Executive summary
This focus group with Core and Higher Specialty Trainees (HSTs) at Darent Valley Hospital (DVH) was arranged as part of wider quality discussion of the clinical learning environment in Respiratory Medicine on Palm Ward at Dartford & Gravesham NHS Foundation Trust.
Main finding from this focus group discussion:
- A rota for registrars makes it easier to see who is assigned to each clinical area, but that due to lack of middle grade doctors the ward is sometimes uncovered.
- There is no substantive consultant cover on the ward.
- Foundation doctors receive little communication about senior decisions for inpatients unless they happen to see the patient with the senior clinician at the time the decision is made.
Seven mandatory requirements have been issued related to developing and supporting learners.
Review overview
Background to the review
Following the Senior Leadership Conversation (SLC) regarding Respiratory Medicine in September 2024, this Trainee Focus Group (TFG) was arranged to hear the experiences of those trainees who have recently worked on the Palm Ward at Darent Valley Hospital.
Who we met with
Learners
- Six Foundation doctors, five Core and Higher Specialty Trainees assigned to Palm Ward (Respiratory).
Review panel
Education Quality Review Lead
- Alison Crocker, Associate Dean for Kent, Surrey & Sussex
Specialty Expert
- Paul Reynolds, Head of School of Foundation
External Specialty Expert
- Martin Brand, Lay representative
NHSE Education Quality Representative(s)
- Alex Bamford-Blake, Education Quality Project Officer, Scribe
Review findings
Quality Domain 1: Learning Environment and Culture
Bullying and undermining behaviour
The panel heard from one trainee that, on her second day, a consultant was being impatient with her lack of knowledge and made snide comments on the ward round. When the trainee addressed this with the consultant, explaining that she felt the consultant was speaking inappropriately to her, he became upset and has not spoken to the trainee since. The trainee’s colleagues attend her patients with him because he won’t take her. The trainee reported this to her Clinical Supervisor, but this behaviour has continued.
The panel heard that one locum consultant was angry at a Foundation doctor who reported that a patient had tested positive for MRSA, had contacted microbiology, and changed antibiotics on microbiology’s advice. The panel heard that the consultant implied that as the trainee had taken the decision to call microbiology without him, then she could manage the patient herself.
The panel were concerned about these reported behaviours. A mandatory requirement has been issued: the Trust must ensure that all consultants attend a civility workshop and provide trainee feedback evidence demonstrating a supportive environment. (RESP-MR-01)
Quality Domain 2: Educational Governance and Commitment to Quality
This domain was not discussed during the focus group.
Quality Domain 3: Developing and Supporting Learners
Ward rounds and consultant ward cover
The panel heard that ward rounds are conducted by locum consultants every morning at 9am after 30-60 minute handover. There are no substantive consultant ward rounds during the week as they are in clinic or bronchoscopy.
Each bay is ‘owned’ by a Foundation doctor and the ward round is carried out with only the consultant, so Foundation doctors do not know their colleagues’ patients.
The ward round and decisions made for patient jobs, such as referrals, bloods, imaging, etc., are completed quickly, but the consultant leaves the ward afterwards so there is no supervision or ability to follow up on these matters. For example, the panel heard that, as a chest drain removal has to be supervised by at least a registrar, there have been instances of a 24-hour delay to removal because senior supervision could not be found.
Locum consultants are perceived as eager to leave the ward. The panel heard one goes to their office and provides an extension number to be reached on, and the other “we don’t know where he goes.” A mandatory requirement has been issued: the Trust must ensure that there is job plan time for substantive or locum consultants dedicated to supporting the foundation doctors on the ward and these consultants must be accredited GMC registered trainers. (RESP-MR-02)
However, the panel heard that ward jobs are sometimes completed by registrars, with registrars sometimes seeing patients on ward rounds without Foundation doctors and conducting procedures without updating the relevant Foundation doctor who is then not aware of up-to-date patient situation.
Ward cover is provided by four ward registrars who are on ward about 30% of the time but sometimes there is one person covering both referrals and the ward. There is no consultant ‘backfill’ if there are no ward registrars. A mandatory requirement has been issued: the Trust must review the procedure for ward cover and ensure that this is disseminated to all staff including the foundation doctors at induction. (RESP-MR-03)
Respiratory referrals
Foundation doctors reported that it is not always clear who is taking respiratory referrals and that they use their WhatsApp group to alert the team of patient details and request respiratory opinion
There is a bleep for referrals carried by registrars: but Core and HSTs reported that while it was clear who was taking respiratory referrals, it was difficult to find a consultant for a referral opinion. This has been fed back informally to consultants but there has been no change. A mandatory requirement has been issued: the Trust must ensure that foundation doctors are removed from involvement in the process of requesting a respiratory referral by other specialties and that this is managed at registrar or consultant level. (RESP-MR-04)
Managing sick or deteriorating inpatients
The panel heard that registrars and IMTs are supportive when Foundation doctors call them and will come from clinic to assist.
The panel heard that on rare occasions a Foundation doctor has used the MET call system to get help when there was a lack of senior staff to attend. A mandatory requirement has been issued: the Trust must ensure that there is a clear escalation policy for foundation doctors needing senior support and provide evidence that this has been discussed at induction. (RESP-MR-05)
Quality Domain 4: Developing and Supporting Supervisors
This domain was not discussed during the focus group.
Quality Domain 5: Delivering Programmes and Curricula
Training
The panel heard that trainees felt there was no formal training and that they have to use the opportunity with a consultant when they are free on an ad hoc basis. Training can be done with a registrar on an ad-hoc basis, but it depends on the registrar and how busy they are.
It was reported that there has been departmental training, but procedural learning has come exclusively from registrars. A mandatory requirement has been issued: the Trust must ensure that foundation doctors receive adequate protected training time to meet their curricular requirements for the foundation programme (RESP-MR-06)
Quality Domain 6: Developing a Sustainable Workforce
Working at or beyond competence
Foundation doctors reported that they are expected to do any interspecialty referrals including to tertiary services in other hospitals which they feel is outside their knowledge base: “‘if we don’t do it, then it doesn’t get done.” A mandatory requirement has been issued: the Trust must ensure that foundation doctors are not making referrals to tertiary centres (RESP-MR-07). The panel heard that first day Foundation doctors are treated the same as IMTs in expectations for patient care.
Areas for improvement
Mandatory requirements
| Review findings | Required action | Reference number and or domain(s) and standard(s) |
|---|---|---|
| The panel were happy to hear of the cultural changes which have been put in place, and which appear to be taking effect. The panel commends the efforts and willingness to change that the operational leads have shown in addressing this complex issue, and also the huge amount of work that the PGME department has done to support this change. | Requirement closed by the panel. | MR-1 |
| The planned IT changes on the ward including functioning adequate IT stock and an e-handover as discussed previously and agreed by the Trust have not taken place. The current system relies on paper lists and manual transfer of patient information from list to list, but the Trust is in the process of moving the whole hospital to IT systems with e-lists and trainees are involved in this workstream. Trainee feedback was positive on both days of the review and therefore this requirement is closed. | Original requirement closed by the panel and new MR issued specifically around handover as below: MR-8 | MR-2 |
| The panel heard that the e-handover system was unfit for purpose and was discarded in favour of a paper system three days after implementation, but the paper system relies on manual transfer of patient information which the panel considered to be a patient safety risk. The panel is aware that the Trust is moving to e-handover systems but during this transition period there needs to be safe transfer of patient information between shifts. | The Trust is required to evidence that handover is robust with safe transfer of patient information between shifts. Evidence required is induction material describing the process of handover so that the system is clear for residents to understand. Evidence required by 3rd October 2025 | MR-8 |
Report approval
Report completed by: Alex Bamford-Blake, Education Quality Project Officer
Review lead: Alison Crocker, Associate Dean for Kent, Surrey & Sussex
Date approved by review lead: 3 July 2025
NHS England authorised signature: Professor Jo Szram, Postgraduate Dean, KSS
Date authorised: 3 July 2025
Final report submitted to organisation: 18 July 2025