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Report reveals shocking, sub-standard treatment at St George’s cardiac unit

Posted: 17/08/2018

Professor Bewick’s independent report on St George’s cardiac unit has been made available. The report (see also here) is a timely reminder that, even in a modern NHS hospital, things can go very wrong indeed.

St George’s Hospital (administered by St George’s Healthcare NHS Trust) has been in special measures since 2016. The cardiac unit carries out adult heart surgery – one of 28 NHS hospitals to do so. The unit has been the subject of two National Institute for Cardiovascular Outcomes Research (NICOR) alerts, in April 2017 and April 2018, which flagged up higher than expected death rates following cardiac surgery. After the second alert, the trust asked Professor Bewick to provide an independent review of the cardiac surgery service at St George’s. One thing to bear in mind is that Professor Bewick was only asked to look at the period from January 2018 to the start of July 2018 so his review does not include the majority of the time covered by the two NICOR alerts.

Perhaps the best way to introduce the reader to the flavour of Professor Bewick’s report and to what has gone on at St George’s is to quote from an appendix towards the back of the report entitled Appendix 5: Practical suggestions to reduce morbidity and mortality (an initial action plan to reduce morbidity and mortality). Here there are suggestions for minimising returns to theatre, renal injury and infection, with actual examples of serious incidents, including patient death. Even from a layperson’s perspective, many of the suggestions seem to be pitched at a worryingly basic level. They reveal a catalogue of shocking, sub-standard treatment:

  • "Timely intervention for recognised post-operative bleeding. Don’t sit on blood trickling into the drains. Reopen the chest before the patient becomes haemodynamically compromised and it becomes an emergency.”
  • “Develop a culture of zero tolerance of imperfect surgery. If a coronary graft doesn’t sit right – do it again at the first operation rather than wait for the ischaemic event in ITU (example one of the deaths in the case reviews presented to SGH Board).”
  • “Develop a zero tolerance rule of needing to reopen for bleeding. Meticulous care with haemostasis. It should not just be left to a junior SpR to close chests at the end of operations. It should be supervised by the consultant, certainly until outcomes are better.”
  • “Recognition of low cardiac output/haemodynamic compromise during the postoperative period is important. Optimising a patient’s condition at an early stage is important in limiting its occurrence.”
  • “Myocardial injury during bypass – either inadequate coronary perfusion pressure or inattention to myocardial preservation during aortic cross clamp periods will cause myocardial damage as will unnecessarily long cross clamp periods.”
  • “Specialist input should be requested early in the deteriorating patient eg failure to request cardiology to manage a post-op tachy-arrhythmia resulting in an avoidable death.”

Among Professor Bewick’s findings and recommendations are the following:

  • Data entry and collection. There were considerable problems with data entry and collection of patient mortality and morbidity rates. An urgent review was recommended into how surgical outcome data was processed and communicated with “new reduce risk and appropriately challenge current practice”.

    There was no audit of data quality and a suspicion of “some under-representation of risk factors”. There was “little evidence” that surgical mortality rates were monitored “until a surgeon feels under threat..” There was insufficient focus on morbidity, with “significantly higher rates of re-operation, stroke and renal replacement…” with little evidence of “significant engagement by surgeons in morbidity review – eg unexpected long ITU stay, unexpected long cross clamp time…”  

  • All current surgical practices to be reviewed.  Problems included inconsistent and multiple rotas; variable response times with some consultants being less risk averse than others; and patient pooling only happening in urgent cases and varying, depending on the surgeon. There was “a reluctance to move to [a patient pooling system] as for several surgeons personal referrals remain more important”.

  • Consultant cardiac surgical team to be restructured. The current consultant cardiac surgical team membership was “incompatible and requires restructuring with some urgency”. “Team-working between disciplines has to drastically improve”. There was also a lack of standard operating plans. Recruitment of a “proficient and credible cardiac surgeon” to lead the unit was recommended. 

Since the publication of Professor Bewick’s report, The Times has highlighted that, given that the report only covered events at the cardiac unit since January 2018, there may be worse to come. According to The Times, “a mass of documentation provided by staff in which they made allegations of incompetence, dubious recruitment and financial conflicts of interest...; allegations of incompetence, cronyism and cover-ups [and] inadequate investigation” remain to be investigated while problems with data collection raise the question of whether the current patient figures “are trustworthy”.

Camilla Wonnacott, an associate in Penningtons Manches’ clinical negligence team, said: “The picture painted by Professor Bewick’s report is of a unit that allowed good surgical and clinical practice to deteriorate to the detriment of its patients. Accurate data on mortality and morbidity, the very data that should have provided an early warning, was not properly collected or disseminated; relationships between surgeons were allowed to fester; clinical and surgical practices did not move with the times. It is of enormous concern that the cardiac unit at St George’s has been allowed to reach this point.

“If you are worried that you or a family member might have been affected by the standard of care at the cardiac unit in recent years, we have a specialist team handling cardiac cases who can discuss your concerns.”

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