The independent panel appointed by NHS Improvement in January 2019 to review the deaths of patients who underwent heart surgery at St George’s Hospital, Tooting, between April 2013 and December 2018, has now published its findings. The Independent Mortality Review concluded that, out of the 202 deaths considered in the review, 102 deaths showed shortcomings in the care received, and in 67 patients, the deaths were probably, most likely, or definitely caused by what was defined as ‘significant shortcomings’ in treatment. The mortality review has been formally referred to the General Medical Council (GMC). NHS Improvement has asked the GMC to consider whether regulatory action is warranted.
The mortality review was published in conjunction with the report from an independent Scrutiny Panel for cardiac surgical services at St George’s - the purpose of the Scrutiny Panel was to provide recommendations for how the cardiac surgery service at St George’s should be conducted going forwards. This article focusses primarily on the findings of the mortality review.
In 2018, Professor Bewick published his Independent Review of Cardiac Surgery Service at St George’s Hospital NHS Trust. His report raised concerns about the standard of care provided at the St George’s cardiac unit. It was followed, in December 2018, by the report of the Care Quality Commission. More information about these two reports and the background to the problems at St George’s cardiac unit can be found in two previous articles: see here for the initial report on the findings, and here for the subsequent developments.
The purpose of the panel set up to review the deaths of cardiac patients at St George’s (the 'Mortality Panel') was two-fold. Firstly, the Panel was charged with identifying and addressing the concerns arising from the two alerts of the National Institute for Cardiovascular Outcomes Research (NICOR) - the alerts had been triggered when the St George’s cardiac unit survival rate fell below the ‘safety limit’ on two separate occasions. Secondly, the Panel was charged with informing the trust’s discussions with the coroner regarding the deaths of cardiac patients who passed away whilst in the care of the St George’s cardiac unit between April 2013 and December 2018.
The Panel looked at three aspects of the care at St George’s: pre-operative care; operative care; and post-operative care. It acknowledged that the majority of patients were elderly and had significant co-morbidity and, accordingly, the cases were complex. The Panel found good examples of patient management within each phrase of care. However, they found that problems raised in earlier reviews, such as “a lack of leadership; poor relationships between teams and specialities; poor communication; MDT [multidisciplinary team] structures which lack rigour and consistency; poor multi-disciplinary working; and an apparent lack of governance” remained. The Panel noted that, until 2018 (when the Bewick report was published), the trust’s current board had been unaware of an earlier report which had also looked into cardiac care at St George’s (the 2010 Wallwork Report) and had made several recommendations which, had they been implemented, “might have improved patient care at the trust”.
Regarding pre-operative care, the Mortality Panel found that several of the referrals from cardiology teams “were not comprehensive and not tailored to the needs of the individual patient”. The Panel’s impression was that there was “a lack of commitment and/or diagnostic rigour on the part of the referring cardiology teams” which contributed to “poor surgical case selection”. Specific examples included a lack of: “clear description of patient’s symptoms; additional investigation(s) when indicated; detail in description of co-morbidities; and a lack of discussion about the benefits of intervention versus conservative management”. The last failing was noticeable particularly in “frail, elderly patients or patients with major co-morbidities”.
With respect to referrals for coronary surgery, the Panel found several cases where “the referral was less comprehensive than it might have been”. Examples include one occasion where there was a “lack of clarity” on why the patient was being referred for surgery; occasions where angiograms were not of diagnostic quality and subsequently were not fully interpreted by the cardiologist making the referral; or where “the cardiologist appeared to be leaving the cardiac surgeon to decide on the significance of the coronary disease”.
Similar problems arose on examination of referrals for valve surgery. The Panel found “a lack of a clear description of symptoms and functional status of the patient”, poor quality echocardiograms (including incomplete valve assessments), referring cardiologists who did not understand about surgical risk in frail or elderly patients and a failure to consider non-surgical options or conservative, medical treatment.
The Panel also found shortcomings in the way that MDT meetings were conducted, including referrals made without the required evidence; a lack of “expected rigour” from cardiologists regarding diagnostic test interpretation, the implications of co-morbidities and consideration of interventional treatment options; a failure to revisit decisions in complex patients, when new information was available or the patient deteriorated; and an “unbalanced” decision-making process where cardiologists “appeared to exert undue pressure on the cardiac surgeons to accept patients for surgery, even when this was high-risk”.
The Mortality Panel found incidents where the risk of cardiac-surgery was underestimated. They found several examples where the risk given to the patient by the surgical team was “substantially lower” than the risk calculated by the current standard used in the UK (EuroSCORE II). In 21% of the cases reviewed, the EuroSCORE II estimated risk was approximately double the risk given to the patient.
Regarding operative care, the Panel noted that they had “identified recurring themes…which contributed to poor outcomes”. There was a “lack of surgical expertise or experience”, including one example where “a surgeon with limited experience of the procedure had difficulty dealing with intraoperative complications and there was no call for more experienced help”. In another example, although three consultants were mentioned in the clinical notes, “none appeared to have clear responsibility for the patient” and the surgery was performed “out of hours by a registrar with no clear consultant supervision”. Other examples included a patient who underwent an “unnecessarily complex operation”; a patient with very complex needs who underwent surgery when they were unlikely to survive; and surgery performed “during the night as an emergency for reasons that were not clear”.
The Panel found “many examples of an experienced ICU team delivering high quality care” including good communication with families, good record keeping, timely involvement of non-cardiac medical and surgical teams, and regular consultant review. However, the Panel also found areas where practice could be improved. These included a failure to recognise that a patient was deteriorating - there were several instances were those caring for a patient were slow to recognise significant post-operative blood loss and there was consequent delay in going back to theatre. On several occasions, this contributed to the patient’s death. The Panel also found several instances where no action was taken on electrocardiogram (ECGs) results which led to the patient passing away. They found several cases where earlier intervention by a critical care outreach team might have avoided the death of the patient.
The press release from NHS England said that the trust has offered an "unreserved apology" to the families of all those whose death was contributed to by failings in their care. The trust has “spoken and written to the families of all patients whose care was reviewed, to share the results as well as to offer a meeting and support”.
St George’s Hospital’s chief medical officer, Dr Richard Jennings, said that St George’s "fully accepts the panel's findings, and we apologise unreservedly for the serious failings in care [which] had fallen way short of the high standards our patients deserved". Dr Jennings said that "[t]he heart surgery service at St George's is now safe, and the current service is very different to the one the trust took urgent steps to improve in 2017."
Camilla Wonnacott, an associate in Penningtons Manches Cooper’s clinical negligence team who specialises in cardiac claims, said: “The mortality review sets out clear evidence of failings in care across the spectrum of cardiac treatment in the St George’s cardiac unit. The gravity of the Panel’s findings is reflected in the move to refer the mortality review to the GMC and in the request, by NHS Improvement, that the GMC consider whether regulatory action is warranted. If you believe that anyone in your family or who you were close to may have been affected by the events in the cardiac unit at St George’s Hospital, we have a specialist team handling cardiac cases who can discuss your concerns.”