Trainee and Freedom to Speak Up Guardian case study

A first year GP specialty trainee was rotating through a training post at a mental health trust in England. They spoke up to their trust Freedom to Speak Up Guardian (FTSUG) about the lack of support available to a colleague working on a night shift.

The FTSUG raised the concern by emailing the medical director and executive director of nursing on behalf of the trainee; and continued to pursue the concern until it was appropriately acknowledged and responded to.

The learning from this incident, including how it was initially handled, resulted in changes being made at a departmental level. The learning was subsequently shared with the trust board in the form of a case study presented by the FTSUG.

Read on to hear perspectives from the trainee and FTSUG.



On a busy night shift at the mental health trust where I was working, two of the nursing team reported sick, and the agency staff failed to turn up. This meant that as doctors in training we had to take on duties of the mental health liaison nurse and site nurse manager, on top of seeing patients. We were completely overburdened - the situation was dangerous for patients and impacting on our wellbeing and ability to do the jobs we were training for.

On this particular night, my colleague tried to raise concerns to the on-call consultant, but no support was given and no further action was taken. I decided to approach our FTSUG to share my worries about what had happened.

Action taken


The doctor came to me to share concerns about their colleague's recent experience and the wider patient safety issues. Although the doctor was happy to be identified as the origin of the concern, we agreed that it was not necessary in the first instance, and that I would contact the medical director (MD) and the executive director (ED) of nursing to give them an account of what had happened and the concerns this raised.

The ED for nursing asked a senior manager to provide a briefing paper about staffing levels and to triangulate with incident reporting. The MD initially perceived the concerns as relating to a nurse staffing issue only and didn't take any further action at this stage


I was unhappy with the lack of response and felt that the MD was not acknowledging that the problems raised were more than just a nursing issue. Inappropriate levels of responsibility were being thrust upon doctors in training, and we were being left to work in isolation with no support from the medical leadership.

I decided to put my concerns in writing, quoting directly from the Francis report in an effort to draw attention to the wider issues at play. This was then circulated to the MD and the ED of nursing by the FTSUG.



As a result, new measures were put in place to make sure that all staff in the team were clear about the escalation process should there be a staffing issue going forward. There has been an ongoing piece of work on safe staffing levels including consideration of a staffing tool to help.


The MD agreed to meet with me to discuss the issues further, though I decided against this as I felt that I had said what needed to be said and the concerns were finally being addressed.

I have since moved on to a new training post. Although it may have been easier to stay quiet in the first place, I felt it was important to speak up so that incoming and future trainees and patients were protected from similar situations.



I have used this example as a case study within the quarterly FTSU board report because I believe it demonstrates the value of the FTSU process. In this case, although there had been a response to a specific incident, it took our joint challenge to bring out the wider organisational issues of management, recruitment and treatment of doctors in training.

Following this experience I have now established standards for managers' response. They are required to complete a template to detail what action they will take, what feedback will be given to the person speaking up and lessons learnt.


I believe that it's important to speak to those who work independently of the organisation, such as an FTSUG, when patient safety concerns are not being addressed and it doesn't seem right to you. Unfortunately, sometimes it's necessary to step outside of the organisational hierarchy, and to keep up the challenge, in order to get heard.

My advice to others would be:

  • Make sure you document concerns in real-time with dates, times and names.
  • Discuss your concerns with peers where you can, especially if it seems to be a matter that is likely to affect them too.
  • Finally, don't be afraid to challenge the perceptions of those in senior positions if your concerns are well founded.

Doctors in training are the eyes and ears of the NHS, as highlighted in the Francis report, and they should be supported to raise concerns without fear.