Executive summary

The trust had provided an action plan to respond to the mandatory requirements of the July 2024 visit, and we had received an update to the action plan in the weeks leading up to this Senior Leaders Engagement. It was a thorough and thoughtful update with additional evidence and demonstrated continued progress to improve patient care and the training experience and environment for doctors in training.

This meeting provided an opportunity to talk through and discuss the progress, the upcoming plans, and for panel members from the deanery and from the GMC to seek clarification on points of interest.

We plan to carry out a two-stage desktop review of progress in September and October 2025, utilising any new evidence between this visit and then including updates to the ongoing action plan and feedback from the relevant medical specialties, the GMC National Training Survey and locally collected data. The trust is asked to submit an update to the action plan by 26 September 2025.

Review Overview

Background to the review

This is the latest quality intervention in a series of visits focused on medical specialties and both the quality of patient care and the provision of education and training of doctors working in the acute medical pathway.

Our Learner/Educator Review took place in July 2024, and we have had a risk open at ISF2 (Intensive Support Framework – level 2, significant concerns) since that time regarding medical specialties.

In the intervening months we have had a high level of engagement from senior leaders at the trust and regular updates to an appropriately ambitious action plan, measuring substantial progress to mitigate the patient safety concerns we had and to embed best practice in supporting doctors in medical training posts who contribute to the medical on-call rota.

Who we met with

• Medical Director
• Director of Medical Education (Whiston)
• Deputy Chief Executive
• Foundation Programme Director(s)
• Divisional Medical Director (Medicine)
• Head of Clinical Education
• Divisional Director of Operations for Medicine and Urgent Care
• Assistant Director of Clinical and Medical Education

Review panel

• Nadeem Khwaja, Deputy Dean for Cheshire and Merseyside
• Paul Baker, Deputy Dean for Foundation
• Simon Carley, Associate Dean for Quality
• Zander Zambas, Quality Support Manager
• Leanne Moore, Quality Coordinator
• Lyndsey Dodd, GMC Education Quality Assurance Manager
• Tanzeem Reza, GMC Enhanced Monitoring Associate

Review findings

The panel shares the trust’s view that the educational experience at Whiston Hospital remains closely intertwined with operational pressures, particularly within the emergency and acute medical pathways. While these pressures are not unique to the site there has been a concerted effort to improve patient flow and reduce delays to senior clinical review. We were told that the time to senior review has improved markedly, supported by a combination of job-planned activity and additional consultant resource. It was described as “very uncommon” for there not to be two consultants present during the day, and the panel was informed that this coverage enables both early review and appropriate escalation of care.

The panel heard that the trust has implemented a line on the rota to ensure clear points of contact for escalation, addressing previous concerns raised in the GMC National Training Survey and local forums, where trainees had reported uncertainty about who to approach. The on-call consultant presence from 8am has been particularly valued, allowing for continuity with the night team and early identification of deteriorating patients.

We learned that the additional consultant cover currently in place is due to conclude at the end of June 2025. However, the trust reported that it is very nearly finished with a business case to recruit to substantive posts, which would provide a more sustainable solution. In the interim, locum and overtime arrangements remain in place to maintain continuity of care. The panel was informed that the number of medical patients in the emergency department has reduced significantly – from 71 previously to 50 in the weeks leading up to the visit and down to 26 at the time of the visit – suggesting that the measures taken to improve flow are beginning to have a tangible impact.

These developments reflect a wider cultural shift towards integrated care and early specialty input. The panel was informed that patients requiring specialist review are increasingly seen in the Acute Medical Unit on the same or next day, and that consultants ensure all patients are reviewed before leaving the emergency department.

Feedback from doctors in training has been triangulated through multiple sources, including the GMC survey, local pulse surveys, the Resident Doctor Forum which the Medical Director and Director of Medical Education often attend, and regular resident doctor meetings with Trust Specialty Training Leads (TSTLs). The most recent internal survey (eight responses) showed feedback was overwhelmingly positive. TSTLs and educational leads reported that trainees are “much happier” with one anecdotal comment from a senior registrar quoted verbatim described the improvements as “a million percent better”. The panel was encouraged by the frequency and openness of engagement between senior leaders and resident doctors. Communication of changes to doctors in training has been proactive. We were told that updates to standard operating procedures, rota amendments, and escalation protocols have been disseminated through multiple channels. We look forward to the further validation through the forthcoming GMC survey results.

The trust is currently piloting a digital solution to address data gaps in the monitoring of post-take ward rounds. We understood that some of the data used to provide the evidence base for recent improvements had to be manually compiled and analysed, but that a new IT project will enable more accurate tracking of patient journeys, including time to senior review and delays exceeding 24 hours. We were told that two consultant-led ward rounds now run simultaneously each morning, with one consultant starting at 8am in resus and the other at 9am. The SHOP model (Sick, Home, Other Patients/Plan) is used to prioritise reviews, and trainees on night shifts are given the opportunity to present cases and receive feedback. While some patients still experience delays, particularly those arriving later in the day, the panel was assured that the new dashboard will support more targeted interventions once fully implemented.

In terms of incident reporting, the panel was informed that the trust transitioned from Datix to the InPhase system at the end of March 2025. The new system includes a tick-box to flag delays related to patients being “stuck” in the emergency department. We were assured that the patient safety manager reviewed all relevant data ahead of the panel’s visit and no serious incidents have been reported in relation to this issue. The panel noted that while the transition to InPhase appears to have been well managed, the trust continues to have access to historical Datix records, which may be necessary for longitudinal analysis and the plan was ultimately to merge the records.

While the focus of the review was the acute medical pathway, we also had prior concerns about the cardiology division which we briefly explored at this time. We understood they were initially included in the broader scoping work for specialties contributing to the post-take ward round, before finding the current solution, and we were pleased to hear it reported that they were continuing to be supported and engaged with as a specialty.

The head of the foundation programme reiterated that previous concern about foundation teaching had been largely alleviated and that additional trainees have been allocated for the August intake, reflecting confidence in the educational environment.

Finally, we talked about other regulatory and governance channels. The GMC were represented on our panel. We also spoke about ongoing CQC actions, as the trust remains engaged with CQC’s improvement process following previous visits. Of the three outstanding items, the panel was told that the issue relating to the time between specialty referral and clinical pick-up is currently being tested and will be reviewed at the Resident Doctor Forum. The trust anticipates that this work will be completed by mid-June, thereby satisfying the remaining CQC requirements.

In summary, the panel recognised the significant effort invested by the trust in addressing both operational and educational challenges. While further work is required to embed these improvements and strengthen the evidence base, the direction of travel is positive. The action plan was well constructed, the presentation was clear and informative, and the level of engagement across clinical and educational teams was commendable. The panel encourages the trust to maintain this momentum and to continue using triangulated data to inform ongoing quality improvement.

Areas for improvement

The ongoing action plan to address concerns in the acute care pathway that is regularly updated by the trust and reported on covers our areas of interest comprehensively.

The key requirement of this visit and report is for the trust to update and re-submit the action plan by 19 September 2025.

Below are elements contained within ongoing actions which we would specifically like to follow up and highlight.

Mandatory requirements

Report approval

Report completed by: Zander Zambas
Review lead: Simon Carley
Date approved by review lead: 27 June 2025

NHS England authorised signature: Raghu Paranthaman
Date authorised: 5 August 2025

Final report submitted to organisation: 15 July 2025