities, as well as sufficient time to complete assessments. This should be supported by all staff on the acute take rota. Please provide evidence of the department’s activities, undertaken in collaboration with resident doctors and consultants, to foster a culture of education and to improve resident doctors’ completion of assessments during take shifts. Please also provide feedback from resident doctors on this topic. Please submit this evidence by 1 March 2025, in line with NHS England – London’s action planning timeline. | AIM5.1 (applies to all of the acute medical take) – Please note that an action (4805) already exists regarding this issue and will be linked. |
| Foundation doctors reported being unable to attend core teaching sessions. These sessions were usually held at King George Hospital, despite most foundation doctors being based at Queen’s Hospital. Foundation doctors had to book these teaching sessions as study leave. These requests were usually approved, unless they were rostered to be on the acute take. | Rota arrangements should ensure foundation doctors can attend core teaching sessions. Please provide evidence that core teaching sessions are automatically included in foundation doctors’ rotas, so they do not need to request study leave to attend and are not rostered to the acute take during these sessions. Please submit this evidence by 1 March 2025, in line with NHS England – London’s action planning timeline. | AIM5.6 (applies to all of the acute medical take) |
Recommendations
Not applicable
Report approval
Report completed by: Gemma Berry, Education Quality Coordinator, NHS England – London
Review lead: Dr Louise Schofield, System Dean – North East London, NHS England – London
Date approved by review lead: 26 November 2024
NHS England authorised signature: Dr Elizabeth Carty, Interim Local Postgraduate Dean
Date authorised: 9 January 2025
Final report submitted to organisation: 14 January 2025