Guy's and St Thomas' NHS Foundation Trust

Guy's and St Thomas' NHS Foundation Trust is a large provider of acute and specialist services for residents of Lambeth and Southwark, across London, the South East and further afield. The trust operates from two acute sites; Guy's Hospital, St Thomas' Hospital and a range of community locations. The Evelina London Children's Hospital is part of St Thomas' Hospital. The boroughs of Lambeth and Southwark are particularly deprived

The trust has 1,277 beds including 1090 general and acute, 75 maternity and 112 critical care beds. 

There were 182,720 A&E attendances at the trust in 2014/15 and 79,700 inpatient admissions. Of the inpatient admissions, 28,084 were elective and 51,616 were non-elective. In 2014/15 there were 1,187, 182 (total attendances) outpatient appointments.

We carried out an announced inspection between 7 and 10 September 2015. We also undertook unannounced visits on 21st, 22nd, 23rd and 26th September.

This was the first inspection of Guy's and St Thomas' NHS Foundation Trust under the new methodology.  We have rated the trust as good overall with Guy's Hospital, St Thomas' Hospital and community services rated as good. In relation to core services most were rated good with services for children and young people and the Emergency Department at St Thomas' Hospital rated as outstanding. Community services for adults and medical care at Guy's Hospital were rated as requiring improvement.

.Our key findings were as follows:

• During our inspection we found staff to be highly committed to the trust and delivering high quality patient care.  
• We saw staff provided compassionate and patients were positive about the care they received and felt staff treated them with dignity and respect.
• The trust had vacancies across all staff groups, but was recruiting staff and staffing levels were maintained in services through the use of bank and agency staff.
• Staff were aware of how to recognise if a child or adult was being abused and received good support from the trust's safeguarding team. 
• The trust had an incident reporting process and staff were reporting incidents and receiving feedback. More work was needed to complete investigations into serious incidents in a timely manner and share learning across directorates.
• The trust had not fully implemented the five steps to safer surgery.
• We observed effective infection prevention and control practices in the majority of areas we inspected. In some community services it required improvement and space between beds in some of the critical care units was limited.
• Patient care was informed by national guidance and best practice guidelines and staff had access to polices and procedures.  
• Patients had their nutritional needs met and received support with eating and drinking.
• There was good team and multidisciplinary working across all staff groups and with clinical commissioning groups, voluntary organisations and social services to deliver effective patient care.
• Staff had attended training on the Mental Capacity Act 2005, but some staff, in both inpatients and community services, were unsure how to translate the principles into practice.
• Staff understood and responded to the needs of the different population groups the trust served and worked hard to meet the needs of individual patients. 
• Patients were largely treated in timely manner with the trust meeting national access targets. However the trust had not met the 62 day cancer access target since 2013.
• Patient movement through the hospital was well managed with systems to ensure delays in seeing patients in the Emergency Department and when patients were well enough to be discharged were minimised.  The number of cancelled operations was low.
• The trust had a backlog of complaints, some with a significant delayed response times. Action had been taken to reduce the backlog and improve response times and the quality of responses.
• Executive and non executive members of the trust were visible in most areas. Community staff knew who they were but, felt they were less visible with the exception of the Chief Nurse.  
• The trust had a clear vision and strategy which staff were aware of and fully engaged in delivering.
• The trust was committed to public engagement and national and individual service surveys indicated that patients had a positive experience when using the trust. The trust had a good working relationship with the Council of Governors who felt involved and able to fulfil their role.
• Governance was devolved to the services/directorates and although there was oversight at trust level this needed to be strengthened.
• Staff were positive about how their local and senior managers engaged with them. They were supported in their personal development and were empowered and supported to initiate improvements in services.
• The trust was in the process of rolling out the electronic patient record and aligning the IT systems. In some community and acute inpatient services staff were using both handwritten and electronic records.
• The trust was facing financial challenges for the first time along with increasing demands on services. Although some action had been taken robust plans were not in place to address the cost savings that needed to be delivered.    

We saw several areas of outstanding practice including:

trust wide

• The use of 'Barbara's story' to engage with staff and enhance a compassionate approach to patient care.
• The trust wide engagement of staff in a culture of improvement and compassionate care that lead to a proud and empowered workforce.

At St Thomas' Hospital

• The use of 'Barbara's story' to engage with staff and enhance a compassionate approach to patient care.
• The specialist support units active within the urgent and emergency department including alcohol, toxicology, homeless, youth support and play therapy for children.
• The role of the security team in the emergency department was embedded into the day to day working of the department. The team was multi-lingual and trained in effective de-escalation techniques and demonstrated outstanding empathy to patients.
• The provision of 'reflection time' to staff within the urgent and emergency department.
• The approach to communication with and support of dementia and complex needs patients via well designed communication boxes and a specialing team.
• The ward environment and signage afforded dementia patients.
• The Proactive Older Patient service.
• The multidisciplinary team support for families attending the neonatal unit.
• The paediatric cardiology service had introduced a home monitoring programme for infants following single ventricle palliation surgery (Norwood 1 operation or hybrid procedure). This allowed these patients to safely live at home with their families while they recovered and prepared for the second stage of their treatment.
• Supportive practice of the mortuary and bereavement team.
• The SPCT was effective and provided face to face support seven days per week, up to 9pm, with calls taken until 11pm and a consultant providing out of hours cover.
• The AMBER care bundle and a range of training courses for staff in end of life care such as the Sage and Thyme training model, simulation days and Schwartz rounds.
• We saw staff in the bereavement office had sourced funding to provide family members with sympathetically designed cloth bags so they had a more discreet way of taking home personal belongings of a deceased patient, rather than use a plastic hospital property bag.
• Staff in the emergency department had sourced funding and designed and produced a bereavement card that they sent to any families whose relative died in the department.

At Guy's Hospital

• The specialist SPCT was effective and provided face to face support seven days per week, up to 9pm, with calls taken up to 11pm and a consultant providing out of hours cover.
• The Amber care bundle and a range of training courses for staff in end of life care such as the Sage and Thyme training model, Simulation days and Schwartz rounds.
• The Guy’s Orthopaedic Outreach Team (GOOT): a fast track discharge and multi-disciplinary support service which improved patient outcomes and reduced length of stay.
• Proactive Care of Older People Service (POPS): an award-winning service and the first of its kind in the UK. The POPS service looks after patients aged 65 years and above to improve their medical health before and after surgery by assessing them before surgery, following their care while in hospital and supporting consultants and ward staff.
• The use of 'Barbara's story' to engage with staff and enhance a compassionate approach to patient care.
• ​Supportive practice of the mortuary and bereavement team.
• Staff in the bereavement office had sourced funding to provide family members with sympathetically designed cloth bags so they had a more discreet way of taking home personal belongings of a deceased patient, rather than use a plastic hospital property bag.

In Community Services

• The trust very recently introduced a specialist nurse for childhood obesity in Lambeth in response to an identified need.

• The Looked After Children (LAC) nurse specialist introduced an opportunistic immunisations for looked after children, which had improved the uptake of immunisations by 22% in this group of children.

• Community services had a dedicated end of life care (EOLC) team as well as a specialist palliative care team (SPCT).

• In community services patient's families and people close to them were given a leaflet that provided clear information about the dying process to help them understand the signs of an actively dying person, why some interventions such as taking blood pressure were stopped and what to expect in the final stages of death.

• The trust had a diabetes information and education service. Staff provided education to newly diagnosed adult diabetic patients and an open telephone service for staff or patients to access expert advice.

• Patients on the Amputee Rehabilitation Unit had access to acupuncture as part of their pain management plans. Patients were complimentary about this service and felt that their pain was better managed as a result of the acupuncture service.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly the trust must:

At St Thomas' Hospital

• Improve governance links between directorates with surgical activity to ensure learning and concerns are shared across these directorates in a timely way.
• Ensure that all women attending the maternity department receive a venous thromboembolism risk assessment.
• Ensure that appropriate levels of midwifery staffing are available in all areas so that women are cared for in the most appropriate environment.

At Guy's Hospital

• Improve governance links between directorates with surgical activity to ensure learning and concerns are shared across these directorates in a timely way.   

In addition the trust should

At trust level

• Continue to improve governance and assurance systems and reduce the backlog of complaints and investigations into serious incidents.
• Continue to work implement the electronic paper record and align IT systems across the services
• Continue to ensure staff attend all mandatory training

At St Thomas' Hospital

• Review barrier nursing arrangements within HDU and ensure the environment meets infection prevention and control guidance.
• Ensure that the full 'five steps to safer surgery' are embedded in operating theatre practice.
• Continue reviewing and improving cancer performance.
• Ensure consent is clearly documented and patients are given documentation of the process. Implement the recommendations from the consent audit 2014.
• Ensure all complaints are responded to in a timely manner.
• Where appropriate utilise day surgery more to reduce the length of stay.
• Address areas of the national fracture neck of femur audit where the trust is performing below the national average.
• Ensure that staff are familiar with the mental capacity assessment process and that this is followed where appropriate.
• Ensure all staff are aware of safeguarding principles and triggers for making a referral
• Continue to increase consultant cover in maternity services
• Ensure that telephone advice given to women in maternity services is documented
• Ensure there is a system in place to check that HSA4 notifications of termination of pregnancy for fetal abnormalities are submitted to the Department of Health.
• Consider reviewing the tools staff use to assess pain and introduce a standard methodology that is consistently used and recorded.
• Consider reviewing the process for completing DNACPR form, determine a specific location where they are kept and ensure staff are aware they can be used as an interim measure on discharge until the primary care team can complete a new one.
• Consider reviewing the escalation process when delays occur with the completion of death certificates.
• Ensure all incidents in the outpatients department are investigated promptly and outcomes of the investigations recorded and shared with team to prevent recurrence.
• In the outpatients and clinical imaging departments ensure all staff are appraised regularly as prescribed by trust’s policies related to staff training and development
• Ensure staff are aware how to arrange for an interpreter.
• ​Ensure that consultants review the results of local audits and implement strategies to ensure results continue to improve towards meeting CEM guidelines.

At Guy's Hospital

• Take steps to increase the number of day surgery cases to reduce bed demand and reduce length of stay. The trust should consider introducing a named day surgery clinical lead to improve coordination of day surgery and provide a single contact for surgical directorates.
• Take steps to improve the working culture within theatres to ensure that all theatre staff have fair access to learning and development opportunities.
• Continue embedding and monitoring use of the ‘five steps to safer surgery’ WHO surgical safety checklist, with a particular focus on pre-briefing and de-briefing.
• Ensure consent for surgery is clearly documented in patient records and patients are given adequate time and documentation to make decisions about their care in advance of their planned procedure date.
• Improve engagement with lifestyles teams in tertiary, secondary and primary care to help surgery patients with smoking cessation, weight loss or exercise programmes to improve local health outcomes.
• Review the process for completing DNACPR forms and determine a specific location where they are kept for end of life care patients .
• Improve the consistency of mental capacity assessments and the recording of them for patients receiving end of life care.
• Review the escalation process when delays occur with the completion of death certificates.
• Reduce delays in 31/62 days cancer waits (diagnosis and treatment) in Outpatients.
• In the outpatients department, ensure all staff are aware of protocols related to obtaining patients’ consent; including protocols for those who might lack capacity to make a decision”.
• Ensure all incidents in the outpatients department are investigated promptly and outcomes of the investigations recorded and shared with team to prevent recurrence.
• In the outpatients department, ensure all staff receive mandatory training and are appraised regularly as prescribed by trust’s policies related to staff training and development.
• On Samaritan Ward, review the provision of toilet facilities for patients.
• Improve mandatory training completion by staff on the medical wards/departments.
• Improve performance on the number of patients starting treatment within 62 days for upper and lower gastro-intestinal illnesses.
• Ensure all staff, including staff working in outpatients departments, are provided with basic life support training.

In community services

• Improve the amount of 'patient facing time' in the health visiting service.
• Ensure the waiting area at Mawbey Brough provides an appropriate environment for children and families.
• Review the use of wooden baby changing tables to promote improved infection control.
• Review the school nursing provision to ensure the full core service can be delivered to schools.
• Ensure that interpretation services are offered to people for whom English is not their first language.
• Take action to reduce the rate of patients who ‘did not attend’ appointments (DNA) among children’s community services.
• Take action to improve the rate of first and second child health reviews.
• mustEnsure that consent for care and treatment is obtained in line with national guidance.
• When patients (aged 16 and over) are unable to give consent because they lack the capacity to do so, the trust should ensure staff must act in accordance with the Mental Capacity Act 2005
• Ensure that all staff undertake training in safeguarding children at the level relevant to their role.
• Ensure that there are systems in place to identify the cleanliness of equipment.
• Ensure that the environment at Dulwich Hospital is suitable for purpose.
• Review the paper and electronic records to ensure that the recordings are complete, accurate and do not contain variances and discrepancies.
• Consider training nurses in the palliative and end of life care to verify death. This would be beneficial to the bereaved as someone closely involved in their relative/friend's death would officially verify death in a timely and sensitive manner and allow the release of the patient's body to an undertakers within an appropriate timescale.
• The trust should ensure that all staff have a clear understanding of Deprivation of Liberty Safeguards (DoLS); that mental capacity is always appropriately assessed and recorded for patients who may lack capacity; and all staff know who can consent on the patient’s behalf and how this information should be recorded in patients’ records.
• Consider training the CNS and EOLC nurses to be independent prescribers and allow the nurses who are trained as independent prescribers to use the skills they have.
• Explore ways to allow patients, who are assessed as able, to self-medicate at Pulross Intermediate Care Centre.
• Ensure patients at Minnie Kidd House have access to specialist seating assessment.
• Ensure that all staff are up to date with their mandatory training.
• Standardise record keeping so that staff can have access to the full multidisciplinary team  documentation in chronological order.
• The trust should ensure that robust arrangements are in place for the management of risk.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Guys and St Thomas NHS Foundation Trust provided adult community services to support people in staying healthy, to help them manage their long term conditions, acute care delivered in people’s homes to avoid hospital admission and following discharge from hospital to support them at home. Services were provided in clinics, outpatient departments and in people’s homes.

The service required improvement in the effective and well-led domains.

The trust infection prevention and control policy had not been followed in Dulwich community hospital and Bowley close rehabilitation service.

Shortage of experienced nursing and therapy staff left some teams overstretched. Record keeping was inconsistent. This meant that before they visited nursing staff did not always have a clear understanding of a patient’s health status when giving treatment. Staff did not always complete a personalised care plan.

In some community teams staff were out of date with their mandatory training.

There was a clear incident reporting system in place and learning was shared between teams. Community nursing staff had access to specialised equipment to meet patients’ needs when required. The service used effective hand hygiene procedures.

Staff gained consent for treatment and involved patients and relatives in decisions. However, healthcare staff tended to refer to other agencies when mental capacity assessments were required. There was a lack of understanding of who the decision maker was and how this information should be recorded.

Staff experienced some difficulties accessing information because the electronic record keeping system was slow and not always available due to connectivity problems. Different health teams had access to different patient record systems, which complicated the process of obtaining up to date information about patients. The Health Inclusion Team did not use the RIO system. They used the EMIS IT system. The Enhanced Rapid Response team, the Supported Discharge Team and the @home team all used RIO and could see the district nursing records.

We found some examples of effective services and improved patient outcomes due to evidence based practice and commitment of staff to promote patient’s independence. Staff used evidence based care informed by NICE guidelines. Teams worked together in a coordinated way and made appropriate referrals to specialised services. The service participated in audits and developed action plans to improve.

There was good multi-disciplinary working with a strong focus within teams and clinics to reduce hospital admission and promote early discharge. Services were commissioned and designed with this purpose.

Patients received a caring service.

Staff were kind and respectful towards them. Staff treated patients with dignity, involved patients and their families in their care and supported them during times of crisis. Staff gave clear explanations for treatment and encouraged patients to reach their goals.

Patients and relatives expressed satisfaction with the service and we found a caring and compassionate approach from staff in the areas we visited. We saw examples of initiatives and ways of working across localities that were providing patients with good access to services and treatment.

Community health services for adults were responsive.

We saw there were examples of very responsive and accessible services such as rapid referral and quick assessment. These were provided by rapid response teams, the “@home” and “supported discharge” teams who worked closely together.

Improvements made by some teams had identified areas where easy access and increased support for example, provision of Foot health training in diabetes patients had significantly reduced the incidence of avoidable foot pressure ulcers.

Patient responses to trust surveys we saw told us they were very happy with the response of services where for example they had been seen immediately and their treatment commenced to prevent hospital admission.

Staff considered the needs of people who may have difficulty accessing services and adapted their care approach to show respect for cultural factors. There was evidence of learning from the complaints received from patients and families.

Many aspects of the service were well led but some aspects of risk management and public engagement needed to be improved.

Staff in adult community services told us they were well supported by local team leaders and managers. Staff across the trust had opportunities to review the quality of care and the way that teams worked. They told us they felt empowered to develop local solutions based on good practice.

There was a clear vision for the service and examples of innovation. Risk registers reflected the key areas of concern to frontline and management staff.

We rated community inpatient services at Guy’s and St Thomas’ NHS Foundation Trust as ‘good’ overall. We found that the services were organised with patient safety as a priority. The rehabilitation services were patient centred and involved them and people important to them. Feedback from patients and relatives was very positive and we observed staff to be caring and compassionate in their approach. A recent successful recruitment campaign meant that the services were adequately staffed, and there was low use of bank and agency staff. Staff were engaged in improving the service and received regular appraisals, supervision and were supported to develop their skills further. There was a robust governance and risk management structure in place and staff were supported to report and learn from incidents.

Staff followed infection prevention and control procedures, all areas we inspected were clean and the environment and equipment was well maintained. Patients had their meals together in the dining area and most patients told us they enjoyed the food provided and were supported if necessary.

Patients were given sufficient information about their environment and what to expect during their admission. Their opinions were sought and listened to. Patients and those close to them were part of the decision making process and they agreed clear and realistic goals to work towards. Staff told us there was a commitment to successful rehabilitation and we saw evidence of good multi-disciplinary working across nursing, therapy and medical teams.

We observed patient records were well managed however nursing, medical and therapy staff recorded their interventions in different formats. This meant that staff supporting patients did not always have access to each other’s notes and there was a potential risk of the healthcare professionals not being aware of a patient’s progress or changes in treatment or care. Medicines were managed appropriately, although not all patients were given the opportunity to self-medicate, if appropriate for them to do so.

Admissions and discharges were well managed although some discharges were delayed due to difficulties in organising ongoing care.

People using the trust’s community health services for children, young people and families were protected from avoidable harm and abuse.

Staff were encouraged to raise concerns and to report incidents and near misses. Learning from incidents was shared with staff through regular meetings and newsletters.

There were robust safeguarding policies and procedures in place. Staff received regular safeguarding supervision and were knowledgeable about their responsibilities regarding safeguarding vulnerable people.

There was sufficient serviced and maintained equipment to meet the needs of patients and staff. Most environments were clean, tidy, suitable and safe.

There were generally enough staff to meet the needs of the people using the service, although school nurses were struggling to deliver a full core service because of having to attend meetings.

There was a high rate of compliance with statutory and mandatory training amongst staff.

The trust’s community health services for children, young people and families provided effective care and treatment so patients had good outcomes.

Staff followed accepted national and local guidelines for clinical practice. A number of pathways had been developed to ensure that patients received treatment focused on their needs. The trust participated in national and local audits so that they could benchmark their practice and performance against best practice.

There was a multidisciplinary, collaborative approach to care and treatment that involved a range of health and social care professionals. Staff had regular supervision meetings and access to learning opportunities to promote their development.

Appropriate handover arrangements were in place for those children and young people moving between services

People using the trust’s community health services for children, young people and families were treated with dignity and respect and were involved as partners in their care. People felt they were listened to by health professionals and were involved in their treatment and care. People using the service told us that they felt well-informed and involved in the decisions and plans of care. Staff respected the choices and preferences of people using the service and were supportive of their cultures, faith and background.

The service was responsive to the needs of people using it and had adapted to meet the diverse needs of the community it served. Complaints from people using the service were learned from and used to improve the service. The health visiting service needed to further improve the amount of patient facing time spent.

The trust’s community health services for children, young people and families was well-led. The integration of children’s community services to become part of Evelina London Children’s healthcare in 2014 has had a positive impact and promotes the ability of the trust to provide a truly integrated model of health care to children across the trust’s acute and community services.

The service actively sought and responded to the views of people using the service.

There was a robust governance framework and reporting structure. Staff had confidence in their immediate line managers and leadership at board level. Staff were proud of their achievements and input into a wider health agenda at local, regional and national level.

We rated the community end of life care services at Guy’s and St Thomas’ NHS Foundation Trust (GSTFT) as ‘good’ overall. We found the end of life care (EOLC) team, specialist palliative care team (SPCT) and community nurses were passionate about ensuring patients and people close to them received safe, effective and good quality care in a timely manner.

During our inspection we asked the trust to gain consent from patients or bereaved relatives to speak with us about the care and support they had received from the community nursing, EOLC and/or the SPCT. We were advised that none of the five patients who were receiving care at this time were suitable to visit due to complex social circumstances and/or communication barriers; it was felt our visit would cause further distress to families and patients at a sensitive time. We were not provided with any contact details for bereaved relatives. 

At the time of our unannounced inspection we followed the request up again. We were told  that the trust had made a decision not to contact bereaved relatives to seek permission to provide us with contact details, therefore we were unable to evidence the views and opinions of people who had recently used the end of life care services. However we reviewed thank you cards and we witnessed staff talking about patients in a compassionate and considerate way during interactions with each other and in their description to us of how they cared for and supported patients and their families. They included patients and their families in discussions about their care and end of life plans; they considered social needs and family dynamics. Staff took conversations about prognosis, death and dying as far as was comfortable for the patient and their family; they displayed patience and understanding about how hard this dialogue could be. We were impressed that staff used other indicators to gain an understanding about the level of acceptance the patient may have. For example we observed one member of staff telling their colleagues at the weekly multidisciplinary (MDT) meeting that one of their patients was starting to accept they were dying as they noticed funeral directors information at their recent visit.

The trust responded to the independent review of the use of the Liverpool Care Pathway (LCP) for the dying patient and the subsequent announcement of phasing out the use of the LCP in July 2014. They created a document called ‘priorities of care’. Holistic assessments looked at the whole picture – the patient’s physical, emotional, spiritual, psychological and social needs were assessed and their carers’ views were taken into consideration. It was an open document so the whole MDT wrote about their interactions with the patient, any changes and the care and treatment provided, such as pain relief, symptom management and nutrition and hydration needs. Patient records/care plans were regularly updated, matched the needs of the patient at the time and were relevant to EOLC.

Staff were able to explain their understanding of the Mental Capacity Act (MCA) 2005 and Deprivations of Liberty Safeguards (DoLS). They told us they would always act in the patient's best interests should they assess the patient lacked the mental capacity to make decisions for themselves. However there was little understanding as to which forms were required to be completed and who could legally provide consent for best interest decisions on behalf of the patient.

There were regular MDT meetings to review all end of life patients who had or were being cared for using the trust’s ‘priorities of care’ or receiving palliative care services. If there was a clinically urgent case then joint visits or ad hoc meeting were organised as necessary. Incidents, complaints and concerns were also discussed at regular meetings and across the trust-wide meetings where appropriate.

Palliative and EOLC was provided by competent staff with a range of clinical and non-clinical skill mix. For example GPs, social workers and psychologists were employed by the trust as part of the team. We observed a flattened hierarchy amongst the teams. They were highly supportive of one another and open to challenge and advice on how to approach patient care and treatment. The EOLC and SPCT were highly trained and received continual consultant, doctor and pharmacy support.

The community nurses were given the confidence to care for palliative and end of life patients through training and support from the EOLC and SPCT. They were able to express their concerns if they felt out of their depth or uncomfortable supporting patients at the end of their life. However some of the community nurses expressed a concern that sometimes there was no time for them to reflect and ‘gather themselves’ after someone dying prior to going to their next patient. Whilst most of the nurses told us it was not always necessary to take time out after a patient’s death there were occasions when “it gets to you.” The senior leaders expressed surprise that staff did not feel they could take time if they required it and assured us they would address this with local managers and team leaders.

We found the end of life care service was well led. Staff in the EOLC and SPCT spoke highly of their managers and valued their experience and the support they gave. All the staff, including those who worked part-time or had been newly recruited, told us they felt part of their team and appreciated by their colleagues. All the community staff said they felt very much part of the wider GSTFT team, one of them told us this was a positive change as they used to feel “like the poor relative” to the acute hospitals.

End of life care was a clear priority for the trust, including services provided within the community. A draft strategy to provide seamless good quality care was due to be presented to the board. The strategy had been developed in conjunction with the clinical commissioning groups (CCGs), local hospices, other hospital trusts and other organisations such as Macmillan Cancer and Marie Curie.