JR CHILD HEART OP INQUIRY: What the health chiefs say (From thisisoxfordshire)

JR CHILD HEART OP INQUIRY: What the health chiefs say

9:00am Friday 30th July 2010

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STANDARDS of care at Oxford’s John Radcliffe Hospital where four babies died were “not what was expected”, a health boss has said.

A major report on children’s heart surgery at the hospital said the paediatric heart surgery unit should remain suspended until arrangements are made for improving care.

Four babies were all treated by the same surgeon and died within three months at the hospital.

Their deaths, between last December and February, prompted the temporary closure of the unit in March and the launch of an investigation by the NHS South Central Strategic Health Authority (SHA).

Yesterday its chairman, Dr Geoffrey Harris, apologised to the families of the babies who died.

He said: “We offer our sincere condolences and we apologise that, in the cases, the standards of care were not what was expected.”

Surgeon Caner Salih, who operated on the four babies, is said to have complained about the age of equipment and poor working practices at the paediatric care unit, asking for operations to stop.

All four baby deaths occurred under Mr Salih’s care shortly after his appointment at the unit. But the report did not criticise his care.

The report included a review of death rates, and found that among 15 patients operated on by the new surgeon, the death rate was 4.8 times higher than would be expected from a national rate.

But the panel noted “all the cases were complex and surgery was high risk”.

The report said: “In Mr Salih’s four cases, we found no evidence of poor surgical practice, but that he would have benefited from help or mentoring by a more experienced surgeon; and that it was an error of judgment for him to undertake the fourth case.”

The report said several problems led to the excess deaths, including the hospital’s decision to appoint a new surgeon, planning for his arrival and his induction and mentoring.

It set out several recommendations, including an overhaul of the system for dealing with serious adverse incidents and better monitoring of death rates.

Prof Stephen Westaby has worked at the unit since 1986, splitting his time between paediatric and adult work.

Yesterday’s report said he took three weeks’ leave as soon as Mr Salih arrived, but it was clear “the two had not satisfactorily discussed the matter” of what would happen in his absence.

Oxford Radcliffe Hospitals NHS Trust is one of the largest NHS teaching trusts in the country.

It was given the top rating of “excellent” for quality of services in the last annual health check by the Care Quality Commission, based on data from 2008/9.

But its children’s heart unit is the smallest in England, carrying out about 120 operations a year.

In 2008, it was decided the unit should expand because of concerns over its long-term future.

Dr Bill Kirkup, chairman of the independent review panel, told a board meeting of the SHA in Newbury, Berkshire, that there were “serious shortcomings” in the care given to the babies.

Criticising the trust’s decision to try to take on more patients in an attempt to avoid closure, he said: “We did find there were serious shortcomings, particularly in the decision to expand.”

Yesterday’s report said Mr Salih was relatively inexperienced and suffered due to a lack of proper supervision by more experienced consultants. But the unit was experiencing an “unusual run of difficult cases”, although the surgical procedures weren’t necessarily unduly complex.

A statement from Guy’s and St Thomas’ NHS Foundation Trust, where Mr Salih now works, said: “We have carefully read the report and do not consider that it provides evidence for Mr Salih’s practice at Guy’s and St Thomas’ to be restricted.

The hospital has until September 17 to report back to the SHA with an action plan.

Sir Jonathan Michael, chief executive of the Oxford Radcliffe Hospitals NHS Trust, said: “Both personally as chief executive, and the Trust as a whole, very much regrets when the outcome of treatment we provide for patients is unsuccessful, and we give our condolences to the families of the babies who died.”

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