Executive summary

In 2025 NHS England received an anonymous written concern raising issues around the culture within the neonatal unit at Chelsea and Westminster Hospital. Following discussion and an initial intervention by the Director of Medical Education and senior hospital management a further anonymous written concern was received.

This review was conducted to ascertain if resident doctors (RDs) in neonatology were well supported during their training programme and whether their learning needs were being met and to assess the learning environment and the culture within the department.

The review panel thanked the Placement Provider (PP) for accommodating this review and appreciated the good attendance.

The review panel was pleased to hear that all doctors received a high-quality induction to the department and the Trust. RDs confirmed that patient care was safe and compassionate, and that they would recommend the unit to friends and family for treatment and peers for training. Some consultants who had more recently joined the department were praised for their positive attitudes, strong educational engagement, and pastoral support, which has led to improvements in overall morale.

However, there was still a pervasive culture of fear and anxiety within the unit, largely attributed to ‘’strong personalities’’ amongst some senior consultants. RDs reported feeling they were treated unfairly, with some subject to inappropriate tones and condescending behaviour. This negative environment led to RDs feeling “terrified” and “scared” before starting their placements and dreading shifts with certain consultants. The reputation and departmental culture was renowned outside of the Trust.

The review revealed a significant lack of consistent and constructive feedback, negatively impacting RDs’ educational development. While all doctors were assigned educational supervisors (ESs), many meetings were described as unproductive and simply procedural or tick-box. Feedback was of low quality and not developmental. The supervision for Locally employed doctors (LEDs) was also found to be less robust; with some feeling there was a lack of interest in their career progression. The RDs also highlighted several practical challenges, including delayed ward rounds that prevented them from taking breaks and a lack of departmental priority supporting professional activity (SPA) days. There was a perceived lack of a shared sense of purpose or teamwork between the RDs and the consultant staff. They also felt there was a lack of trust in junior staff, with some expressing a desire for more autonomy.

To address these issues, the RDs proposed implementing regular, constructive feedback processes and possibly reallocating some Educational Supervisor (ES) roles. They also requested that SPA days be appropriately scheduled and respected.  A review of the psychological support meetings was also suggested as the location of the meetings based within the department which made it difficult for RDs to speak freely. It was also noted that the neonatal psychologist led these meetings for the RD which led them to not be able to speak freely since they were working with the same person on clinical cases on the neonatal unit.

The review panel noted that while the unit provided a valuable learning experience and ensured patient safety, a significant shift in its work culture was needed. Addressing the issues of disrespectful behaviour, inconsistent supervision, and insufficient educational support was crucial for improving morale and ensuring a more supportive and equitable environment for all learners.

NHS England’s Intensive support framework (ISF) rating of Neonatal intensive care unit at Chelsea and Westminster NHS Foundation Trust (Chelsea and Westminster Hospital) Trust is at ISF 3. This report includes specific requirements for the PP to take forward, which will be reviewed by NHS England-London as part of the three-monthly action planning timeline.

Review overview

Background to the review

NHS England – London conducted a Learner review following anonymous feedback concerning the learning environment and culture within the Neonatal intensive care unit at Chelsea and Westminster Hospital. The review aimed to ascertain that the resident doctors are well supported during their training programme and that their learning needs were met. The anonymous complaint raised specific concerns which can be placed into four separate themes: culture, leadership and management; patient safety and low RD morale.

The content of the review report and its conclusions are based solely on feedback received from review attendees. The following evidence provided by the PP was used by the review panel to formulate the key lines of enquiry for the review:

• Neonates ES CS list
• Neonates trainee staff list
• Neonates non-trainee staff list
• GoSW neonates report 2025
• Chelsea and Westminster neonates exchange report
• Instu register March – September 2025
• Endout – simulation report Anaes NICU June 2025 pneumothorax
• Sendout – simulation report Anaes NICU June 2025 Major Haem
• STINE course synopsis flyer updated 2017
• STINE register six months
• Teaching – weekly and monthly teaching programme Chelsea NICU
• RE learner review – neonatal intensive care unit – Chelsea and Westminster Hospital NHS Foundation Trust (Chelsea and Westminster Hospital)
• Junior meeting January 2025
• Resident doctors meeting minutes November 2024 and April 2025
• Response to resident doctor feedback January 2025
• PGME committee meeting minutes April and July 2025

Who we met with

Learners

• 11 resident doctors and locally employed doctors working in the Neonatal intensive care unit

Review panel

• NHS England- London, System Dean- North- West London, Richard Bogle – Education Quality Review Lead Role
• NHS England – London, Head of the London Specialty School of Paediatrics, Atefa Hossain – London Specialty School of Paediatrics representative
• Sarah-Jane Pluckrose, Lay Representative 
• NHS England – London Education Quality Co-ordinator, Sahariyea Siddique – Education Quality representative 
• NHS England – London Education Quality Co-ordinator, Lauren Thomson – Education Quality representative (observing)        

Review findings

The review panel was pleased to hear that all resident doctors (RDs) and locally employed doctors (LEDs) had received good inductions into the local department and the Trusts. The international medical graduates (IMGs) were particularly complimentary of having participated in the IMG Induction run at the West Middlesex Hospital and having the opportunity to shadow colleagues for 2 weeks prior to starting their placements. This was an example of good practice which the review panel were impressed with.

The review panel requested the RDs to describe their experience of working within the neonatal intensive care unit (NICU) using 3 words. Some of the feedback received included, intense, busy and learning. The RDs attributed this intensity due to it being the nature of the job working in a busy surgical tertiary NICU. However, this was sometimes further intensified with the presence of what were termed “strong personalities” within the consultant group which was mirrored by some nursing staff too. Some nursing staff were perceived as being unsupportive as they would sometimes question the RDs’ clinical decision making and in some cases this went as far as undermining behaviour.

The RDs told the panel that some consultants interacted with certain members of staff in various ways depending on their personalities. The RDs stated that if you were a particularly timid person, described as being a “shrinking violet’’, you would be more prone to being spoken to in a condescending way with inappropriate tones of voice. They told the panel that the tone used in such interactions felt less like an effort to educate and more like a display of the consultant’s own knowledge and experience. The RDs informed the panel that due to such strong personalities, they found some consultants challenging to work with and described them as very authoritative and that there was no conducive way to talk to them. They believed that not everyone was treated fairly and that some consultants had favourites amongst the learners. The RDs also described the environment as unfriendly.

The RDs further explained that before starting their placement at the unit, they were warned by previous peers who had worked at the department, therefore some RDs stated they were “terrified” before they started. This was also the case for those that were returning to the unit having worked there before.

During a discussion about the challenges of training, the RDs indicated that some consultants had been difficult to work with. While some RDs acknowledged having adapted to these challenges, they noted that they did not expect others to do the same. The RDs stated that shifts varied with some being more strenuous than others. They stated that they were able to anticipate their shifts by reviewing the rota and identifying which consultants they would be working with, which often led to a feeling of anxiety.

The review panel enquired about what constituted a ‘dreaded’ shift. The RDs responded that such shifts had occurred when working with certain consultants. Examples were given of behaviours such as delayed starts to ward rounds or ward rounds which were fragmented and were interrupted by consultants leaving the unit to attend meetings. This then led to delays in completing the ward round which often ran into the mid-afternoon without any concern as to whether the RDs had been able to from take a meal break. The RDs expressed that some consultants showed a lack of consideration for whether RDs had taken a break to even have a drink. Some RDs informed the panel that consultants had called them during their breaks to remind them of incomplete tasks; some of these tasks were deemed as non-urgent and non-time sensitive by the RDs. Despite this, the RDs were considerate that on occasion fragmented ward rounds were at times due to the consultants also having to complete other duties, such as attending meetings which could not be re-arranged.

When the review panel asked the RDs about the morale within the department, the RDs indicated that there had been a slight improvement. They told the panel that some of the senior consultants had demonstrated positive changes. However, the RDs speculated that this improvement might be primarily due to the intake of the newer consultants who were described as being “very friendly” and having a positive attitude and engagement with education. The RDs suggested that this positive shift could have been a result of dilution, suggesting that the positive influence of the new consultants may be offsetting the negative influence of the seniors. The RDs had the perception that the consultants seemed to be separate groups and not one consultant body. Additionally, the RDs observed what appeared to be a 3-tier structure among the consultants and characterised one group as exceptional, another as neutral, and a small subset as less effective.

The RDs informed the panel that currently there was a two-tier consultant rota with one consultant resident in the hospital and another non-resident at home. The panel learned that from September 2025 the rota will transition to all consultants being a non-resident on call. The change will also result in an additional senior RD on night shift. The RDs confirmed that had been prior notice of the proposed changes and were able to provide feedback. They told the panel that they do not anticipate much impact on them and perceived it to be beneficial in the sense that they will be able to make decisions autonomously. The RD did not know what impact assessment had been performed by the Trust with regards to this rota change and what impact it would likely have on their daytime non on call work patterns. 

The review panel was pleased to hear that all RDs had assigned educational supervisors as well as the LEDs. However, it was noted by the panel that the supervision for the LEDs was not as robust as the RDs’. Some LEDs reported receiving less encouraging feedback from their ES and said their experience has differed from the RDs and felt that some consultants displayed a lack of interest in the career development. Some LEDs told the panel of instances where they were not granted access to certain information as they were not consultants which concerned them as they are unable acquire certain knowledge without access to the necessary information.

The review panel was encouraged to hear that the RDs were invited to grand rounds. These were described as a very good learning experience where robust differences in opinion regarding patient management were litigated. The robust discussions occurred between consultants and were not directed to RD and the RD described the experience as useful and not threatening. The RD also attended the perinatal mortality review tool meetings as this was a good learning experience. However, the RDs explained that there was no follow up meeting just for the learners as a teaching mechanism.

The review panel enquired about the Local Faculty Groups (LFGs) and the extent to which the team was responsive to concerns raised. The RDs commended the college tutor for their active engagement and acknowledged that certain issues had been addressed. However, they also noted that several longstanding concerns remained unresolved. One persistent issue highlighted was the insufficient allocation of administrative and SPA days. The RDs conveyed to the panel that SPA days do not appear to be prioritised by the department. Consequently, learners who wished to undertake project work often felt compelled to do so outside of their scheduled hours, typically staying late after their shifts. There was no consistent support amongst the consultant staff for RD to take SPA days and they were not rostered into their rota.

The review panel was disappointed to hear of the lack of consistent and constructive feedback provided by consultants. It was noted that RDs often had to actively request feedback, which they believed had had a negative impact on their progress of their educational development. The RDs reported that direct feedback was rarely received, and when it was, it was often indirect and relayed through colleagues. Furthermore, some of the feedback received was described as neither developmental nor beneficial. While some of the RDs shared positive experiences of their ESs being engaged and supportive, others reported that their meetings with ESs lacked substantive feedback. These meetings were perceived as procedural, resembling a checklist of operational items rather than meaningful and were therefore considered unproductive.

Several RDs informed the panel that they had not consistently received the educational supervision and support required to meet curriculum standards. Additionally, the panel were informed that some ESs were unable to allocate sufficient time to meet with RDs at appropriate times. The RDs expressed that if they were struggling with their training, they wouldn’t raise this with their ESs, rather they would search out a consultant that they knew would be supportive. Alternatively, they would speak to their peers instead. The panel noted evidence that the learners were very supportive of one another. The RDs also commended some consultants for their pastoral support, noting that they often went above and beyond in supporting learners.

The review panel enquired whether there was a sense of fear among the RDs that mistakes would lead to personal blame. The RDs clarified that any fear was usually from the potential risk of causing harm to patients. However, they noted a fear amongst this unit was higher compared to other tertiary units. This was attributed to the way which consultants conveyed their feedback; often implying that they would have approached the situation differently.

The RDs informed the panel that they were happy to submit Datix forms and that written outcomes were provided within a few months and stated that they were usually satisfied with the responses received. However, they also noted that despite having quarterly meetings to review Datix themes and the circulation of a spreadsheet via email to all staff, there was little evidence of tangible changes being implemented to prevent recurrence of similar incidents.

Despite everything that the review panel had heard, they were encouraged to hear that the learners would recommend the department to their peers. However, it was noted that such recommendations may be dependent upon individual personalities, given the presence of “strong personalities” within the department. As such, the RDs would recommend it for individuals at a later stage in their training. Nevertheless, the review panel were pleased to hear that RDs would be happy for their friends and family to be treated within the neonatal intensive care unit. The review panel heard that the staff in the neonatal intensive care unit were focused on delivering safe, effective, compassionate care to their patients and there were no concerns over patient safety. Some RDs stated that they would be happy to work at the unit as a consultant and some LEDs had been in the department for a long period of time

The review panel enquired about potential improvements for the next cohort of learners. In response, the RDs recommended the implementation of regular feedback mechanisms, including both positive and constructive developmental input.

The RDs also proposed a reassessment of the allocation of ES roles, suggesting that preference be given to individuals who demonstrate a genuine commitment to supporting the educational needs of learners. Additionally, they expressed a desire for greater professional respect, specifically requesting that SPA days be appropriately rostered and not dismissed as insignificant.

Concerns were raised regarding a perceived lack of trust in junior staff, with the RDs requesting greater autonomy to carry out interventions. The LEDs also requested more dedicated time and check-ins to support their roles effectively.

Furthermore, the RDs noted that while access to a psychologist was available, the individual was based within the unit and worked in the same department, therefore was perceived as limiting, with some RDs feeling unable to speak openly, describing the support as somewhat artificial.

Areas that are working well

Good practice

Areas for improvement

Mandatory requirements

Recommendations

Report approval

Report completed by: Sahariyea Siddique – Education quality co-ordinator, NHS England-London
Review lead: Dr Richard Bogle – System Dean North West London, NHS England – London
Date approved by review lead: 2 September 2025

NHS England authorised signature: Prof Vivienne Curtis – System Dean North Central London, NHS England – London
Date authorised: 26 September 2025

Final report submitted to organisation: 26 September 2025