Between 2013 and 2018, the National Institute for Cardiovascular Outcomes Research (NICOR) triggered two alerts to St George’s University Hospitals NHS Foundation Trust. NICOR collates data on unit-based outcomes for cardiac surgery nationally, and survival rates at St George’s cardiac surgery unit were highlighted as falling below the pre-determined ‘safety limit’ during two separate periods between April 2013 and March 2016, and April 2014 and March 2017.
The cardiac surgery unit, previously considered an international hub for cardiac surgery and research, supports the Major Trauma Centre and Heart Attack Centre based at the Trust.
The first alert generated an internal review of deaths during that time, which resulted in an action plan based on the results. After the second alert, the Trust commissioned an external review, which attracted widespread media coverage of the Trust's cardiac services.
NHS Improvement subsequently commissioned an independent External Mortality Review Panel to investigate deaths following cardiac surgery in the period April 2013-December 2018.
Published in March 2020, the External Review concluded that there were significant shortcomings in the care of 102 patients, which either probably, most likely, or definitely contributed to the deaths of 67 of them.
St George’s University Hospitals Trust then apologised unreservedly to the families of those who had lost relatives due to negligent care in treatment. The report has since been referred to the GMC (General Medical Council), to consider whether regulatory action is warranted, at NHS Improvement's request.
The Trust shared the results of the report with the families of all patients whose care was reviewed, and offered support. NHS Improvement also appointed an Independent Scrutiny Panel to sit alongside the Trust as it implemented actions to ensure services were safe. Further recommendations were made as a result.
The Care Quality Commission (CQC) became involved, and inspected the Trust between July and December 2019. Reassuringly, it found that the hospital’s incoming senior leadership team had made significant improvements, and the most recent inspection found no safety failings. Meanwhile, the families involved live with the painful knowledge that, with better medical care, their relative may not have died.
While the report was published in March 2020, the NHS has had to deal with the Covid pandemic which, of course, took precedence. However, now that things have settled somewhat, I am receiving enquiries from families affected by the Independent Mortality Review of Cardiac Surgery at St George's Hospital report.
Only by pushing for transparency and disclosure from hospital trusts will positive change happen and we welcome the Trust's decision to seek external review in these circumstances.
Meanwhile, the Times reported this weekend that St George’s is operating at a third of its former capacity because of staff departures and restrictions on surgical practice, according to a group of cardiac anaesthetists. Two expert heart surgeons at St George's had restrictions placed on their practice by the Trust and there is now only one consultant cleared to operate on higher-risk patients. At least seven cardiac consultants have left since the report was published. The Coroner investigating deaths at St George's has disagreed with the report's findings and concluded that its findings were 'limited by several factors' and that the process was 'less than perfect.' Further inquests have been scheduled, and it remains to be seen what the outcomes may be.
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