REFLECTIONS on PORTSMOUTH
In order to clarify my reflections I need to provide a brief summary of my former training etc. as this did significantly have influence on my subsequent consultant role.
- I initially started my training as a surgeon in Bristol, but there was a really unpleasant dispute between the SR and the consultant that I was training with, which resulted in it being very difficult for me. I passed my surgical primary, but the most positive thing at the time was that the best individual who had participated in the training was Professor Cedric Prys-Roberts, and I ended up having a discussion with him about the potential option of anaesthetics instead. His recommendation was that in order to get the best experience I should go for a year in a DGH, and as a result I ended up doing so in Gloucester.
- When starting there I was initially given the first month in their intensive care unit and I found it very interesting. I was also helped several times by the current physician registrar who had already trained in anaesthesia - Gary Smith. I then went on to having a full 3 weeks of anaesthetic training before being on-call etc. and over the rest of the year all went well.
- I moved on to Cheltenham as locum registrar, then on to Southampton, where things initially didn't go well as I failed on my first anaesthetic primary. I was however well supported by the then current SR responsible for training areas (Derek Pounder), and passed the primary the next time. I was then told that I could possibly apply for a registrar role there, but that I would not be appointed!
- So I moved on to Cambridge, and although I had only passed the primary a few months before I was recommended to go for the final, which I passed first time. The really unpredicted positive result of this was that Brisbane, Australia had wished to arrange a registrar swap in order for them to have experience of liver transplant surgery. As none of the other registrars had passed the final I was given the offer of doing this. I ended up spending over a year in Brisbane, which was great experience, particularly as I was then given the opportunity of spending several months in Longreach with the
Flying Surgeon Service.
- As I had had little training in paediatrics I was given the option of spending a month in Melbourne, where the training was really excellent. I did however then learn that their paediatric ICU was exceptional and resulted in my thought that it could be of significant benefit to return there later if possible.
- Having moved back to the UK I applied for the SR role in the SW, and was appointed to Exeter / Bristol and Bath.
My main negative learning point from all of the areas that I worked in the UK (Gloucester, Cheltenham, Southampton, Cambridge, Newmarket, Exeter and Bristol) was that care for seriously ill children was never really adequate compared with my Australian experience. Having decided that I wished to specialise in intensive care in a DGH, and had learned that there was not an option in the UK for training in paediatric intensive care unless the aim was to be a paediatric intensive care specialist, I made the application to Melbourne PICU in order to be able to have the essential core skills for the care of sick children.
- The two of us who arrived there at the same time (the other UK colleague Charlie Ralston ended up as Medical Director of the Birmingham Children's Hospital) found it initially very challenging, but the training was excellent, and having spent the full year there we both ended up with really good experience.
- While working in Melbourne I received a message from Gary Smith suggesting that I should apply for a consultant role in Portsmouth. I agreed to do this, and had to travel back to the UK for the interview. On the Thursday I met up with Guy Turner and he told me that if I was interested in intensive care I would probably get the job, as he was definitely not. Guy was appointed in Chichester and became the St Richard's Medical Director.
- Having therefore been appointed, I then had to fly back to Melbourne on the next day, as I was on call for the PICU that weekend, I had a very busy time on call, but on the Monday I had the final examination for the Faculty of Intensive Care Medicine (FICM) “ and not surprisingly, as I was almost asleep, I didn't pass it that day!
- I therefore had to arrange for a further post in Australia as the FICM exams were only every 6 months. At the end of my PICU time I was therefore appointed as a locum consultant in ICU in the Princess Alexandra Hospital, Brisbane - and thankfully with excellent further training I then passed the exam, and thus became a Fellow of the A&NZ FICM and the A&NZ CoA.
When I came as a consultant
- I returned to the UK in June 1990, and took on my PHT consultant post.
- I was effectively put into the role as the ICU consultant at St Mary's, as a small unit had just been created at that hospital in a portacabin.
- There were only 3 ICU beds, which were pretty much full all the time. The most unpredicted issue for me was that I was working literally right next to the paediatric wards, and learned then that St Mary's was actually the second largest paediatric inpatient area in the UK.
- What was also surprising and completely unknown previously was that there were no paediatric intensive care units south of Great Ormond Street (GOS) in London.
- In the first few weeks several sceptical consultants at St Mary's had said to me "we don't need an ICU in this hospital", and what was the really most surprising was that one of the then most senior paediatricians told me that "children do not need intensive care". Fortunately his younger colleagues did not agree with him!
- Within a short time of this comment I was asked to provide advice for a 2 year old child with meningitis, and I explained that as she was virtually unconscious and significantly hypotensive she had to be transferred to our unit. She had to be intubated and ventilated, required significant fluid, inotropes and vasopressors, but then made a full recovery.
- Very unfortunately though, the next child that I was called to had just been left on the ward for several days despite continuing deterioration, and died just as I arrived. I therefore strongly stated that any seriously ill or deteriorating child should be always referred to us for assessment, and as consequence the numbers or referrals and child admissions to both ICUs (because of limited bed space in St Mary's) started to escalate significantly.
- The only full-time trainee working with me at St Mary's was usually just an SHO, I had to spend very long times on the unit ensuring the patients were treated appropriately.
- In the first year I also had a responsibility for ventilated patients who had been transferred to the renal unit at St Mary's. Although one of their consultants had had good training in intensive care, he could not be there very often as he had to work in several different places, and as result these high risk renal failure patients ended up being looked after by relatively inexperienced trainees. Having worked on this for several months, and noted that the death rates were high we did a summary of such cases over the recent years, and found that the death rate was almost 90%. We therefore strongly campaigned that all ventilated patients should be cared for in ICU, and although this resulted in a fall-out with some of the renal consultants, this was eventually achieved. Over time the majority of them did then agree that it was the correct decision.
- Fortunately a new unit was created in 1991 and when it was formally opened it was attended by the then Prime Minister John Major. It had 4 beds.
- In addition to this I worked with Gary Smith to provide a full back up time both of the units, as in the early years we also had some other anaesthesia colleagues who were prepared to cover the on-call, but they often didn't have the full understanding of the details of care that could be required.
- For all paediatric cases we both had to completely involved, and this resulted in us often spending whole days and nights in the 2 hospitals for several years.
- We also effectively became the regional paediatric intensive care service for the area, and as consequence Gary and I ended up being referred sick children from St Richards, Isle of Wight, Haslar, Chichester, and even Dorchester. We did all the required retrievals, and if any of the children had to go to GOS or elsewhere we also did these transfers, and as a result whichever of us was not "on call" had to become so to provide back-cover.
- Pete McQuillan joined us as an SR, having previously passed his A&NZ FICM before I did! He worked really well with me at St Mary's and having applied and been appointed for a consultant post he decided that he needed further training in paediatric intensive care. So he went to Melbourne for this, and Gary and I covered him for a full year - for nothing!
- Unfortunately Gary Smith (who I had first met in Gloucester where he was incredibly fit and one of the best at playing football) ended up with significant health problems and was off on sick leave several times, the result of which was that I ended up covering both ICUs for weeks at a time.
Significant remembered cases over the first few years
- In addition to doing the ICU work, I was also doing my required anaesthetic lists at St Mary's. These were general surgical cases, gynaecology, and urology.
- The urology cases were mainly paediatrics, and although I had not regarded myself as a paediatric anaesthetist, having done the PICU training I was quite happy doing this. Over the subsequent years I resulted in taking on many paediatric lists, and helping colleagues with any difficult child cases.
- As I was often in the hospital until late at night I also provided anaesthesia for quite a number of urgent obstetric cases, which I did actually enjoy as obstetrics was my other preferred area for being involved in.
- Unfortunately an anaesthetic decision was made in the early 90s that nobody could be allowed to have a second speciality if they had already gone for their first one. Not surprisingly I gradually ended up moving away from being able to provide obstetric cover.
- Working in gynaecology and urology was fine, as they were good surgeons and nice people.
- It was very hard with the general surgeon (PW! Do you want the name included?). Although he was a reasonably good surgeon he seemed to hate all anaesthetists, and blamed us for any patient complications.
- One particularly bad day we were doing a complicated case on a patient - which required an additional bit of work done by another surgeon. When the second surgeon had finished I then learned that the surgeon had gone to QA without even having told me, and I ended up waiting for more than 2 hours with the patient asleep, with an open neck, and chest, and no surgeons around. Not surprisingly we ended up with a fall out on this.
- One day he mentioned to the theatre staff that there was a patient on the surgical ward who was not responding, but no investigation had been initiated. I decided to check out the patient, who was 18 and was deeply unconscious - so I arranged for his intubation / ventilation and transfer to ICU and on further testing confirmed that he had significant liver dysfunction. We ended up transferring him to Kings in London, where he thankfully recovered completely, and when came back to St Mary's he explained that he had only taken a few extra doses of paracetamol because of a flu-like illness.
- We also had a tragic case when or our trainees had been called to re-site a naso-gastric feeding tube on the ward after a patient had been discharged from the unit following surgery. Unfortunately the tube had been misplaced into the lung, and the patient ended up with severe respiratory failure and died. We were obviously blamed for this, and ended up with a formal assessment by the coroner. In post-mortem however it was discovered that the patient's death had actually been caused by MRSA infection and not by the tracheal tube.
- A two year old was referred to us as an emergency with breathing problems, and I had to rush in to St Mary's. Before my arrival the child had gone into cardiac arrest, but fortunately the SHO had provided CPR and intubated him. He was subsequently stabilised and it was decided that he needed a tonsillectomy. Anne Davies was happy to do it, but he had been referred to GOS by the paediatrician so I did the transfer. After this was done he was further investigated and was found to have Pompe's syndrome. He has been regularly addressed and treated, and his parents have remained often in touch with me, as his father (Allan Muir) had become the Chair of the International Pompe Association (IPA) and I have been invited to provide advice / assistance on several other similar patients since. The boy is now in his early 20s and is apparently going well.
- A baby girl was referred on the ward with deteriorating cerebral status and no confirmed diagnosis. My assessment was liver dysfunction, and I asked the parents if she might have taken paracetamol. Their answer was "no", but then the grandparent said "what about a few days ago when you had found her eating a lot of those pills found on the floor?". It was then confirmed that she had taken a lot of paracetamol, and had developed severe liver failure. As the only then option for paediatric liver transplant was in Cambridge I contacted them and it was agreed that she should be transferred there - so I did this by helicopter transfer. Having arrived at the Cambridge paediatric ward fully ventilated late at night I was met by the then registrar (who is now one of our best paediatric consultants), who explained that she would be seen by the consultant the next morning - but the child died before he arrived.
- A 55 year old male with severe pancreatitis went through a pancreatectomy and ended up in St Mary's and QAH units for 6 months. When he eventually completely recovered, and had his tracheostomy removed, for the first time I learned when he talked that he was Scottish!
- In Christmas week 1995 a 5 year old girl was admitted with severe meningitis, and required full ventilation, a PA catheter, inotropes and vasopressors etc. and was in a very severe condition for a full week. She started to recover, but her legs had become ischaemic and she ended up having both lower legs having to be removed. She was very strongly supported by the media and Sir Cliff Richard in her subsequent years. She is now working at QA.
A woman who was the child-minder for Virginia Bottomley, the Secretary of State for Health, was admitted to intensive care in serious illness. The following day I found Mrs Bottomley sitting on a chair in the corridor waiting to visit her. Unfortunately she did not survive, but Mrs Bottomley (now Baroness Bottomley) was obviously very grateful for the care provided.
A family driving home from Southampton with a boy and a girl on the back seat, were crashed head-on by a lorry which crossed the centre of the M27. Both parents were killed, and the son ended up with his father's head on his lap. They were both admitted to A&E, and the young girl was bleeding significantly. She was rushed to theatre, but the then consultant anaesthetist could not stabilise her for surgery, and so the then registrar Pete McQuillan rushed in and did so. The on-call surgeon (a very senior renal consultant surgeon) apparently said "I don't do children", but fortunately Magnus McLaren quickly took on the case and managed to sort out her major hepatic bleeding problem. She and her brother both fully recovered (he had multiple leg and arm fractures) and they then ended up having to live with their grandparents for the following years. She is now a police officer.
A former colleague, Barbara Green, who had worked with us in intensive care when I joined was learned to have had a cerebral problem in and had required neuro-surgery and admission to the ICU. We tried to arrange for her to be returned to the UK, but were told that this couldn't happen until she had recovered. About 2 weeks later we were told that she could be returned, so I arranged to do this with Cega. When we arrived there I was amazed to then find that the unit that she had been cared in was really excellent, and I also learned that she had required further brain surgery because of continued bleeding. The transfer to our unit went fine, and she made a pretty good recovery. It did seem pretty clear to us though that if she had developed the problem in the UK she would almost certainly not have been accepted to the Southampton neuro unit, and she certainly wouldn't have gone through the very detailed care which made her survival.
In 1997 I received a phone call from St Richard's, Chichester, and was asked if I might be able to help with a 3 year old girl. I asked whether this was urgent, or if I could wait for the ambulance, and was then told that she was having CPR! I therefore called an assistant nurse, took all the necessary equipment, and drove rapidly by car to St Richards. The child had been admitted with a potential diagnosis of a chest infection, but had developed severe ischaemia and had been intubated / ventilated, but progressed to severe bradycardia. On quick assessment it was clear that she had severe pulmonary oedema, and that the in-situ tube was not enabling adequate ventilation, with a pulse rate of about 30/min. I therefore went for re-intubation with a larger tube, but when I removed the initial one the massive fluid reflux was significant, with the mouth completely filled. Fortunately I managed to drain it and re-intubate, and within a few minutes the pulse rate came up to normal - although the sats were still only about 86%. I also then learned that she had been given about 4 doses of full atropine because of the bradycardia.
Having stabilised her we returned to QA (my car driven back by one of the ambulance men), and over the next few hours I tried all potential methods to try to improve her condition (high PEEP, nitric oxide etc.) but it had become clear that her diagnosis was a viral myocarditis, and she remained on 100% oxygen. Having done many ECMO cases in Melbourne I decided that we should try to arrange this with GOS, but explained to her mother that she may still not survive if she had already got cerebral problems. However, when I mentioned her name (Lauren) she opened her eyes, and so I strongly felt that ECMO was appropriate. This was arranged, but GOS then sent a trainee to receive her, and I wasn't happy with this, so went with her to London. On arrival there was obviously some scepticism about the adequacy of care, and she was put onto a high-frequency oscillator, but became significantly more hypoxic again. So ECMO was agreed.
She was on ECMO for 14 days, recovered, and eventually returned to our unit doing really well. She is now just over 18 and is having a good life.
A 15 year old girl had a fall out with her family and ended up with a kick, which caused a spleen injury. She arrived at A&E, had a PEA arrest and had CPR before then being rushed to theatre. Having had the splenectomy she was admitted to ICU, but continued to bleed significantly, and ended up having to go back to theatre several times. About the 5th time the then surgeon said "no, I don't think it's worth doing'", and following an argument he said "OK, I will do the operation if you are prepared to be responsible for the decision". It was done, but she continued bleeding, and fortunately the then experienced surgical registrar (who is now a consultant in Salisbury) agreed that he would continue any further procedures. She ended up requiring a total of 15 laparotomies, and had 57 units of blood and 24 FFP, but moved on to full recovery and is now in her early 30s - and is a very good friend.
A child with Down syndrome was referred from St Richards to Gerry Madden for assessment. He was checked under anaesthesia, and there it was agreed that the airway was OK, although intubation had been difficult (I was doing the list, and was joined by ... but neither of us managed to intubate) so we just stayed with an LMA until Gerry did his assessment having pre-oxygenated to provide him with required short time. Having been returned to St Richards he was then referred to GOH for the same assessment, and rather strangely because they had difficulty with intubation the mother was called and told that a tracheostomy had to be done urgently. The child was then returned to St Richards, and a few days later was found to have arrested as the tracheostomy had blocked. Pete McQuillan was called to the rescue, and the child was transferred to our ICU, but didn't recover because of severe brain ischaemia. Having discussed this tragic problem with the parents I ended up taking the child to them let her pass away at home. The learning point was that no children with a tracheostomy should be transferred to a hospital that doesn't have experience of the detailed care required.
A 5 year old boy was rushed to St Mary's hospital having arrested in a dental procedure. He had been anaesthetised by a GP, and within a few minutes of the intubation became significantly hypoxaemic and then arrested. The called emergency ambulance had an A&E trainee registrar on board, and when he arrived he was surprised that there was no CPR taking place, so he did this. When the child arrived at St Mary's the on-call paediatric consultant noted that the lungs were not moving, so she removed the tube and re-intubated, and within a few minutes the CPR resulted in normal heart rate and BP - so it seemed pretty clear that the initial intubation had failed. The child was then transferred to QA, but unfortunately had suffered severe brain ischaemia and ended up dying. After further assessment of the Poggo dental service provided it was learned that many similar deaths had occurred around the UK, and as a result Gary Smith and I highlighted this to the Dept of Health. This resulted in a formal group being created, and an agreed decision that no patients should be anaesthetised for dental procedures unless they were in an officially approved hospital area that was supported by experienced anaesthetists. This resulted in the creation of our local Poswillo unit.
A child admitted to the unit having drowned had severe brain injury and ended up being confirmed as dying by brain stem death. The parents were obviously devastated, but confirmed that they did wish to go for organ donation. So we contacted the organ donation service, but were then told that there were none who required it in any countries!
A patient was referred to QA from Gosport having had a surgical procedure but then developed abdominal bleeding problems, and they had not been fixed. Following the transfer one of our surgeons sorted this out, but as she was in renal failure and had respiratory problems she was in the unit for several days. She made a good recovery, and as she would then have to be transferred to the renal unit which was still at St Mary's, she was kept with us for a further 2 days after having been weaned and extubated etc. She was doing well, sitting out of bed, was able to eat and drink, and talk to her family. So on the Friday the transfer to St Mary's was arranged, and she had also been formally assessed before this by one of the renal physicians. The ambulance service was delayed however, and the transfer didn't occur until the evening.
Very unfortunately, and without ever a confirmed diagnosis, having been admitted to her renal ward bed in the early morning she developed a cardiac arrest and required CPR. The resulted in her being re-transferred back to ICU, and very sadly although she recovered she had significant ischaemic brain injury.
She did eventually manage to go home, but obviously with serious disability. Several years later a legal process had been developed, and I was accused of having made the wrong decision for her transfer to the renal unit. This resulted in me having to solicitors in London, and it was then discovered that there was an individual from Nottingham who was supporting their claim. We then learned that although he was a Professor, he had had no training or experience in intensive care. Having therefore raised this as a concern a different assessor (Bob Winter, ICS President) took this on, and having been provided with all of the documents which confirmed her condition (by the ICU doctors notes, the nursing notes, and the renal consultant assessment) the claim was dropped. It still did continue for Haslar hospital though, and as there seemed to have been surgical errors it did prove successful on this.
A 5 year old daughter was sitting on the back of her father's car in a field with a behind trailer and going to pick up a horse. She fell off the car and was run over by the wheel of the 1 ton trailer. She was rushed to the A&E Dept, and we had been prepared in advance of her arrival by the trauma call system. She had major abdominal distension, and a low blood pressure, and although she just managed to speak to her mother she couldn't see anything presumably because of the major blood loss. I managed to insert 2 cannulae, initiated O-negative blood transfusion and rushed her to theatre. The on-call surgeon Miss Walter started the laparotomy and found that the liver and the IVC were completely ruptured, but managed to repair them. With the insertion of a central line, adrenaline, major blood transfusions and RFVII haemostasis was obtained and maintained and she temporarily stabilised, but then moved onto a cardiac arrest. I immediately asked Miss Walter to open the diaphragm and provide manual cardiac squeezing, which went well and her condition recovered. The bleeding cause was sorted, and for the next several hours she was carefully monitored while waiting for the arrival of the PICU retrieval team.
What then was very unfortunate was that the PICU team seemingly didn't seem to realise just how very severe her condition was, as she was disconnected from our monitoring, transferred to the retrieval bed connected to the mobile ventilator, and then re-connected to their monitors, by which time she had developed a cardiac arrest and died. It seems almost possible if she had just been transferred to our unit she may have survived - but perhaps not.
A 12 yr old with very significant hydrocephalus from birth, and severely disabled functioning brain, was admitted for an elective tonsillectomy in 1999, and ended up being referred and admitted to QA ICU because of breathing problems. After 2 weeks of ventilation, it was eventually managed to restore self-ventilation, but the consensus of all involved was that it would not seem reasonable to repeat this if his condition continued to deteriorate. This was formally explained and agreed with his parents by Gary Smith and the Chief Exec. He was transferred to the paediatric ward at St Mary's, discharged home 2 days later, but was then re-admitted within a few days with further deterioration. As the decision had been agreed that there should be no further ICU referral, the paediatricians appropriately explained that they would just ensure that he remained comfortable, but that he may pass away. The result of this was that the family actually ended up fighting with and punching many of the paediatric team, and pulled their boy out of the hospital.
Over the next few months and years there were multiple inappropriate media publications and legal claims made on the grounds that no appropriate care had been provided, with no mention anywhere of the fact that he had been admitted for a full 2 weeks in intensive care and that there had been a formal agreement that he would not benefit from this again â€“ and because of 'confidentiality' we were not allowed to provide any of this very relevant information, despite having explained this to the GMC. Not surprisingly the boy did pass away a few years later.
When the PICU was created in Southampton they had difficulties with having only initially 4 consultants and Pete McQuillan and I ended up helping them quite often. One of their consultants ended up dying while on call, and the stress of this resulted in us having to cover them for over a week.
We were therefore both appointed as Honorary Consultants for the Southampton PICU.
Additional learning points
- Having developed a reputation for our paediatric care I was invited to become the general ICU representative on the National Coordinating Group for Paediatric Intensive Care. I fully supported this process, despite the fact that the creation of a regional service would result in it being in Southampton. I campaigned however that general ICUs must continue to be able to provide care for sick children, but this was effectively ignored, as the majority of those involved were just interested in their own PICUs becoming regional centres.
Despite having written several letters etc. to the DH chair there was no response, and after the formal process had been confirmed we then found that a decision had been made to come and assess the Portsmouth service. In order to confirm our service I arranged for several of the children and parents we had cared for to attend those doing the assessment. I subsequently learned that the initial target had been to formally discontinue our paediatric service, but the quality shown and supported by the related families actually resulted in the DH individuals having to change their plan!
In 2009 I was invited to then join the Standards Committee of the PICS, and then subsequent formal guidance created by the then President of the PICS (Ian Jenkins) has confirmed that general ICUs must have core paediatric skills, having proved in the South West surveys that only children who will benefit from a PICU admission need to be transferred. This has also been agreed by the IBTICM and the new Faculty of ICM.
- Pete McQuillan, Gary Smith and I did a lot of surveys of our paediatric cases, and tried to submit the related information as formal publications, but all specialist assessors (i.e. paediatric intensive care consultants) always declined these applications, as they were not prepared to accept that DGHs could provide paediatric intensive care. It was very disappointing that these excellent documents were not published, as our survival rates for children with meningitis were better that any other formal publication!
- One of the issues that Gary Smith and I decided was that as some anaesthetic trainees really didn't want to spend time in intensive care it would seem sensible to offer trainee posts to those from other specialities. This initially worked well locally, but after several years the system was changed and resulted in us then having trainees from other specialties having to join us when they had no interest in intensive care. Fortunately over time this has resolved into a good system, rather similar to the A&NZ one, and as a consequence we now have the benefits of having several consultants from other specialties who have also had formal training in anaesthesia and intensive care.
- I was encouraged to join the Advanced Paediatric Life Support (APLS) process, and ended up chairing this service for many years, with many related links to other hospitals in other places in England. The APLS course was considered very good by many, but for a few the process was regarded as difficult and some individuals failed despite having well-established paediatric experience. It was also really only applicable to experienced doctors and nurses, and therefore had no benefit to normal individuals.
For this reason I made a decision to create a less complex but more useful course called the PEARS (Paediatric Emergency And Resuscitation Course - i.e. Pears instead of Apls!), the target of which was not to have to pass an exam, but simply for all who participated to have an improvement in their core skills. It went very well for many years, and went through several updates in the 2000s - but unfortunately has now been dropped by the Resuscitation Group who didn't even talk to me about this. The worrying result of this will be that many will no longer manage to maintain or update their core paediatric skills.
- The reputation of the PEARS course was such that John Burden suggested to me that we should modify it to provide essential skills for all surgeons, and thus created the SPEARS course (Surgical Paediatric Emergency And Resuscitation), which was attended and formally supported by the Royal College of Surgeons of England. Thankfully this is still being continued, with highly positive feedback.
- Member of South & West Region Working Party on Paediatric Intensive Care 1995
- Member of South & West Paediatric Intensive Care Audit Working Party 1995-1996
- Member of South & West Region Paediatric Intensive Care Professional Advisory Group 1997-1998
- Member Regional Paediatric Intensive Care Long-term Strategy Group 1997-present
- Member of Regional Paediatric Intensive Care Clinical Forum 1997-present
- Member of Independent Review Panel, Bristol Royal Infirmary 1997.
- Independent Assessor Complaints Process for Southampton General Hospital
- Member of Dept of Health (DH) National Coordinating Group for Paediatric Intensive Care 1996-2000
- Examiner for the Royal College of Surgeons 1997 - 2002
- Member of DH National Steering Group for PIC (2000-2003)
- Member of DH Specialist Advisory Group on Sedation and General Anaesthesia in Dental Practice 1999-2000
- Member of DoH Hyperbaric Oxygen Therapy Advisory Group (2001-2)
- Critical Care adviser to Meningitis Research Foundation (recommendations published 2003)
- Intensive Care Society
- Member of Council, 2003 - 2012
- Editor, Journal of the Intensive Care Society 2004-2008
- Chair of Standards, Safety & Quality Committee, 2004-2008
- Honorary Secretary of the Intensive Care Society, 2008-2010
- President 2011-12
- Member of the Paediatric Intensive Care Society Standards Update Group 2008-9
- Member Emergency Planning Clinical Leadership Advisory Group 2005-present.
- Chair, Critical Care Contingency Planning Group (CCCP group)
- Chair, DH, Division of Emergency Preparedness / CCCP group Infection Control and Paediatric Subgroups
- Pandemic Influenza Planning Activities for DH (2005-2009)
- Critical care representative / advisor for:
- Healthcare Pandemic Influenza Group
- Pandemic Influenza Scientific Modelling Group
- Pandemic Influenza Surveillance Group
- Pandemic Influenza Secondary Care Planning Group
- Paediatric Intensive Care Standards Revision Group
- House of Lords Scientific Advisory Group Sessions
- H1N1 related activities for DH 2009-2010; member
- Pandemic Influenza Clinical and Organisation Group (PICO)
- Scientific Advisory Group for Emergencies (SAGE)
- Paediatric Critical Care Planning Group
- Influenza Clinical Information Network Group (Flu-CIN)
- Flu-CIN Steering Committee
- Health Protection Agency Teleconferencing (co-chair, contributor and editor of H1N1 Critical Care & Paediatric Critical Care clinical guidance)
- Member, Intercollegiate Board for Training in Intensive Care Medicine (IBTICM)
- Member, Intercollegiate Committee for Training in Paediatric Intensive Care Medicine (ICTPICM)
- Member, Equivalence Committee IBTICM
- General Medical Council - Critical care advisor / contributor to:
- Best Practice Guidance for a Pandemic
- End of Life Care Guidance
- Director, Wessex Advanced Paediatric Life Support Course (until 2007)
- Advanced Paediatric Life Support Instructor (Middlesborough, Plymouth, London and Stoke)
- Trainer, Care of the Critically Ill Surgical Patient, Royal College of Surgeons of England Course
- Designer and Director, Paediatric Emergency and Resuscitation Seminars (PEARS) Courses for Portsmouth Hospitals NHS Trust
- Co-Designer / Director of the Surgical Paediatric Emergency and Resuscitation Seminars (SPEARS) Course
- Co-author ESICM PACT Infection Control Module
- Co-author and editor of HPA H1N1 Critical Care Adult Guidance
- Co-author, HPA H1N1 Paediatric Critical Care Guidance
- Co-author, DH H1N1 secondary care guidance, pregnancy guidance