Executive summary

The learner/educator review visit was triggered due to concerns regarding Internal Medicine Training (IMT) doctors training experience. The deanery panel met with foundation doctors, IMT doctors and their supervisors.

Verbal feedback was provided to the senior management team and medical education team on the second day of the visit. Positive findings from the review include

• Excellent medical rota coordination, with positive comments from all groups the deanery met with about the impact the new rota coordinator has made
• Good foundation training and happy foundation doctors
• Good Guardian of Safe Working
• Good simulation facilities
• Excellent medical education team
• Good teaching
• Good induction in the emergency department

There are 9 mandatory requirements relating to                                                                                             

• Mixed experiences of local induction
• Lack of encouragement to complete Datix reports
• Lack of exception reporting processes
• Insufficient senior support for IMT doctors out of hours
• No self-development time in IMT rotas
• A shortage of clinic and specialty time in IMT rotas
• Lack of senior review at weekends leading to handover lists for foundation doctors
• Large amounts of unproductive tasks for foundation year 1 doctors i.e. discharge summaries
• Dispensing duties and medication/equipment checks absorbed into Foundation doctor year 2 role

An action plan will be requested from Noble’s Hospital. A senior leadership meeting to discuss the report and progress made will take place in November 2025. The deanery will also meet with IMT doctors in November 2025.

Review overview

Background to the review

The deanery last held a learner/educator review at Noble’s Hospital in May 2023.

The 2025 visit was triggered due to concerns regarding Internal Medicine Training (IMT) doctors training experience. IMT placements at Noble’s have historically been very good and in 2023 were ranked the best in the country. A deterioration in the quality of training was noticed in mid-2024. A reduction in Specialty and Associate Specialist (SAS) doctors impacted on placements at Nobles. Day to day work became dominated by general medical duties to the detriment of training opportunities. Also, IMT doctors received no self-development time, had difficulty getting to clinics and obtaining annual/study leave.

This also impacted foundation doctors due to the availability of middle grade support. Some SAS doctors were leaving as their expectations were not met, as there was no continuity of work or preparation for their roles. A medical staffing needs assessment was undertaken by Mersey Internal Audit Agency (MIAA) in March 2025.

Who we met with

Learners

• 20 Foundation Doctors (9 FY1 and 10 FY2)
• 5 Internal Medicine Training Doctors/1 GP Specialty Training Doctor

Educators

• 11 Educational/Clinical Supervisors

Senior Management Team and Education team

• Chief Executive Officer
• Executive Medical Director
• Interim Executive Director of Operations
• Director of Medical Education
• Guardian of Safe Working
• Directorate Manager for Medicine and Emergency Care
• Specialty, Associate Specialist and Specialty (SAS) Lead
• Senior Matron for Medical and Emergency Care
• Medical Rota Coordinator
• Medical Postgraduate Coordinators

Review Panel

• Deputy Postgraduate Dean, North West School of Foundation Training and Physician Associates
• Training Programme Director, Internal Medicine Training
• Quality Support Manager
• Quality Coordinator
• Quality Coordinator  

We would like to thank the medical education team for facilitating the sessions with resident doctors and their supervisors and for making the visiting team from the deanery feel very welcome.

Review findings

Foundation Doctors – Foundation Year 1

Domain 2 Educational Governance and Commitment to Quality

Datix and Exception Reporting

All foundation year 1 doctors (FY1) felt that completing Datix reports was discouraged. The panel heard of an AMU consultant who commented that they do not like Datix and would be “very cross” if FY1s submitted one. The feedback received from Datix reports was varied.

FY1 doctors said they have not been shown how to use the Datix system but have learnt as they have gone along and through peer support.

All FY1s knew who the Guardian of Safe Working (GOSW) is and said he is very good.

FY1s felt that exception reporting is not encouraged and none of the group had exception reported. They said they have not been shown how to exception report and some FY1s felt this was deliberate to save money. Some FY1s were asked to email rather than exception report but did not hear anything further.

Equality, Diversity and Inclusion

The panel heard that the hospital is very welcoming and did not hear of any negative experiences. A FY1 who was a medical student at Nobles chose to do their foundation training in the Isle of Man over Manchester due to their previous positive experience.

In surgery the panel heard that FY1s have overheard derogatory comments made about transgender patients. This was a discussion including consultants and nurses. The comments were not made in front of patients but FY1s felt this was unprofessional.

Domain 3 Developing and Supporting Learners

Induction

Foundation doctors described a mixed experience of local induction. A&E induction was described as good. The panel heard that some foundation doctors did not receive an induction when they first started their rotation and some said they got details on how things work from previous cohorts. The panel heard that foundation doctors felt welcome on their surgical rotation, but said they had difficulty getting to clinics.   

Some foundation doctors described local induction as a “bottom-up approach” they felt this needs to be more of a robust consultant led top-down approach clearly outlining what is expected of them when they work on the ward.

Rota Management

All foundation doctors said that since the new medical rota coordinator has been in post, things have begun to improve. Staffing is improving with more locum contracts. One foundation doctor commented that there is a noticeable difference since the rota coordinator has started as staffing is more consistent and wards are safer. The panel heard weekdays are better following the introduction of the “casino shift” (6pm-2am) around 3 weeks ago. The rota coordinator is visible and comes to the wards to see if everyone has turned up and to ask if wards needs anything more. Rota coordination in surgery was described as not as consistent as medicine.

In medicine foundation doctors felt that during 9-5pm they are learning. They commented that if the deanery had asked them this 3 weeks ago, their response would not have been as positive. However, they said they still struggle to get released from the ward to attend clinics.

Senior Support

Foundation doctors in surgery said the workload is manageable and out of hours senior support is available.

Foundation doctors in medicine described a culture whereby nurses are generating requests to see patients over the weekend that medically can wait until Monday. The additional requests on top of their workload can make weekend shifts overwhelming. Foundation doctors felt that some nurses are not confident as some patients going into the weekend have either not been reviewed by a doctor or had a senior review. 

Some medical foundation doctors said they do not feel they can always escalate to the speciality locum doctors as they felt some have the knowledge of a medical student and they know more as foundation doctors. The panel heard that some have had several Datix reports made about them and said the “good ones” have left for training posts.

The panel heard that the A&E rota is heavy working 1 in 2 weekends. They said the biggest change is that there are now 2 IMT doctors overnight. Also, handover tasks can be inappropriate. Foundation doctors explained they have highlighted the issues to the Clinical Director of Medicine. The foundation doctors suggested that coordination with nurses regarding what is appropriate to handover is an issue. The panel heard that the handover lists given to them out of hours have already been reviewed by a senior nurse but they still receive bleeps for medically stable patients. Doctors on each ward are responsible for handing over to the weekend team. They felt the handover list for weekends could be improved as it consists of several sheets and a single handover system as used in surgery would be better.

Foundation doctors felt they could approach the Clinical Director for Medicine and said that Jess and Donna in medical education are “amazing”.

Domain 5 Delivering Curricula and Assessments  

Training Experience

The panel heard that FY1s are expected to undertake a large volume of educationally unproductive tasks. FY1s felt that surgical rotations were mainly ward rounds and were provided with a list of jobs. The described difficulties in getting any theatre experience.

The panel heard there were queries regarding misogynistic behaviour of a consultant surgeon.  FY1s said that now only male resident doctors are placed in surgery and rather than address the problem the hospital no longer allocate female resident doctors on the rotation. They felt the surgeon’s behaviour was not held to account.

FY1s said there is a culture that discharges are an FY1 job. An example provided was around surgical discharge summaries whereby a FY1 returned from over 2 weeks leave with 25 discharge summaries waiting for them to complete.

Another example heard on the stroke ward involved 8 discharge summaries that could have been done whilst a FY1 was on leave but were left until the foundation doctor returned. When asked why these were not completed when they were on leave the response was “but you’re back now”

Recommendation of Placement

FY1 doctors were asked if they would recommend their placement at Noble’s Hospital and all said “yes”

Foundation Doctors – Foundation Year 2

Domain 2 Educational Governance and Commitment to Quality

Datix and Exception Reporting

The panel heard the same as in the FY1 group that completing Datix reports are not encouraged and heard they are actively discouraged in surgery with feedback from Datix reports being variable. They explained that recently the clinical governance team came to a meeting which was very useful. One resident doctor was unsure where to send a Datix and emailed the Director of Medical Education and received a positive response.

As heard in the FY1 group, FY2s have also experienced difficulties with submitting exception reports. FY2s explained that exception reporting is not a straightforward process involving approval from the consultant on the day and on-site Nurse Manager and the request is often not responded to.

FY2s do let the Foundation Programme Director know of their additional hours so the medical education team can keep track of the hours.

Equality, Diversity and Inclusion

Some FY2s had experienced racial and prejudicial behaviour from some patients but said that hospital staff are lovely. They explained if a patient is displaying racist behaviour, they can ask a member of staff to accompany them. The panel heard of some misogynistic behaviour in surgery as also highlighted by FY1 doctors.

The panel heard as in the FY1 group that FY2s have heard anti trans comments being made. The example provided was in paediatrics. They explained that staff are respectful in front of patients, but when they have gone derogatory comments are made.

Domain 3 Developing and Supporting Learners

Induction

A&E induction was also described as “good” by FY2 doctors as heard in the FY1 session. FY2s said they knew what was expected of them, who to go to for support and shown where equipment was. GP, paediatrics, radiology and trauma and orthopaedics induction were also described as good.

Community psychiatry induction was described as very good. The panel heard that a FY2’s supervisor was on leave when they started their placement and came in specifically to meet them to ensure they were settled.

All FY2s felt part of the team, the panel heard that in paediatrics there are a lot of administrative jobs that are given to FY2s, for example discharge summaries, however this is getting better.

Workload

The panel heard there have been occasions when foundation doctors are moved around the hospital when short staffed. FY1s have been tasked as outlying doctors which they said is normally a speciality doctor responsibility therefore they have limited supervision when tasked with this role. FY2s advised FY1s to escalate this issue to the medical education team and the previous rota coordinator. They were advised this was a one-time occurrence. However, the panel heard this happens every few months.

FY2s explained that dispensing in the emergency department is a problem for themselves and registrars. The panel heard there is like an unwritten rule in order for patients to be discharged quicker FY2s are often responsible for to take out (TTOs) medication and this seems to have been absorbed into their job.  FY2s said they are not trained to do this. An example was provided from a FY2 who prescribed liquid antibiotics and did not realise this had to be reconstituted. No harm came to the patient but was very stressful for the foundation doctor.

FY2s explained they are responsible for A&E checks which include checking drawers are stocked with equipment and medicine trolleys are stocked this includes around 150 items. They explained that they are not trained to complete these checks, document and reorder any items and said this takes a significant amount of their time. This has been escalated to some consultants who agreed this needs to change. FY2s explained that this is a nursing issue.

Rota Management

FY2s described an improved situation in A&E over the last 3 months which aligned with the experience of FY1s the deanery met with. All had worked on A&E and felt the new rota coordinator and the introduction of the “casino shift” 6pm to 2am meant that FY1s are supported. As with the FY1 group they said that the new medical rota coordinator is very obliging and will work hard to accommodate any study leave and if he is unable to FY2s know he will have tried very hard. They said that other specialty rota coordinators are not as helpful.

Domain 5 Delivering Curricula and Assessments 

Training Experience

FY2s as with FY1s described a supportive medical education team and said they are “great”. They said the simulation facilities are good and get regular access. They said teaching is good compared to their peers working in other hospitals in the UK. They felt part of a wider multi-disciplinary team which they felt was better than their peers experienced in other hospitals.

FY2s explained there are no research opportunities at Noble’s, and this is a big part of their training and have to go off the island for this.

Recommendation of Placement

FY2 doctors were asked if they would recommend their placement at Noble’s Hospital and 9 said “yes” with one saying “maybe” but said this was a positive “maybe” and their response was due to flights off the island.

Internal Medicine Training Doctors (IMTs)

Domain 1 Learning Environment and Culture

Handover

The panel heard that handover takes place between 9-9.30am and IMT doctors have a phone instead of a bleep. An IMT doctor explained that gastroenterology handover sometimes has taken place in the patient day room and in some instances in the in-patient wating room. They said sometimes registrars hand over privately to each other.

When asked if any teaching occurs at handover, they said this depends on who is leading it. Some said handovers have been conducted better at previous hospitals they have worked in.

All confirmed they have got the work place-based assessments, MiniCEX and numbers on the take they need.

Supervision and Teaching

Most IMTs felt their educational supervisors were good, however clinical supervisor experience was variable. There was one example of an IMT doctor not knowing who their clinical supervisor was until a few days before they finished their placement and one IMT doctor had no clinical supervisor in their current placement.

IMTs confirmed they have protected teaching time on Wednesday afternoons. IMT peer teaching is on a Tuesday this is not protected so attendance is variable as it depends on ward staffing.  

Domain 2 Educational Governance and Commitment to Quality

Datix and Exception Reporting

IMTs also said that Datix is discouraged, and it is not the culture amongst doctors at the hospital to complete them. An IMT said they had completed a Datix today and said there is a culture amongst nurses to complete Datix reports. An IMT said they had been at the hospital for 11 months and had not been shown how to incident report. The panel heard from an IMT that they were told they will not pass their ARCP if they speak up. IMTs had not witnessed any duty of candour.

The panel heard that feedback from a Datix a pharmacist completed was shared regarding prescribing errors today.

As heard from the foundation doctors IMTs said they have not been told how to exception report and have escalated this several times.

Bank Shifts

IMTs described the difficulties they have experienced in joining the bank, one IMT doctors had been trying since January. Some of the challenges were due to the ID checks required.

Domain 3 Developing and Supporting Learners

Like the foundation year 1 doctors IMTs also described variable experiences of local induction. They said they received generic work schedules when moved to wards with no specific induction. For example, there is no cardiac catheterisation laboratory at Nobles, so patients are referred across and IMT doctors was not told how to do this and there was no handbook available. Some IMTs had to email several times for to ask for their work schedule with one IMT receiving this 2 days before their placement.

The panel heard that there are not always pharmacists on the wards and TTOs are done by hand which they were unaware of. The panel also heard from an IMT that when they were on the coronary care unit there were no staff they could ask for support during their first few days on their placement and they said they felt “drained” and “stuck”.

One resident doctor described how they commenced their rotation on a Medical Emergency Team (MET) call with no induction and were given a bleep without knowing how it worked.

Senior Support

IMT doctors felt there is a shortage of staff usually on a night shift and there can be 1 IMT and 1 specialty doctor covering the acute medical unit (AMU), intensive care and all of the wards. The panel heard of an example of whereby an IMT doctor was looking after a young asthma patient that required an arterial blood gas, they then had to go to the other side of the hospital to get the result, they also had 2 patients that were very unwell with one escalated to intensive care (ICU). One patient went into cardiac arrest and waited 5 minutes for the registrar to arrive. The patient passed away. The second patient for ICU also died. The IMT sat with the family and the bed manager. The registrar took 10 minutes to arrive then left to go back to ED. They said they were unable to contact the consultant on call. The IMT doctors said this was “very stressful” and when the consultant arrived, they were unaware that the IMT had contacted them during the night shift. Most IMTs said they have had similar situations out of hours as this is normal staffing levels overnight. IMTs have fed back that more doctors are needed out of hours.

The panel heard that there are no additional doctors in medicine during the Isle of Man Tourist Trophy (TT), but there are in the ED. They said there were 8 doctors in the ED sending patients to clerk with only 2 doctors clerking all night on the first day of the race. Once IMTs had escalated this was increased to 3 doctors.

IMTs felt that senior support has not got better as some of the locum specialty doctors do not know the wards and felt that some work at the same level as they do to some degree. However, some IMTs felt staffing had improved recently. The panel heard that locum doctors were not receiving induction, and the better locum doctors were leaving for training posts. Some locum doctors were unaware of guidance and escalation protocols due to not having a good induction. IMTs said some locum specialty doctors lack leadership and do not provide any advice or options for example an IMT described a patient who had a seizure, and the speciality doctor did not know how to handle the situation and said this was “frustrating”.

An IMT said in placements at previous hospitals they had learnt a lot from their senior support but have not had the same experience at Nobles.

The panel met with the rota coordinator as part of the visit, and he confirmed that recruitment is underway for 3 new specialty doctors commencing in September 2025 to support out of hours. He confirmed he will be in post until September 2026, and an advert is out for a full-time rota coordinator to ensure succession planning.

Rota Management

IMTs explained that rota coordination has been a struggle, but the new rota coordinator is very good and works with resident doctors to find a solution. Before the new rota coordinator started IMTs had difficulty getting annual/study leave and the answer they got to everything was “no”. For example, a IMT who had an injury was still put on MET calls involving running to different parts of the hospital rather than allowing their request to complete paperwork instead. This resulted in the resident doctor taking sick leave.

IMTs said the new rota coordinator is “wonderful and so supportive” and works with them to find solutions.

Domain 5 Delivering Curricula and Assessments 

Clinic Time and Specialty Experience

IMTs were asked if they have managed to get all of the experience needed to meet their curriculum. IMTs explained there is a lack of opportunity in specialties. They also said getting clinic opportunities can be challenging as there is no independent time for them to see patients on their own due to workload. Some IMTs commented they are so busy and “overstretched” they felt they have not gained the experience they need. For example, their time in cardiology is 80% on the stroke ward and therefore do not feel they have the skills they need and said they do not even know how to refer to the Liverpool Heart and Chest Hospital and follow up referrals and has to ask their consultant also there is no catheterisation laboratory. One IMT explained that they are the senior on the ward with an FY1 doctor as the consultant comes twice a week. An IMT had raised their experience within gastroenterology with their Training Programme Director (TPD) as in 4 months they had only attended 5 clinics. They explained that there is no gastroenterology ward at Nobles and wards are general medicine. They also said they have had no exposure to nephrology. They said there are things going on and are opportunities, but they cannot get to them. The TPD said they would try to get taster weeks for gastroenterology and CCU.

IMTs explained that they were not going to have enough clinics to meet their ARCP requirements, but the new rota coordinator facilitated this by scheduling clinics. They said they all get their clinics now but have been really stressed over the last 3 months regarding the clinic issue. One IMT said they were brought to tears with the stress.

IMTs said that they always see the rota coordinator around and he is the “best thing ever” IMTs said even if he cannot accommodate your request, you know he will try his best.

IMTs said that the hospital’s simulation facilities are good, and the clinical skills laboratory is great. They said Matt who leads simulation is very good. They felt they needed more procedural exposure in general.

Self-Development Time

All of the IMTs said they do not receive any self-development time, they said they have escalated this issue but have been told that as they receive teaching each Wednesday afternoon, then they are not entitled to self-development time. Dr Newton, IMT TPD on the panel confirmed that IMT doctors are entitled to 2 hours per week self-development time. She said that normally this is taken as 1 day a month or in half days.

Supervisors

Domain 4 Developing and Supporting Supervisors

The panel lead gave some background to the visit outlining challenges IMT doctors have faced and asked supervisors how they perceived the situation. Supervisors said that the hospital are recruiting specialty doctors and felt the night time rota was improving with the introduction of the “casino shift”. They felt that the working environment was more positive than in the last 3 months and recognised they are not where they should be quite yet. They said they have seen a strong willingness from management to improve things.

The panel heard from the education lead for SAS doctors (as many of the specialty locum doctors are SAS doctors) there is a weekly meeting for SAS doctors, and they have recently held their first SAS doctors away day which received positive feedback and are planning to hold these twice a year. They said they meet weekly with the Director of Medical Education to discuss educational issues.

Specialty Experience

Supervisors explained that the expectations of IMT doctors coming to Nobles are not realistic and the way the hospital works should be explained prior to their arrival. Resident doctors expect for example 4 months in cardiology, gastroenterology, renal etc. Consultants clarified that there are no specialty designated wards and are general medicine/geriatric wards and felt there should be some expectation management regarding what qualifies as a specialty post. They said they are clear about this in induction as Nobles is a small district general hospital and some resident doctors are happy with this.

The panel lead suggested that perhaps they could be described as a speciality with general internal medicine (e.g. cardiology with general internal medicine. The TPD for IMT outlined that in 2023 Nobles was top ranked for IMT experience. The panel said that speciality experience can be provided without dedicated in-patient beds for example pacing and endoscopy. The panel lead asked consultants why specialty experience designed around the resident doctor could not be accommodated and the TPD for IMT emphasised that IMTs are not getting the specialty experience they need and used nephrology and gastroenterology as examples. Consultants said there is specialty stuff going on, but IMTs just need to be able to get to it. The panel lead said this can be done and is an organisational issue of the rota.

Self-Development

The panel informed supervisors that IMT doctors are not receiving self-development time that they are entitled to and have had difficulties getting to specialty clinics. The panel lead asked why IMTs were not receiving self-development time. The panel lead said the lessons learned from foundation doctors is if it is on the rota it will happen. Some consultants were unaware of the requirement and some said this was the first time they had heard about this.

The TPD for IMT doctors outlined the requirement was established around 2 and a half years ago. This is usually bundled into a day a month for IMT1s and IMT2s. Consultants agreed to ask the rota coordinator if this can be scheduled onto the rota and did not see why management would refuse if staffing were available.

They recognised that the new rota coordinator will not always be in post and there needs to be a system to continue to improve the IMT experience. They felt that the MIAA staffing report is a good starter for 10. They informed the panel that the new management structure in Manx Care will be in place by the end of August and then consultants can begin to push for the MIAA report recommendations to be implemented.

Supervisors felt that specialty doctors are being much better treated now. They explained that specialty doctors are often international medical graduates and are new to the UK. These doctors have a period of shadowing and do not go on call for the first 4 weeks or until they feel competent to do so.

The new rota coordinator meets with surgical consultants once a month to identify any issues that may need addressing.

Induction

The panel fed back that they heard there is a lack of local inductions with the exception of A&E.  Some consultants were unaware that this was an issue. The panel heard that in endocrinology and diabetes they have requested volunteers to produce an induction handbook a part of a quality improvement project. Surgery also felt this was a good idea.

Supervisors confirmed they had recently met with the DME to ensure out of programme resident doctors receive an induction, work on this is underway.

Datix

The panel lead asked supervisors what is the hospital’s position on Datix. Supervisors felt that the use of Datix was becoming established. They explained that a daily rapid review meeting or “huddle” takes place at 11am each morning where any incidents and lessons learnt can be discussed. In surgery team attendance is encouraged and surgery have been lauded on their use of Datix, and its use is encouraged in handover. This contrasts with resident doctors experience with Datix whilst on surgical placement.

Supervisors said that the hospital would like staff to engage more with the use of Datix. One supervisor felt the use of Datix is functional and needed to be better.  

Supervisors were asked if they were supported as educators? They confirmed they have job plans and receive education days.

Equality, Diversity and Inclusion

The panel explained that they had heard in the resident doctor sessions incidences of unprofessional comments made by some staff including nurses regarding transgender patients once the patient had left. The panel heard that the SAS lead has asked 2 transgender patients to speak at their EDI forum and set time aside, but unfortunately, they did not attend.

Areas that are working well

Areas for improvement

Mandatory requirements

Report approval

Report completed by: Paula Fletcher, Quality Support Manager
Review lead: Professor Paul Baker, Deputy Postgraduate Dean, School of Foundation Training and Physician Associates
Date approved by review lead: 11 August 2025

NHS England authorised signature: Dr Raghu Paranthaman, Deputy Postgraduate Dean
Date authorised: 25 September 2025

Final report submitted to organisation: 25 September 2025