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The true pressures on Derriford Hospital’s junior doctors have been revealed, with serious safety concerns being raised after an incident occurred where only two staff were left to look after 436 patients during a night shift.

The issue of staff rotas and vacancies was brought up in Plymouth Hospitals NHS Trust board papers in July, in which a report outlined the feelings and concerns of junior doctors about the safety of patients.

In the Guardian of Safe Working Practice detailed report, which provides assurance to the Committee and to the doctors themselves that those in training are safely rostered and that their working hours are compliant, two reports were picked out which raised an “immediate safety concern”.

But Derriford Hospital insists that patient safety is of paramount importance to them as well as the safety of their staff - the hospital added that staffing is being reviewed on a weekly basis and that additional support through temporary roles is being applied where necessary.

The report shows that on May 2 of this year, one junior doctor wrote: “There are supposed to be a core number of three senior house officers (SHOs) on the rota, today there is only myself. The on-call full shift for neurosurgery (SHO) is under the empty slot on the rota and has not been filled.

“The other SHO due to be in work today is now off post-nights as she was moved to nights last week last minute to cover another gap in the rota.

“The rota coordinator has put the shift out for locum. This gap in the rota has been known about for at least five days. A datix is also being completed.”

Derriford Hospital’s board papers reported that the incident was immediately notified to the directorate manager who put in support with the registrar and ensured the consultant on call was aware of the situation. In addition, on a daily basis, plans to review medical staffing were being put in place.

Another issue raised on May 23 said: “Pulled from breast surgery day job at 11am and told I must come in and cover medical nights overnight for the rest of the week, despite being on surgery. Told on the phone that the deputy medical director had talked to my consultant and said I must do this, as there would otherwise only be a single SHO looking after all of the medical patients in the hospital.

“After discussion with my consultant we reluctantly agreed that the best measure from a patient safety perspective would be for me to attend this shift, despite it being unsafe and bad for my personal training/development.

“Unfortunately, I did not manage much sleep before coming in for the night due to the short notice. Other than myself, there was only one doctor on ward cover nights (out of three) and two SHOs and an F1 in MAU (the medical assessment unit).

(Image: Lucy Duval)

“Between myself and the other SHO on ward cover we were responsible for the care of 436 patients between the two of us, while carrying the crash bleep which covers the whole hospital (and incidentally kept us busy from around 04:00- 07:00). We have datix'd the unsafe environment and want it to be noted while having done our best, this was a very unsafe shift from the patient perspective.”

The papers noted that the incident raised a number of complex issues in terms of rota planning, staff and patient safety and impact on education for the trainees.

Concerns were passed on to the care group mangers and discussed at the Junior Doctors Forum and at executive level at the newly formed Medical Workforce Improvement Group.

As of July, Derriford Hospital had 462 doctors and dentists in training, 71 trust grade doctors but were needing to fill 101 vacant junior doctors posts - compared with 58 vacancies six months ago.

Medicine contains the largest junior doctor rota which has been “seriously affected” by the overall doctor vacancy rate, which is a national problem.

From April to August 2016 there was a 0 percentage of doctor vacancies which has since jumped to 37 per cent between August and December of this year.

Because of the increase in empty job posts, rotas have been altered to cope, meaning that the number of doctors on each ward during the normal working day has had to be revised down.

Those in respiratory covering Hexworthy, Honeyford and half of Meldon wards used to have a core number of nine doctors– they now only have 10 doctors in total and the core has been reduced down to six doctors caring for the same number of patients. The report states that this change is the same in almost every department.

The medical cover at night is also being reduced to "levels which may be unsafe" with only two doctors looking after 450 patients where previously there were three. There has also been a reduction in doctors rostered to support weekend ward rounds.

The papers added that junior doctors support a large number of the uncovered shifts through bank and locum working over and above contract.

However, the Trust had 122 preceptees going through recruitment checks with the vast majority of those due to start in August and September with a small number in July. The hospital said this will have a “considerable positive impact on our vacancy levels across the organisation over the next three months.”

Some of the trainee doctors feelings were captured in comments in the paper: “Working with little number of doctors especially at nights, a med reg (sic) is stressed to the extent of having significant trouble at home, affecting communication skills with nursing and consultant colleagues, and doctors from other specialities for their unrealistic expectations, and is seeing occupational health and their GP for work stress.”

Another wrote: “I was so busy I didn’t have a single break this weekend. I felt ill as all I ate were a couple of biscuits from the patient tea trolley.”

In May, the Medical Executive Committee’s (MEC) main topic for discussion was rota gaps. There was representation from the care groups, medical HR and junior doctors in addition to the regular members of MEC.

In recognition of the scale of the problems, a Medical Workforce Improvement Group was established. The group had its first meeting on June 2 and has been meeting weekly.

The Trust board said it very much welcomed the report and was keen to understand the issues from the perspective of junior doctor colleagues and the Safe Working Hours Guardian. This was part of the hospital's on-going and constructive dialogue, to ensure that they have the right staff in the right place delivering high quality, safe care.

“The Guardian of Safe Working Hours is responsible for protecting the safeguards outlined in the 2016 terms and conditions of service for doctors and dentists in training,” said Steven Keith, director of people for Plymouth Hospitals NHS Trust.

“We work closely with the Guardian, as well as junior doctor representatives, to ensure working hours within the Trust are safe and that we review all exception reports; putting in place improvements where required.

“Patient safety is of paramount importance to us and so too is the safety of our staff, which is why we have measures in place to safeguard their working hours.

“We continually monitor our vacancies and will explore other options, where we can. For example, we have appointed into a number of support roles, such as doctors’ assistants, who support the work of our medical staff and teams. This is an area that we are expanding.

“As a Trust we review on a daily and weekly basis, the numbers of staff, including doctors, nurses and allied health professionals, needed on our wards, providing additional support, through temporary staff, where necessary.”

A message from Dr Phil Hughes, Medical Director for Plymouth Hospitals NHS Trust

As a patient or relative or friend of a patient, it is vital that when you or they are in hospital, you feel safe and confident in the care being provided, as well as in the staff who are giving it. I want to take this opportunity to reassure you that we are a safe hospital and as the medical director of Plymouth Hospital, I have confidence in the staff and teams providing you with this care.

When you come into hospital your care is provided by a multidisciplinary team. This workforce and the cover they are providing is determined based on the needs of the patients we have in the hospital at the time. Therefore, it is always changing to reflect who we are needing to care for.

During the day you will be seen by a senior consultant, who will determine a suitable care plan to be put in place for you. If there are any concerns with your health or the treatment you require, it will be escalated during this time.

In the evening, a team of doctors are on hand and they are supported by a comprehensive on call rota. In addition, we have an acute care team providing assistance throughout the night, made up of senior nurses with particular skillsets, who are adequately resourced to assess whether there has been deterioration in a patient’s status and if so, they will escalate accordingly.

(Image: Lucy Duval)

Like other trusts nationally, we do have difficulties recruiting to and filling our junior doctor posts and so, as our responsibility to ensure our junior doctors and the hours they work are safeguarded, we have had to explore other options, where we can. This has meant creating and appointing into roles, such as doctors’ assistants, physicians associates and clinical fellows, who support the work of our medical staff and teams.

The story published by the Herald today [September 15], highlights a paper that was presented to us as a trust Board in July 2017. The paper, which is available for anyone to read on our website, was discussed in much more detail during our public meeting.

The examples in the paper are what we call exception reporting – meaning experiences such as those included in the report are the exception, not happening all of the time, but it is imperative that they are raised, and actions taken, to ensure they do not continue to happen. We take the working lives of our junior doctors and the responsibilities we place upon them very seriously.

We do recognise that we have to do more to meet the challenges with doctor recruitment and that is why we have established a group, with an executive leadership, to look at how we can improve things with our rotas.

Our staff work exceptionally hard and we would like to publicly acknowledge and thank them for this.