Postgraduate School of Anaesthesia and ICM Quality Management Visit to Plymouth Hospitals NHS Trust


8th August 2014


Postgraduate School undertaking visit:School of Anaestheisa/ICM

Primary author of report (name and job title): Dr James Pittman, Head of School

Provider visited: Plymouth Hospitals NHS Trust (PHNT)

Visit team (names and educational job titles)


Dr James Pittman

Panel 1 Members

Dr James Pittman, Dr Roland Black,  Dr Susan Underwood

Panel 2 Member

Dr Emma Hartsilver, Dr Anna Weiss

Medical externality

Dr Susan Underwood

Lay representative

Mr Bill Wylie


No. of trainees seen

No. of trainers seen



Twenty five

Evidence considered prior to review taking place: Questionnaires, 2014 GMC NTS

Date visit report ratified by HESW – Peninsula

16th October 2014

Date visit report made available to provider

16th October 2014

Date provider ratifies visit report

10th November 2014

Circulation of this report: PPME Quality Team, PHNT Director of Medical Education


Executive Summary

Plymouth Hospitals NHS Trust is one of the largest providers of acute care in the country and is the major tertiary referral centre for Devon and Cornwall. It provides secondary services to a local population of 400,000 and a range of tertiary services (Cardiac, Neuro, Paediatrics and Hepatobiliary Surgery) to approximately 1.5 million patients. All services are provided on a single site at DerrifordHospital. It is the regional Major Trauma Centre.

The Departments of Anaesthesia and  Intensive Care Medicine in Derriford Hospital are the largest local education providers in the Peninsula School of Anaesthesia and ITU. The Department provides training across all the modules covered by the RCOA curriculum including the specialist training modules of Cardiac, Neuro and Paediatric Anaesthesia. Until recently, the Department has provided a full complement of pain training , including advanced. The imminent appointments  into currently vacant consultant posts should help to reinstate  and improve overall pain training .

The Anaesthetic Department has 60 general consultants. There are 12 ITU consultants and 9 cardiac anaesthetic consultants. There are approximately 38 Anaesthetic trainees: seven CT’s, 6 ACCS trainees, 16 ST yr3-4, 22 ST yr5-7, 3 clinical fellows and 12 SAS/ Trust staff. There are 2 College Tutors and 28 Educational Supervisors in Anaesthesia. There are separate educational supervisors in ITU. There are individual clinical leads for Anaesthesia and ITU. The Anaesthetic Department has 2 administrative staff, as does the ITU.

The Department covers approximately 23 operating theatres, 5 cardiac theatres, 2 paediatric theatres, 3-4 pain sessions/ day and a busy obstetric unit.

The critical care unit has 28 beds (staffed to 14 level 3 and 12 level 2). The regional neurosurgical centre is at Derriford, and the critical care unit has 10 beds nominally allocated to Neuro-ICU. The hospital also has a 16 bedded cardio-thoracic ICU (admitting post surgical cardiac, thoracic and vascular patients). The critical care unit admitted 1455 patients in 2012/13, with >60% requiring level 3 care. There is scheduled consultant presence from 8am to 9pm every day. During the week, there are 3 consultants on the unit (2 for general, 1 for neuro) and at the weekend there are 2 consultants until 1pm. There is a ICM Faculty Tutor and Deputy. The critical care unit at Derriford Hospital is recognised for training in ICM at all levels. There are 2 ‘Advanced’ trainees (ST 6/7) and 2 ICM CCT trainees (ST 3/4). There are 7 additional rotated trainees.  There are a minimum 3 trainees on the unit during the day and 2 at night.

The Department and particularly the Clinical Leads and College Tutors, should be commended for trying to improve the training environment over the last few years as demonstrated by the GMC trainee survey and other metrics. This visit has highlighted areas that can be further improved and developed, including aspects of the training programme that extend into the responsibility of the School and Peninsula Postgraduate Medical Education (PPME).  For example, a better regional post fellowship academic teaching programme needs to be set up.

Clinical and educational supervision of anaesthesia and ITU trainees is generally good and trainees are happy that they know who is supervising them at all times. The exception is when they are working on the cardiac ITU where supervision and support is lacking. This area of training was the subject of a recent triggered visit by PPME with an action plan being monitored for delivery.

Further training and support of the Educational Supervisors needs to be explored by the School of Anaesthesia and ITU, so that the trainee assessment process and requirements of the School are familiar to all. Education Supervisors have a very important role in the delivery of training in a LEP and they are essential in driving the process forward, in addition to reacting to instruction or guidance from PPME or the RCOA. Educational Supervisor roles should be recognised with motivated and enthusiastic individuals selected to fulfil these positions.

Derriford offers a very good training environment but the opportunities are not maximised and can bypass trainees. The heavy work load that the department covers puts a considerable strain on the balance between service and training. Continued efforts need to be made to maximise trainees opportunities on a regular basis. Workload is an issue for the department and arrangements need to be put in place to resolve this.  The Department should consider whether it can continue to provide the additional training requirements required for medical students, paramedics and the Antarctic survey. Trainees spend too much time covering on-call for adult and cardiac ITU. This is at the expense of day time sessions and emergency anaesthesia training.  The ITU is a supportive environment but very busy: there is potential for the workload to be overwhelming and training compromised. Trainees do not gain satisfaction from the cardiac anaesthesia module and changes need to be made. Acute and chronic pain training needs to be reviewed and improved. The recent reconfigurations of pain services seems to have impacted negatively on trainees participation in their allocated pain modules.

Anaesthesia and ITU training at Derriford is crucial for the delivery of the anaesthetic curriculum within PPME. It is essential therefore that it provides a training environment that is supportive, comprehensive and good quality. This is a great challenge and is made harder by financial pressures, expanding clinical demands, relatively small and new speciality tertiary services, essentially fixed or declining numbers of trainees, constraints of working hours, limited potential for expansion of permanent staff (consultant or SAS) and increasing expectations of the quality of training programmes.

Despite a supportive trainer team the Department needs to continuously appreciate the daunting and challenging work environment that trainees arrive into. Induction needs to be comprehensive and re-enforced more than once. Speciality areas need their own induction timed for when the trainees join that service. Further focusing on the pastoral needs of trainees would benefit even the more confident trainee. At any one time the Department is the base for a large percentage of the Specialist Trainees within the Peninsula School: Overall satisfaction of specialist  training in Anaesthesia was reported as the lowest in the country in the GMC survey. It is therefore essential that the Department work even harder to optimise the time trainees spend in Derriford.


Key recommendations


Induction of trainees can be further improved. Induction needs to occur prior to trainees starting individual speciality modules. This should be implemented immediately. (for more details see page 2, areas of development) (Include Trust Fellows – see page 9)


Training, teaching, support and supervision of trainees doing Cardiac Anaesthesia needs to improve (see page 4)


Encourage trainees to greater independence of practice, whilst still being supported. For example, development of dual supervision training lists and letting trainees self-select lists. Trainees need to do less ITU on-call and more emergency anaesthesia (page 5 & 7))


The College Tutor needs to have a standing agenda slot at divisional meetings to communicate training issues and developments to permanent staff. Trainee representative to be appointed.  Educational Supervisors need to drive the training process rather than react to it.


Training in acute and chronic pain needs to be improved and be reviewed in 6 months’ time


Trainee meetings: Formal and/or social to discuss training issues and maintain morale



Dr James Pittman

Head of School for ICM and Anaesthesia



Areas of good practice

Department / Programme / Specialty

Area of good practice

Derriford anaesthesia

In-theatre teaching


Core training in anaesthesia – trainees have a dedicated novice clinical supervisor


Consultant duty floor anaesthetist tries to re-allocate trainees to best training opportunities


Primary FRCA training and  Final FRCA regional teaching days


Study leave seems to be readily obtained


The College Tutors and Clincal Leads have worked hard to improve the training environment

Derriford ICM

ITU offers good clinical support for trainees


Consultant programme includes a teaching week, provides protected teaching sessions and thorough induction for new trainees



Summary of the visit

Patient safety inc. handover and induction

Trust induction is satisfactory but long and some things do not appear relevant. A half day induction into the trauma service seems excessive. It was felt that there was a disconnect between the induction expectations of trainers and the trainees. There is half day departmental induction at the start of placement but information provided may not be relevant until months later. Sub specialty induction ought to occur at the start of modules in specialised areas eg cardiac.  Trainees are not initially introduced to eportfolio or the schools workbooks and paperwork.

CT’s never feel that patient safety is compromised. Induction is generally excellent although perhaps includes a little too much information too early for novice anaesthetists such as PCA and epidural use which is relevant a little later in the training but then never revisited. Obstetric and ITU inductions are excellent. There was no induction for paediatrics or pain. The Secretary who organises the rota is extremely helpful and approachable.

ST trainees comment that induction is overall good for general anaesthesia, however when an ST starts or returns to Derriford later in training, an assumption is made regarding their competence and experience, so induction is often lacking or brief. The CT and ST experience and training received in other hospitals prior to arriving in Derriford varies enormously and cannot be assumed. There were reports of no Cardiac module  induction  or ITU induction for ST trainees. On occasions ST trainees new to the Department report that they start on the rota in ITU, Cardiac or Neuro doing weekend shifts and even weekend nights with no formal general or speciality area induction. Cardiac trainers report that 2 consultants now deliver the induction and it has an increased focus. No specific Neuro anaesthesia induction exists but the trainers felt this was not required Whilst recognising that the general induction should be sufficient to cover the Neuro department, the panel felt that trainees should still be asked whether they required an additional induction. 

ITU: The norm is that each trainee would have a ½ day induction to the working of the unit and a meeting with the Faculty Tutor, where the educational objectives are established.

The annual and study leave request process is different in different modules and the ST’s feel it would be useful to have information on all of this at the start of the year rather than finding out when the module starts,  when issues may be too late to rectify.

The Department is trying to improve how it meets and greets new trainees as they join a large department

Allied Healthcare workers identified no patient safety issues. Allied health care professionals felt the trainees orientation and induction varies depending on the department but is reasonably good.

No patient safety issues were identified but trainees feel this is a very challenging environment to work in.


/ Programme / Specialty

Area of development


Whilst the induction process appears mostly satisfactory it could be developed to better meet the needs of the trainees, both in timing and content. Speciality induction prior to starting a module, information regarding leave taking, familiarisation with eportfolio and workbooks are examples.

Specifically the ST trainees would appreciate a more in-depth induction each time they return to Derriford including cardiac, neuro and ITU induction. This should also include detailed information regarding the peculiarities of the rotas and leave requests within each module.

The ‘meet and greet’ of new and returning trainees.

Supervision – clinical and educational (inc. career guidance, feedback)

CT clinical supervision is always clearly defined , protected and readily available. There are opportunities to debrief and discuss critical incidents. CT’s commented that they do not feel affiliated with their training organisation, PPME,  or familiar with the support for training or personal / professional needs that the School strives to provide.

In anaesthesia the clinical support for ST’s from senior colleagues is excellent. It is always clear who the responsible senior doctor is and how to contact them. Individual Educational supervisor performance is variable with some less engaged with the roles of the post. WPBA are well used but can be better used. Correct use of sit down CBD’s away from theatre, choosing from 3 cases presented by the trainee, does not happen. CBD’s are usually completed in-theatre regarding the relevant patient being anaesthetised on that list. The informal in-theatre teaching is all excellent.

The Clinical Supervisors who are not Educational Supervisors appear to have no knowledge of Deanery support available to the trainees. The ST trainees feel PPME are irrelevant to them on a day to day basis. They have no idea that careers advice, mentoring and coaching is available through the Deanery. Their perception is that the issues they have are managed by and only relevant to their clinical placement. In this case, Derriford. They feel the ARCP process and Deanery are driving the need to complete non-clinical CV activity and that this is unnecessary, of no personal benefit and peculiar to the SW Peninsula.

Trainees felt there was good support for audit, research, presentations and portfolio development.

Trainers felt it was clear who they were supervising and the process worked well. Trainers would like to have better benchmarking of WPBA’s. Most had undertaken the PPME ES training. Several would like to attend an ES training update day. There is concern that the reduction in SPA time-for ES, from 0.25 to 0.125 will impact on the quality of ES supervision.  The College Tutor work supervising trainees exceeds the time paid.

ITU: trainee clinical and educational supervision is excellent. There is substantial day time   consultant level cover that extends through to 10pm.  It is always clear who is supervising the trainees. Educational supervision is well established although the workbooks and WPBAs requirements are in development. More guidance is required but good in house support comes from the RA. Different ES’s take FY/ ACCS/CT/ Advanced trainees.

Trainees are discussed at weekly ITU meeting ensuring timely feedback during their module. Need to develop ITU mentoring system

Input from Allied Healthcare workers in neuro ITU felt that some training opportunities were lost. For example, breaking bad news is a valuable opportunity regularly missed. The trainee never accompanies the consultant unless they are an advanced trainee. In cardiac ITU the trainees would benefit greatly from increased consultant presence.

Pain medicine offered traditionally excellent training and WPBA opportunities. These are currently not  fully utilised and  not always recognised by the wider department . The format of formal CBD lends itself very well to assessment of pain competencies.   Supervised training opportunities in pain ( acute, chronic , paediatric, Pain rapid access clinic) are often missed by trainees because of other training or service commitments. CT pain training can be completed by negotiating pain session allocation through the Anaesthetic office.


Department / Programme / Specialty

Area of development


WPBA are not consistently well used. PPME should work towards improving clinical/ educational supervisors understanding of their use in anaesthesia. PPME and ES’s should Increase clinical supervisors and trainee awareness of their organisation’s  role.

Consolidation of the training and development of a team of quality Educational Supervisors in the department

Trainee should accompany consultant to break bad news on neuro ITU as learning opportunity.

ITU mentoring system.

Increased Consultant presence required for training on cardiac ITU

The available facilities and opportunities  for pain training have to be reviewed regularly. Pain  training allocation must not be jeopardised by competing  modular training or  service delivery demands


Training environment (inc. access to educational resources

Generally the feedback on the training environment provided in Derriford was positive. The opportunities are numerous and the trust potentially offers an excellent training environment. This was specifically mention as good in Neuro and Obstetrics, however it was claimed to be non-existent in cardiac ITU.

Access to the anaesthesia training opportunities in the LEP are not though maximised. Trainees felt that they could be allocated to better training lists. On arrival in the department it was not made clear to trainees that this was possible and they did not feel encouraged to move their lists to obtain these opportunities. Trainee felt there was a lack of major neuro cases and paediatric opportunities were limited.

The Cardiac training is repeatedly highlighted by trainees as not satisfactory. The learning opportunities in the OR are good but trainees felt that they had limited access as they were often required to do cardiac ITU, where the consultant support and input was lacking. Trainees are allocated lists rather than being encouraged to choose to go to where the best opportunities/ trainers exist.

The cardiac anaesthesia service recently undergone a triggered review with the department’s action plan being monitored for implementation. Some attempts to improve areas identified in this previous report have been made by the trainers. These include a leaning agreement and some recruitment of non-trainee staff to undertake cardiac ITU responsibilities. A structured teaching programme is planned but has not yet been started.

The trainees could benefit from better access to IT systems.

ITU: The trainees felt they had learnt a lot on the adult ITU, the opportunities were excellent and they felt supported. Trainees all claimed that the work load was extremely busy with current staffing levels. One trainee expressed feeling overwhelmed at the workload. Trainees have protected learning every Thursday afternoon. This consists of structured tutorials and simulation sessions which have been mapped against the FICM competencies. In addition there is a weekly journal club, weekly case review meeting, monthly M&M, radiology teaching and monthly practical sessions (echo, lung US).

PAIN: CTs expressed that training was available, albeit often only on demand. This amounted to as much as 5 pain ward rounds, 4 chronic pain sessions and 2 chronic pain procedure lists for a CT2 trainee.     The anaesthetic department was flexible and accommodating in organising pain attachments on request. The quality of training received was perceived as good.

Most STs will have completed their intermediates pain modules at other training facilities in the region. There were currently no trainees taking part in higher or advanced pain training.


Department / Programme / Specialty

Area of development


General: Develop more opportunities for trainees to move around  to optimal learning  lists

The Cardiac Anaesthesia service has an on-going plan with focus on anaesthetic trainees spending more time in the OR rather than ITU. Trainees should be encouraged to choose the lists they would like to attend rather than being allocated. This will better match their needs and trainees will gravitate to the better trainers. A teaching programme needs to be developed and suggest this is delivered in SPA time rather than during pressurised DPA sessions. Greater consultant presence on the cardiac ITU needs to be prioritised.

The demands of the adult ITU service are considerable and the department need to be proactive in service development planning so that the training opportunities are not compromised.

Review and utilise the varied and excellent training facilities in pain medicine and their provision of close supervision. In particular ,  consider more intense acute pain training early in CT.

Work load

CT’s feel valued but over protected. They would like to be given more responsibility. The leap to ST3 work and responsibility feels too great.

ST’s feel valued within the department despite its size. They would like to work more independently and think that dual supervision lists would be ideal.

Allied Healthcare workers feel valued by the Anaesthetic Department.

Consultant Anaesthetists are acting down during the day almost every weekend, occasionally at night. This will impact on training time and motivation.

Trainee numbers are limited and reducing which has a negative impact on training. The loss of military trainees has reduced the department’s numbers. Proportionally too much time is spent doing on-call, predominantly general and cardiac ITU. More time doing emergency anaesthesia is requested.

Due to limited hours and on call rotas trainees may have a minimal number of actual in theatre clinical days per module which has a negative impact on training.

ITU: work load is heavy and with the expansion of trust activity, such as trauma, the responsibilities of the anaesthesia /ITU Department are arguable critically high.  There is a planned development of a critical care practioner role.

PAIN: Despite of clear guidance on pain training through the local educational advisor, pain training seems to take a back seat as compared to other training priorities. This may be influenced by the geographical and conceptual distance between the acute and chronic pain services. There seems to be little communication between the paediatric and adult pain services and training opportunities in this area are not flagged up. 

Department / Programme / Specialty

Area of development


Offer dual training lists and  increase distant supervision to increase clinical experience

Expansion of permanent staff to meet the service needs of the LEP

Identification of available training opportunities in pain and consideration of  integration of pain training through all contributors to pain services.

Adequate experience / achievement of curriculum competencies

Modular training exists within the department in addition to ITU, Cardiac and Neuro.

CT: Once the CT trainees are obstetric trained they get no more general theatre on call experience as it is then all obstetrics. This may be from the end of CT1. They leave the department out of practice in general anaesthetic emergency work. Otherwise the CT curriculum competencies can be comfortably achieved.

Overall the ST’s find the hospital flexible and helpful but comment that the training is formulaic and it can be hard to fine tune the Advanced training in ST7 – however the department is supportive and helpful to this end.

The cardiac module contains too much cardiac ITU work and too little in theatre cardiac experience. This makes the completion of the cardiac module difficult within the allotted clinical module time. Trainee list allocation is not done by the trainees. If extra daytime experience is required after the end of the cardiac module this can be extended but will then eat into other modules experience and have a knock on effect. Trainees therefore sometimes come back to cardiac theatres on their days off in order to complete the cardiac module.

Thoracics: trainers feel that there are more opportunities for trainees to gain experience.

Neuro: trainees feel that there are few craniotomies and mostly spinal cases. Trainers feel that there are adequate opportunities and support moving trainees around to get required competencies. 

The excellent clinical learning experiences available at Derriford are often missed. This is a shame. This is partially due to the constraint of service delivery, modular training and the restriction on hours.

Paediatric training is limited in the whole school but the trainees find that gaining extra experience is possible to arrange. Paediatrics advanced training – there are fellowships available wordwide but the trainees require a level of higher training to apply for these than they are unable to gain as a trainee in the Peninsula. Until now there have been 2 x 6 month placements available at BCH for this higher training. BCH have recently changed this to 1 x 12 month placement so only 1 trainee per year would be in any position to be able to apply for a paediatric fellowship. This is disadvantaging any Peninsula anaesthetic trainee with a serious interest in paediatrics.

The ST’s get no emergency anaesthesia experience when on their modules.

Pain training – CT trainees leave Derriford with very little acute pain training and no knowledge of acute pain trouble shooting or PCA and epidural pump set up. ST commented that there is no pain module and this part of the training can be difficult to complete. Trainees are not getting any basic acute pain training and are not seeing patients postoperatively for pain reviews. There is poor communication between the department trainee coordinator / CT / ES and the pain consultants regarding the trainees pain training. There is no communication between the acute pain and chronic pain teams. Paediatric pain management is completely separated from the acute and chronic pain teams and is being delivered by anaesthetists. The trainees are therefore getting no paediatric pain management training and no acute pain training.

Twighlight obstetric on call exists but if this was changed to an evening general / emergency anaesthetic list this could be a better learning opportunity for trainees.

ITU: Derriford provides ICM training at all levels. Trainees on the unit are exposed to a large and diverse casemix allowing for adequate experience and obtainment of competencies.

Department / Programme / Specialty

Area of development


The access to Neuro, paeds thoracic and cardiac cases. Letting trainees allocated themselves to lists would empower them and help ensure they received the training they need.

The access to emergency anaesthesia for CT (particularly after obs training) and ST’s

Emphasise at department induction that secretaries are very helpful and will try to allocate trainees to appropriate lists when requested.  

Utilise evening lists for emergency and elective general anaesthetic training rather than the Twighlight obstetric shift.

Reduce the cardiac ITU workload and increase the in theatre time.

Open up the opportunities for learning for senior trainees.

Paediatric Anaesthesia  Lead to discuss with the Deanery the need to negotiate 2 protected x 6 month paediatric posts for higher training at BCH per year with a possible 12 month post as an additional NOT alternative.

PAIN: Identify and advertise all training opportunities in pain . Collaborate on the provision of protected pain modules across all settings ( out patient, in hospital, adult, paediatric) . Allow pain trainers to prepare for trainees by early publication and dissemination of annual  training module allocations. Encourage trainees to consider higher training and outline further training opportunities in  and out of region.

Teaching – local, regional and study leave

CT:  informal in-theatre teaching excellent.

Primary FRCA  teaching good with protected time. No significant problems getting S/L

ST: local informal teaching generally excellent. Final FRCA teaching has recently been modified and is good. No local teaching for post fellowship trainees. No cardiac anaesthesia teaching programme

Post fellowship study days are difficult to get study leave for and are generally poor. Post fellowship study days also occur rarely, maybe only one last year. The ST’s feel that once the final FRCA is passed (maybe as early as ST3), there is no formal clinical teaching given and this is greatly missed. The ST trainees attend the M&M department meeting but are not invited to attend any divisional meetings or other management meetings, which is a great shame as senior trainees are missing out on valuable experience opportunities. Trainees unable to attend department monthly CME meetings.
The trainees should have trainee led journal club meetings but arranging these and their quality depends on the trainees. They often do not happen. Some protected teaching time in ICM but not anaesthesia.
Study leave easy to get if book well in advance.

ITU: Regular departmental weekly ½ day bleep free teaching programme. no ICM exam centred revision course. A regular regional ICM teaching programme needs to develop as trainee numbers expand. Basic ITU course run 2x/ yr.

Pain : no formal educational sessions at ST;  Primary FRCA pain syllabus teaching for CT

Department / Programme / Specialty

Area of development


Post FRCA teaching programmes and opportunities

Encourage Trainees to attend divisional and monthly CME meetings

Work towards a structured regional ICM teaching programme

Bullying and harassment

CT’s none experienced

ST’s none experienced.

Department / Programme / Specialty

Area of development


Trainees referred to some consultants they try to avoid. Feedback to trainers may have improved this.

Additional comments / feedback

Trainees would recommend this training programme to others except those wishing to specialise in paediatric or neuro-anaesthesia

No College Tutor slot in the divisional meeting agenda.

No formal trainee meetings.

No trainee representative at divisional meeting

Development of a school diary on the website would be helpful

School support for fellowship development eg. neuro and vascular.

Departmental Induction for trust fellows was not good.

Supervisors from PHNT should be given priority on the training courses held in Plymouth to improve attendance and reduce travel times.

The Department has a considerable additional workload from paramedic, medical student, Antarctic survey training

No lists badged as ‘ for training’, where time pressures would be reduced.

Request for better clarity on the requirements for cardiac training.

Department / Programme / Specialty

Area of development


College tutor/ ‘Education’ standing agenda item in divisional meeting would support better communication and feedback of training and trainee issues

Department to consider reducing additional training responsibilities

Consider labelling some lists as ‘for training’

Trainee meetings: Formal and/or social to discuss training issues and maintain morale




Visit Panel Chair Declaration

This completed report is a true and accurate account of the discussion that I participated in or that were reported to me from this visit.

The key recommendations identified within this report have been identified with good faith.

I can confirm that any areas of significant concern that have a direct impact upon patient safety have been brought to the attention of the relevant Director of Medical Education (or equivalent), responsible Medical Director and Executive Lead for Quality at Health Education South West Peninsula Postgraduate Medical Education.

Chair name:


Dr James Pittman

Chair educational role:


Head of School for Anaesthesia  & ICM

Date of signature:


19th September 2014