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The European working time directive (EWTD) was introduced into National Health Service hospitals for doctors in training in August 2004.1 Mounting evidence had shown that fatigue in doctors contributes to adverse events in patients.2 However, the implementation of potential quality improvements requires an understanding of whole healthcare systems.3 Before the introduction of the EWTD, our stroke ward had a resident senior house officer who provided weekday care, ensuring that all patients were medically reviewed on a daily basis. This is required, …