Executive summary

The review panel was grateful to the placement provider (PP) for accommodating this review and facilitating good attendance. PP representatives described actions that had been taken to address ongoing issues along with plans for future improvements. The review panel noted that the department was working hard to address issues and acknowledged an investment in improving staffing levels within the Emergency department (ED).

The review panel was pleased to hear that the PP Executive team was committed to resolving cultural issues within the ED and tackling challenging consultant behaviour. However, PP representatives acknowledged that there were still instances of inappropriate behaviour displayed by some Emergency medicine (EM) consultants and that culture within the department still needed to be improved. The review panel recommended that the PP continued efforts to further strengthen channels to raise concerns.

Although the departmental teaching for resident doctors had improved within the department, the review panel noted that learning outside of formal teaching sessions needed to be enhanced. PP representatives acknowledged that the lack of educational content in handovers and board rounds was an ongoing problem.

The review panel noted concerns about ongoing issues with communication both within the ED and with other departments. The PP representatives acknowledged that this was a challenge. It was noted that there had been significant progress within the last 12 to 18 months, however there was ongoing work to make improvements in these areas.

NHS England’s Intensive Support Framework (ISF) rating of emergency medicine at Kingston and Richmond NHS Foundation Trust remains 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

An urgent risk Learner and Educator Review was conducted in April 2023 in response to concerning intelligence received in March 2023 regarding the emergency medicine learning environment at Kingston Hospital. This intelligence, which originated from resident doctors (RDs), outlined issues around escalation of concerns, a lack of departmental teaching, poor culture, bullying and undermining behaviour and patient safety concerns. The review resulted in seven Immediate Mandatory Requirements (IMRs) being issued and emergency medicine at Kingston Hospital was escalated to General Medical Council (GMC) enhanced monitoring in June 2023.

A follow up review in October 2023 did not result in further IMRs but did find several ongoing areas of concern including variability of confidence in consultants and consultant behaviours towards RDs, understaffing, lack of prioritisation of training in allocating RDs (especially at foundation year 2 (FY2) level) and difficulty accessing resources such as standard operating procedures (SOPs) and necessary documentation.

Following the October 2023 review the action plan responses were monitored and crosschecked against the 2024 GMC National Training Survey (NTS) results. Emergency medicine FY2 was identified on the NHS England- London GMC NTS results concern list due to a deterioration in results since 2023 at the Kingston Hospital site. Negative outlier results were reported in clinical supervision out of hours, workload, handover and supportive environment and lower quartile but non-outlying results in clinical supervision and teamwork.

The PP was notified in December 2024 that unless there was evidence of significant progress and improvement in learner feedback at the next action plan reporting cycle, a review would be initiated. This Senior Leader Engagement Visit (SLEV) was planned in response to limited progress against the action plans. As the programme remains under GMC enhanced monitoring, a GMC representative was be invited to join the review panel.

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:

• Emergency department culture and behaviour action plan- April 2025
• Breakdown of educational & clinical supervisors and learner groups within the department
• Guardian of Safe Working Hours report- 2024-2025
• Kingston Emergency department teaching feedback August 2024 – March 2025
• Teaching attendance June 2024 – April 2025
• Kingston Emergency department teaching timetable August 2024 – August 2025
• Emergency department induction feedback – December 2024 and April 2025
• Local Faculty Group (LFG) Emergency department minutes- 27 March 2025
• Local Faculty Group (LFG) Emergency medicine minutes- 27 February 2025

Who we met with

• Director of Medical Education
• Medical Education Manager
• Educational Lead for Emergency Medicine
• Foundation Training Programme Director
• Guardian of Safe Working Hours
• Clinical Director / Clinical Lead for Emergency Medicine
• Medical Director
• Associate Director of Unplanned Care
• General Manager, Cluster 1
• Chief of Medicine
• Chief People Officer

Review panel

• System Dean- South West London, NHS England – London, Bhanu Williams, Education Quality Review Lead
• Head of School of Emergency Medicine, NHS England – London, Jamal Mortazavi, School of Emergency Medicine Representative
• Foundation School Director, NHS England – London, Mark Cottee, Foundation School Representative
• General Medical Council Education Quality Assurance Programme Manager (London), William Henderson, General Medical Council Representative
• Education Quality Coordinator, NHS England – London, Lauren Thomson, Education Quality Representative
• Deputy Education Quality Manager, NHS England – London, Louise Brooker, Education Quality Representative
• Education Quality Coordinator, NHS England – London, Rebecca Bennett, Education Quality Representative (Supporting role)

Review findings

Consultant staffing levels and clinical supervision

Placement provider (PP) representatives informed the review panel that the department had recently increased the number of paediatric emergency medicine and emergency medicine consultant posts, with a new appointment to enhance senior decision-making cover. It was noted that one consultant was already in post, and three more were to start in August-September 2025.

The review panel asked how the department had made changes to supervision in the paediatric area of the Emergency department (ED). PP representatives reported that there was a consultant on the rota 7 days a week until 10pm, with most evenings having consultant presence until midnight. PP representatives also informed the review panel that consultant job planning allowed for an overnight consultant on Mondays which had been in place for 18 months. The PP representatives advised that this overnight consultant was now viewed as a permanent addition to overnight staffing.

PP representatives advised that there had been a strong commitment to try and improve supervision and senior decision-making cover, with emphasis on creating a more standardised rota structure to paediatrics in the ED. It was hoped that this would also positively impact on handover and assist with balancing shift allocations among the RDs. It was reported that following a rota review, the PP reduced the amount of out of hours work for foundation year 2 (FY2) resident doctors (RDs), so they worked mostly at times when they could be supervised by senior doctors. The PP representatives also informed the review panel that a bank registrar-level doctor post had been allocated to paediatric ED overnight, and it was communicated to all staff groups in the ED that they must remain within paediatrics. The PP representatives advised that this bank role had been in place for 6 months and was an approved and funded permanent fixture of the rota.

PP representatives also noted having access to the performance evaluation tool 360 feedback to collect feedback on supervision. The PP advised that they planned to introduce this for all consultants in the ED.

Culture

The review panel asked how the Executive team was addressing the reported instances of bullying and undermining behaviours by emergency medicine (EM) consultants. PP representatives acknowledged that there were still instances of inappropriate behaviour from some EM consultants. PP representatives described examples where anonymous concerns were raised regarding consultant behaviour, and the Executive team had provided feedback to the specific consultants and outlined the PP’s expectations for appropriate behaviour. The PP representatives advised that the feedback meetings had been followed up with formal letters containing actions moving forward.

The review panel enquired about the Executive team’s approach to cultural improvement within the ED. PP representatives acknowledged that there were ongoing issues relating to the general culture, and that they were implementing strategies to improve this. It was reported that there were ongoing challenges around communication both within the ED and with other departments. However, PP representatives advised that there was work underway to make improvements in these areas. The review panel was informed of good relationships between some departments, however there were difficulties amongst some surgical specialties.

PP representatives advised that relationships between the senior nursing and consultant teams had been a challenge. It was confirmed that the teams were now working in an open plan office setting, which had improved rapport between them in the last 12 to 18 months. It was also reported that nursing colleagues participated in the induction process for doctors, to help build relationships between RDs and senior nursing staff.

Raising concerns and feedback

The review panel enquired about the culture of raising concerns in the ED. PP representatives advised that they aimed to build an open culture of speaking up by empowering leadership closest to the department to address concerns at the earliest opportunity. The PP representatives felt encouraged that RDs had raised concerns about behaviour to the Executive team. However, the PP representatives acknowledged that it would take time to build up the credibility for RDs to have confidence that their concerns would be addressed.

PP representatives advised that Datix reporting was encouraged within the department, and that the outcomes of these reports were discussed in a monthly governance meeting attended by RDs. It was reported by the PP representatives that Datix numbers had reduced across the organisation, and a communication scheme had been implemented to encourage reporting.

The review panel noted that there were regular Local Faculty Group (LFG) meetings and PP representatives advised that they were actively engaging with RDs to gather feedback. It was reported that PP representatives had amended the format of the LFG meeting at the request of RDs to enable them to raise concerns. The PP representatives also informed the panel that they had conducted anonymised surveys every quarter, which included all the learners working in the department, as an additional means of gathering feedback.

PP representatives informed the review panel of further changes to internal department processes following RD feedback. It was reported that a RD in specialty training had redesigned the governance processes within the department, which was highly successful. PP representatives also noted planned changes to how exception reports were submitted. The PP representatives clarified that following feedback from RDs, exception reports would be submitted to Human Resources (HR) as opposed to educational and clinical supervisors.

Teaching

The review panel enquired about the educational experiences of FY2 RDs in the ED. The PP representatives informed the review panel that they received full supervision and had the autonomy to select the cases they wanted to work on. It was further advised that FY2 RDs had support from senior decision makers when discussing cases prior to discharge. The review panel was also informed that FY2 RDs had the opportunity to learn paediatric phlebotomy and cannulation skills if they wanted to.

The review panel asked about the educational experiences of RDs in speciality training in the ED. PP representatives felt the teaching provided was meeting the requirements for the curriculum. It was noted that teaching was available to RDs through weekly grand rounds and a monthly journal club. PP representatives confirmed that RDs were always released to attend regional teaching and had recently hosted a regional session which was well received. PP representatives also confirmed that RDs were released to attend skills training at other PPs where they were not able to provide the specific procedures within the hospital.

However, it was noted that teaching in practice still represented a challenge. PP representatives acknowledged that the educational value of handovers and board rounds was inconsistent, and more work was needed to improve this. PP representatives described a need for standardisation and a board round check list to enable more uniform learning experiences. PP representatives felt that standardisation was required due to differences in how consultants worked within the department.

The review panel further enquired whether RDs in specialty training had the opportunity to be the Emergency Physician in Charge (EPIC) during the day. PP representatives acknowledged that this was important as RDs in specialty training needed to learn how to run the department, however noted that it did not occur consistently and required improvement. The PP representatives confirmed that standardisation of the responsibilities and expectations of the role was required.

Although the departmental teaching for resident doctors had improved within the department, the review panel noted that learning outside of formal teaching sessions needed to be enhanced. PP representatives acknowledged that the lack of educational content in handovers and board rounds was an ongoing problem.

Rota allocation

The review panel asked how the department had ensured fair rota allocation to the paediatric ED at night, following previous reports of gender bias in this process. PP representatives reported that a non-clinical administration manager completed the rota and ensured that shift allocations were balanced and equitable. The review panel was also informed that the PP had standardised the shift patterns within the ED, including start and end times.

Areas that are working well

Areas for improvement

Mandatory requirements

Report approval

Report completed by: Lauren Thomson, Education Quality Coordinator, NHS England-London
Review lead: Bhanu Williams, System Dean South West London, NHS England-London
Date approved by review lead: 20 June 2025

NHS England authorised signature: Elizabeth Carty, Postgraduate Dean, NHS England- London
Date authorised: 16 July 2025

Final report submitted to organisation: 17 July 2025