Executive summary
This focus group with General Surgery foundation and higher specialty trainees working at DVH was arranged as part of a wider quality review of the clinical learning environment in the General Surgery department at Dartford and Gravesham NHS Foundation Trust. This is considering concerns raised regarding the learning environment and culture of the department, including allegations of undermining behaviour towards HSTs. The initial Senior Leadership Conversation in September 2024 had been followed up by a series of work programme meetings and this trainee focus group meeting was to triangulate trainee feedback with the reports of ongoing progress during the work programme meeting process. During the review, the panel heard feedback from the Foundation Doctors.
Main findings from the focus group discussion:
- Peer group support is good. Consultants are mostly approachable for questions, although some can be harder to reach.
- The lack of clarity around inpatient ownership at the weekends can contribute to incivility from ward nurses.
- For escalation, there is always a registrar available for advice both in and out of hours.
- No undermining behaviour.
- The IT systems issue still needs to be resolved.
- Handover systems which rely on paper and manual transfer of patient information need to be replaced with the previously promised e-system.
- Trainees find the workload at the weekends very busy especially when there are acutely sick or deteriorating inpatients.
- The trainees expressed that they would recommend the job to a friend.
The remaining two open mandatory requirements issued at the original SLC were closed by the panel after the trainee focus groups. However, there were further MRs issued after discussion with the Dean which are detailed below
Review overview
Background to the review
This education quality intervention was arranged by the Kent, Surrey and Sussex (KSS) School of Surgery to review progress with mandatory requirements (MRs) issued following a Senior Leader Conversation (SLC) which took place on 27 September 2024 and remained open for monitoring.
The review focused on Foundation Doctors (FY1s) and Higher Specialty Trainees in Surgery (HSTs), in Darent Valley Hospital (DVH), Dartford and Gravesham NHS Foundation Trust.
Who we met with
Learners
- The panel met in person with five FY1s and one FY1 trainee who work in the General Surgery department of DVH. One panel member later met virtually with two HSTs in May 2025.
Review panel
Education Quality Review Lead
- Miss Alison Crocker, Associate Dean
Specialty Expert
- Dr Paul Reynolds, Director of KSS Foundation School (for first meeting)
- Miss Ginny Bowbrick, Head of School of Surgery, KSS (for second meeting)
External Specialty Expert
- Susan Astbury, NHSE Education Quality Lay Representative
NHSE Education Quality Representative(s)
- Chidi Onyeze, Education Quality Project Officer
Review findings
Quality Domain 1: Learning Environment and Culture
Handover
Foundation doctors (FDs) reported issues with poor communication between teams regarding patient handover. When FDs were asked about the handover process, the panel heard that each firm has a list of patients in editable word documents on the Trust’s shared drive that all have access to. When patients move from the on-call list to the firm lists, it requires trainees to manually cut and paste their information. This process has resulted in a few instances this year where patients were lost due to incomplete or inaccurate transfers. The FDs stated that a new e-system was implemented 1 day before placement of two F1s started, and it only lasted 3 days as it was unfit for purpose. Consequently, teams have reverted to using printed lists from the word documents. Please see original Mandatory Requirement MR-2 and new MR-8 below
The panel heard that doctors benefit from two days of shadowing, during which they receive information about handover arrangements. They expressed appreciation for this experience. However, they noted that “there is only borderline enough IT to do the job. Additionally, the computer in the ward office is broken, although the panel were informed that work is underway to address this issue. A new mandatory requirement (MR-9) has been issued for a working computer to be installed in the ward office, to allow the FDs to do their work.
When asked about ward rounds, FDs reported that time is allocated for preparation before the morning ward round.
Escalation
The panel heard that critical care outreach teams are readily available and provide valuable assistance. For out of hours, they will contact registrars or the outreach team for support and there is always a registrar available for advice, including out of hours.
Weekend arrangements
When asked about patient care at weekends, the panel were informed that there are two teams for patient care at weekends. The ward cover consists of two F1 doctors and a registrar who does not participate in the acute take. They are responsible for seeing all the inpatients admitted during the week before the start of the weekend take on Friday mornings which can be up to 40-50 patients. The panel learned that time-sensitive tasks arising from the ward round, such as urgent NG tube placements or imaging, can be delayed because of the length of the ward round which sometimes continues until 6pm, leaving only two hours to complete these tasks: or the ward round is delayed as the jobs are done.
The panel were informed that the on-call team includes an SHO, a registrar and a consultant who do not come to the wards as they are based in the acute take areas. The panel heard from one trainee that they had never seen a consultant on the ward at the weekend.
Patients admitted during the weekend (from Friday morning to Monday morning) fall under the care of the on-call team, who must see all these patients daily while also managing new admissions and emergency theatre cases.
The panel heard that all the patients are on the same wards, resulting in new admissions being mixed in with previous admissions. Since those admitted during the week and those admitted at the weekend are under different teams, this causes confusion as there is no system to indicate which patients belong to which team. This leads to ward F1 doctors receiving bleeps about patients who are not under their care, which they understand can be extremely frustrating for the ward staff and can contribute to incivility. A new mandatory requirement (MR-10) has been issued to cover this.
Additionally, there is no clear system indicating which inpatients are stable or unstable, or which level of doctor needs to see them. The FDs reported that there is an informal agreement to mark each patient on the inpatient list as ‘stable’ or ‘unstable,’ but this information can be lost when transferring patients from one list to another.
The FDs recommended having an extra registrar on duty during weekends in view of inpatient workload. They also emphasised the need for clearer guidelines on how weekend operations should function. Typically, consultants on call during the weekend are busy with new admissions or theatre cases and rarely come to the wards.
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
Peer group and consultant support
The panel heard that peer group support is good. Consultants are mostly approachable for questions, although some can be harder to reach. Please see Mandatory Requirement MR1.
The panel heard that foundation doctors sometimes opt to consult other registrars, especially those from different firms, rather than directly contacting consultants. The foundation doctors feel able and happy to escalate issues in this manner, even if there is no SHO available, as registrars are consistently accessible.
Good working relationships were described overall, with no concerns relating to negative behaviours.
Quality Domain 4: Developing and Supporting Supervisors
This domain was not discussed during the focus group.
Quality Domain 5: Delivering Programmes and Curricula
Workload
The panel heard that FY1 trainees find the workload at the weekends very busy especially when there are acutely sick or deteriorating inpatients.
Quality Domain 6: Developing a Sustainable Workforce
This domain was not discussed during the focus group.
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 3 October 2025 | MR-8 |
Report approval
Report completed by: Chidi Onyeze, Education Quality Project Officer
Review lead: Ms Alison Crocker, Associate Dean
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