Executive summary

The review panel was appreciative of the extensive pre-review evidence provided by the placement provider (PP) and the preparations made to accommodate the review. The review panel noted from the evidence submitted in advance of the review and the feedback from learners that there were excellent training opportunities within the Cardiac Surgery department. The review panel emphasised that the focus of the Urgent Concern Review was the concerns raised around bullying and undermining within the cardiac surgery learning environment.

The majority of resident doctors (RDs) and locally employed doctors (LEDs) spoke very highly of the cardiac surgery training and reported that there were fantastic education opportunities and teaching available in the department. The review panel was pleased to hear that the majority of RDs and LEDs would recommend their post in cardiac surgery to colleagues.

The review panel noted that although many learners reported that their experience in the Cardiac Surgery department had been positive, there were several learners who described a different experience. The review panel was informed by several RDs, LEDs and consultants that there had been instances of inappropriate communication from cardiac surgery consultants, including reports of shouting at learners and making belittling comments about learners in the presence of colleagues and patients. The review panel was concerned to hear individuals felt this behaviour was accepted by the wider team.

The review panel was concerned that there was a disconnect in information that learners felt comfortable sharing anonymously and that was reported to the PP in more open forums. The review panel noted that learners were reluctant to share specifics about concerns relating to inappropriate behaviour from consultants in cardiac surgery.

The review panel also noted concerns about how learners requiring additional support were managed in the Cardiac Surgery department.

NHS England’s Intensive Support Framework (ISF) rating of cardiac surgery has been increased to ISF 2. 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

NHS England – London’s Education Quality team undertook a supportive and exploratory Urgent Concern Learner and Educator Review of anaesthetics and cardiothoracic surgery (within the cardiac surgery learning environment) at St George’s Hospital, following the placement provider’s (PP’s) response to a negative patient safety and bullying and undermining (PSBU) comment from the 2025 General Medical Council (GMC) National Training Survey (NTS). The comment was shared with the PP via the NHS England – London Education Quality Management Portal (QMP) in March 2025, as per the usual process. In response to this the PP conducted an anonymous survey with 14 respondents of resident doctors (RDs) and locally employed doctors (LEDs) from cardiac surgery, thoracic surgery and anaesthetics. The initial findings from the survey indicated issues with bullying and undermining behaviours, gender discrimination and sexual harassment, and other unprofessional interactions and behaviours which learners felt might have an impact on patient safety and were reported to be mainly from cardiac consultant surgeons to cardiac surgery RDs.

There have been several interventions for cardiac surgery at the PP since 2018 and the department was removed from GMC enhanced monitoring in July 2024. Given the previous issues around departmental culture identified in the Cardiac Surgery department NHS England-London required assurances from the PP that high quality education and training was being provided in a safe and supportive learning environment to all learners that work within the cardiac surgery environment. Anaesthetic and thoracic surgery learners and consultants were invited to the review in view of their shared learning environment. 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:

• Breakdown of the number of educational and clinical supervisors within the anaesthetics, Cardiac Surgery and Thoracic Surgery departments.
• Breakdown of the number and type of all learner groups within the within the Anaesthetics, Cardiac Surgery and Thoracic Surgery departments (including multi-professional learners and any LEDs).
• Freedom to Speak Up Guardian Board report- January 2025
• Anaesthetics Local Faculty Group meeting minutes- March 2024, July 2024 and December 2024
• Cardiac surgery Local Faculty Group meeting minutes- July 2024, September 2024, November 2024, February 2025 and April 2025
• Thoracic surgery Local Faculty Group meeting minutes- March 2025
• Scanned meeting notes from meetings with Education Lead for cardiac surgery and individual RDs and LEDs- December 2023- May 2025
• Serious Incident (SI) report in which learners were involved in the case- 2023
• Letter of support from previous resident doctor in the Cardiac Surgery department
• Log books for 5 current cardiothoracic RDs in training posts and LEDs in cardiac surgery
• Teaching programmes for cardiac surgery April 2024- August 2025
• Summary of training in cardiac surgery- May 2025

Who we met with

Learners

28 resident doctors (RDs) in anaesthetics, cardiac surgery and thoracic surgery training posts and cardiac surgery and anaesthetics locally employed doctors (LEDs) working in the Cardiac Surgery department.

Educators

25 clinical and educational supervisors in the Anaesthetics, Cardiac Surgery and Thoracic Surgery* departments.

Please note as there were fewer than 3 thoracic supervisors in attendance the contents of that particular session have not been included in the report to protect the anonymity of the attendees.

Placement provider team

• Director of Medical Education
• Medical Education Manager
• Educational lead for Cardiac surgery
• Educational leads for Anaesthetics
• Joint College Tutors for Anaesthetics
• Educational lead for Thoracic surgery
• Freedom to Speak Up Guardian
• Head of Medical Workforce
• Cardiac Surgery Clinical Care Group Lead
• Thoracic Surgery Clinical Care Group Lead
• Joint Clinical Leads for Anaesthetics
• Clinical Director of Anaesthetics
• Site Chief Medical Officer
• Group Chief Medical Officer
• Assistant General Manager for Anaesthetics
• Service Manager or Cardiac and Thoracic Surgery
• Cardiology and Cardiac Surgery Clinical Director
• Divisional Chair for Surgery

Review panel

• System Dean for South West London NHS England- London, Bhanu Williams, Education Quality Review Lead
• Head of the London Specialty School of Surgery NHS England- London, Celia Theodoreli-Riga, London Specialty School of Surgery Representative
• Sarah-Jane Pluckrose, Lay Representative
• Education Quality Coordinator, NHS England- London, Rebecca Bennett, Education Quality Representative

Review findings

Culture

Placement provider (PP) representatives reported that following triangulation of intelligence they believed there were issues with culture in the Cardiac Surgery department. PP representatives acknowledged that there had been significant improvements to teamworking and culture in the Cardiac Surgery department over the last 5 years but reported that they recognised the importance of acknowledging current issues with teamworking, particularly as it can impact on safety. PP representatives informed the review panel that they were committed to investigating and resolving these issues and the PP representatives welcomed the NHS England Education Quality Review to help with this. PP representatives reported that the Cardiac Surgery department had worked hard to ensure learners in their department felt supported and had access to pastoral support. PP representatives confirmed that the Anaesthetics department had a strong history of being supportive and having a good culture around raising concerns. PP representatives also advised that there had been significant recruitment of cardiac anaesthetists to address scheduling issues.

PP representatives reported that the Postgraduate Medical Education (PGME) team had worked with the Cardiac Surgery department for a long time and significant work had been done to make improvements. PP representatives acknowledged that culture was hard to change but advised that the Cardiac Surgery department had done a lot of work on teamworking and team building. PP representatives informed the review panel that the Organisational and Development (OD) and simulation work was ongoing. PP representatives reported that support from the senior leadership to resolve issues in the Cardiac Surgery department had been good. Previously, the PGME team had been supporting the cardiac surgery LFG meetings, to help provide psychological safety for learners to raise concerns. It was noted that this support had stopped as there had been significant progress in engagement, and it was felt that it was no longer needed. PP representatives reported that they would look at reinstating the independent LFG meetings for learners in the Cardiac Surgery department as there had been success previously with this approach. PP representatives noted that the PGME team were pleased to see the improvements in training and pastoral support in the Cardiac Surgery department but noted disappointment that cultural issues were recurring.

PP representatives informed the review panel that they were aware of broader cultural issues in theatres across all specialties and acknowledged that people did not always behave appropriately. It was noted that to address this the PP had restructured the training programme for theatre safety across all specialties. It was also noted that a behavioural charter had been developed by staff working in theatres and was due to be implemented soon. PP representatives advised that work was needed to establish the escalation process for instances where the charter is not followed. PP representatives reported that active bystander training had been commissioned for staff across the whole PP. They also described theatre simulation sessions which had been run to improve communication and team building in theatres. It was reported there had been 60% uptake of this simulation training from the cardiac surgery consultants so far, with more sessions planned.

Cardiac surgery consultants reported that they did not believe there was an issue with frequent bullying or undermining in the department. It was noted that learners might have witnessed negative interactions in isolation but may not have seen the follow-up or debrief to address them. Cardiac surgery consultants confirmed that they would feel comfortable challenging inappropriate behaviour if they were to witness it.

Resident doctors (RDs) in cardiac surgery training posts unanimously reported excellent training opportunities in both clinical and academic research and support for ongoing career development and aspirations. They reported that they had not witnessed or experienced any bullying or undermining behaviour from cardiac surgery consultants. Cardiac surgery RDs described supervisors as kind and supportive, even following surgeries with negative outcomes, and noted they had not perceived a blame culture in the department. RDs advised that the cardiac surgery debriefs following surgery were thorough and were carried out for all cases. It was also noted that the World Health Organisation (WHO) debriefs with the theatre team were very good.

Several cardiac surgery locally employed doctors (LEDs) informed the review panel that they had been made to feel welcome when they joined the cardiac surgery department and had been well supported. Some international medical graduates (IMG) LEDs advised that they had been welcomed to the department and colleagues had been very helpful with inducting them to the NHS. Several IMG LEDs also noted that the consultants in cardiac surgery had been understanding of them having trained and practised in different healthcare systems and learning environments. Some cardiac surgery LEDs reported that the junior team in cardiac surgery were helpful and worked well together. Many cardiac surgery LEDs reported that they had not witnessed or experienced any bullying or undermining behaviour in the Cardiac Surgery department. Some cardiac surgery LEDs also reported they did not feel they were treated differently because they were an LED.

Many anaesthetics LEDs reported that they had not witnessed or experienced any bullying or undermining in cardiac surgery theatres. Anaesthetics learners reported that the rapport and communication between cardiac surgery and anaesthetics consultants was good. Some noted that the consultant anaesthetists and cardiac surgeons had been welcoming and supportive of anaesthetics learners. Some anaesthetics RDs described the cardiac surgery theatre as often very emotionally charged and anaesthetics consultants had advised part of their role was to help ensure the environment was safe and supportive for the cardiac surgery consultants.

When asked if they had experienced or witnessed any bullying or undermining in the Cardiac Surgery department, several learners (including cardiac surgery LEDs, anaesthetics RDs and anaesthetics LEDs) reported that they had. The review panel noted that the learners were very reluctant to describe what they had witnessed or experienced. However, some cardiac surgery LEDs reported that they had experienced being shouted at publicly by cardiac surgery consultants and in some cases had been told to leave theatre. Some anaesthetics learners informed the review panel that they had witnessed cardiac surgery learners being asked to leave theatre in a way they would deem inappropriate and rude. The review panel was also informed by anaesthetics learners that they had witnessed cardiac surgery consultants shouting at cardiac surgery learners in theatre and they felt it was unacceptable. It was noted that there had been several incidents that the anaesthetics learners felt had been inappropriate and unprofessional, however, they acknowledged that they had not seen if there had been any follow-up or debrief afterwards. Some cardiac surgery LEDs felt that there was an issue with the way negative feedback was delivered. Some felt that they had been criticised repeatedly for minor issues and felt belittled.

Some learners advised that sometimes in theatres there was a need for cardiac surgery consultants to give commands or alert colleagues to something urgently which might be considered as shouting, however they made the distinction that it was not targeted or personal and therefore they did not think it was inappropriate. However, some anaesthetics RDs reported that there was a big difference in what anaesthetics learners and cardiac surgery learners deemed acceptable in terms of shouting in theatre. Anaesthetics LEDs and RDs felt that the terms bullying and undermining were subjective and therefore some behaviours that they would consider bullying and undermining might be considered normal by the cardiac surgery learners. Anaesthetics learners reported that they felt the cultures of the Cardiac Surgery and the Anaesthetic departments were very different.

Some anaesthetics consultants reported witnessing belittling behaviour from cardiac surgery consultants. Some anaesthetics consultants reported that several of the cardiac surgery consultants did not appear to empathise well with some cardiac surgery learners. It was reported that some anaesthetics consultants had witnessed cardiac surgery consultants complaining about the performance of cardiac surgery learners in public settings.

Anaesthetics consultants described cardiac surgery theatre as a stressful environment and noted it was not uncommon for very direct communication to occur, which they believed was appropriate to ensure patient safety. However, they acknowledged that those with little cardiac surgery theatre experience might be unfamiliar with this level of intensity in theatres. Cardiac surgery consultants also noted that those with less experience of cardiac surgery theatres might find the communication between specialties different to what they had experienced previously. It was noted that there had been a lot of work done to educate people on the cardiac surgery theatre environment.

Anaesthetics consultants informed the review panel that they had experienced raised voices in theatre which were appropriate for the situation but noted they had not experienced any swearing. Some anaesthetic consultants advised that there had been some improvement in communication for several of the cardiac surgery consultants. However, they also reported that there had been instances where cardiac surgery consultants had been short tempered with theatre staff. Anaesthetics consultants advised the review panel that there was always an anaesthetics consultant in theatres with anaesthetics learners. It was noted that some anaesthetics consultants would feel comfortable addressing cardiac surgery consultants about potential inappropriate behaviour, but not all anaesthetics consultants felt this way. Some anaesthetics consultants reported that they would feel apprehensive about discussing concerns around behaviour with cardiac surgery consultants as they anticipated a hostile response.

Raising concerns

The review panel highlighted a disconnect between the feedback that the PP was receiving in forums a such as Local Faculty Group (LFG) meetings and the feedback from external or anonymous surveys. PP representatives advised they were aware that generally people were reluctant to raise concerns due to fear of negative repercussions and lack of confidence in the system to resolve the issues. PP representatives reported that the senior leadership wanted to help improve the experience for the learners.

PP representatives stated that they wanted to ensure learners felt comfortable with raising concerns and acknowledged that more work was needed to signpost learners to the various internal reporting routes. PP representatives reported that there had not been any concerns raised via the Freedom to Speak Up (FTSU) service regarding the Cardiac Surgery department. However, the PP representatives recognised that more work could be done to increase visibility of the FTSU service in the Cardiac Surgery department.

Anaesthetics consultants also noted concerns that anaesthetics learners had not raised issues about the culture in the Cardiac Surgery department directly or formally with the Anaesthetics department. Anaesthetics consultants reported that they were open to receiving concerns from learners and noted that the department would explore this issue further.

Cardiac surgery consultants agreed that any bullying or undermining behaviour was not acceptable but advised that it was difficult to address issues where concerns have been raised anonymously or without specific details. Cardiac surgery consultants acknowledged that the issues needed to be identified and addressed, and hoped to identify the reasons that learners did not feel comfortable raising concerns so that these could be resolved. Cardiac surgery consultants informed the review panel that no issues had been raised at the LFG meetings which were held every 6 weeks and that more work was needed to signpost learners to other avenues to raise concerns outside of the department.

Education opportunities and teaching

The majority of learners advised that they would recommend their post in cardiac surgery to colleagues, however there were several who would not.

RDs in cardiac surgery training posts unanimously reported that training in the Cardiac Surgery department was excellent and confirmed there were great theatre opportunities and support from trainers. Cardiac surgery RDs reported that they were also learning good management skills from the consultants in cardiac surgery. Cardiac surgery RDs were particularly complimentary of the efforts of the Cardiac Surgery department to run education events which were inclusive of IMGs.

The majority of cardiac surgery LEDs reported that they had access to plenty of opportunities to operate with different consultants and experienced a wide variety of cases. Some cardiac surgery LEDs reported that they felt trusted by the consultants and felt they were able to work at the level they wanted to. It was noted by some cardiac surgery LEDs that there were previous issues with LEDs’ access to training opportunities however this had improved and generally LEDs had good training opportunities. Cardiac surgery LEDs reported that cardiac surgery consultants discussed cases in a formal and structured manner which they found helpful. Several cardiac surgery LEDs reported that the workload in the department was conducive to preparing for exams and publishing articles. Cardiac surgery LEDs also noted that the facilities were good, including the registrar room.

However, some cardiac surgery LEDs felt that there was a discrepancy in the allocation of surgical opportunities between different LEDs in the team. Some cardiac surgery LEDs reported that a more structured and formalised process for allocating theatre opportunities would be preferred.

Cardiac surgery consultants reported that they did not distinguish between RDs in NHS England training posts and LEDs, however noted that it was not always possible to give everyone equal training opportunities as these need to be safely tailored to individual ability and experience. Cardiac surgery consultants advised that they were aware this was sometimes frustrating for some LEDs. Cardiac surgery consultants acknowledged that progression opportunities for some LEDs were limited and advised that this was challenging for LEDs who had been in the role a long time or where there were competency issues. Cardiac surgery consultants advised that there were times where it was not appropriate to offer the same opportunities to everyone as learners’ skills and experiences were different, and it was not always safe to allow everyone to do the same things. Cardiac surgery consultants noted that this was sometimes challenging for some LEDs to accept. The review panel was informed by cardiac surgery consultants that some of the LEDs had done very well in the department and several LEDs had been accepted into NHS England training posts or had gone through the Certificate of Eligibility for Specialist Registration (CESR) route.

Educational governance

PP representatives clarified that the Cardiac Surgery and Thoracic Surgery departments were separate and distinct.

PP representatives reported that the Postgraduate Medical Education (PGME) team had worked with the Cardiac Surgery department for a long time and significant work had been done to make improvements. PP representatives acknowledged that culture was hard to change but advised that the Cardiac Surgery department had done a lot of work on teamworking and team building. PP representatives informed the review panel that the Organisational and Development (OD) and simulation work was ongoing. PP representatives reported that support from the senior leadership to resolve issues in the Cardiac Surgery department had been good. Previously, the PGME team had been supporting the cardiac surgery LFG meetings, to help provide psychological safety for learners to raise concerns. It was noted that this support had stopped as there had been significant progress in engagement, and it was felt that it was no longer needed. PP representatives reported that they would look at reinstating the independent LFG meetings for learners in the Cardiac Surgery department as there had been success previously with this approach. PP representatives noted that the PGME team were pleased to see the improvements in training and pastoral support in the Cardiac Surgery department but noted disappointment that cultural issues were recurring.

Induction

Cardiac surgery consultants advised that new RDs and LEDs received a full induction to the department. It was reported that new starters had 2 weeks of shadowing and received an induction pack. It was also reported that cardiac surgery consultants reviewed all entry notes made by new starters for the first 4 weeks and feedback was provided. Cardiac surgery consultants also noted that the Education Lead met with new starters initially and again at 4 weeks, after which they met with them every 6 weeks in line with the other learners in the department. It was also noted that new starters were offered opportunities for anaesthetics experience as well.

Areas that are working well

Areas for improvement

Immediate mandatory requirements

N/A

Mandatory requirements

Recommendations

N/A

Report approval

Report completed by: Rebecca Bennett, Education Quality Coordinator, NHS England-London
Review lead: Bhanu Williams, System Dean for South West London, NHS England- London
Date approved by review lead: 1 July 2025

NHS England authorised signature: Elizabeth Carty, Postgraduate Dean, NHS England- London
Date authorised: 15 July 2025

Final report submitted to organisation: 17 July 2025