Editor’s blog Thursday 29 July 2010: Radcliffe paediatric surgery review is out

The Radcliffe paediatric surgery review is published here.

One-liner - the service is suspended until it can be safe - i.e. probably forever. Preface and exec summary copied below.

Preface
This report covers the findings of a review into services for children’s heart surgery in Oxford. These services are complex and challenging. The babies whom they treat suffer from conditions that can have devastating consequences, and are often life-threatening. To restore as healthy and full a life as possible – and sometimes just to offer any prospect of survival – takes intensive and technically demanding work from a clinical team including many professional disciplines as well as surgery.

Even then, success is far from guaranteed, because the inherent risks of both the underlying condition and the treatment are high, often very high. Sometimes despite excellent treatment and superb teamwork, the outcome is sadly the death of the patient; nor is it always possible to say what has tipped the delicate balance in an individual patient and precipitated a post-operative death.

The families of babies who require these services face extraordinary demands. Within a brief period of time, they must come to terms both with the existence of a condition that will threaten their newborn baby’s health and life, and with the need for one or more operations which carry a significant further risk. They must then place their baby’s future into the hands of the clinical team, initially strangers but whom they will generally come to know and rightly trust. I am conscious that to such families, our report must come as an intrusion, probably unwanted, into that relationship. I am deeply sorry for that intrusion. They have suffered enough.

Our purpose in carrying out the review was not to pick over the detail of individual cases it is now too late to change, nor to castigate those who did all that they could. We were concerned to discover whether more deaths had occurred than expected, and if so what may have contributed to that occurrence, so that we could recommend how to improve systems, organisations and services. I believe that we have a duty to do that for the sake of future patients and their families.

In reporting the results of our review, we have had to remain detached and analytical, and the language we have used may at times appear cold as a result. I apologise for that too. Despite our necessary detachment, we have not lost sight of the human tragedies inherent in the events that we have reviewed.

Dr Bill Kirkup, Review Panel Chair

Executive summary
In March 2010 the South Central Strategic Health Authority (the SHA) commissioned an independent review of paediatric cardiac surgery and clinical governance at the Oxford Radcliffe Hospitals NHS Trust (the Trust). The SHA convened an independent panel to carry out this review.

The Review followed four deaths after paediatric cardiac surgery between December 2009 and February 2010 by a newly appointed surgeon. The SHA asked the panel to review all deaths from January 2009, and mortality statistics from 2000.

The Panel’s statistical analysis found that overall there were more deaths than would have been expected from national mortality rates for the procedures carried out, but in only two groups of patients was the difference statistically significant in the sense of being unlikely to have occurred through chance alone. First, the fifteen cases operated on by the new surgeon, for which the rate of mortality was 4.8 times higher than that expected from national rates.

Second, less common procedures (those that were carried out fewer than 11 times each) between 2000 and 2008 for which the rate of mortality was 5.3 times that expected from national rates.

The panel’s review of the clinical notes for babies operated on from January 2009 identified eight deaths within 30 days of surgery from cardiac causes. We found no errors of judgment that directly led to any of the deaths. All the cases were complex and surgery was high risk.

The panel’s experts, however, considered that several cases may have had a better outcome with different surgical management. In Mr Salih’s four cases we found no evidence of poor surgical practice, but that he would have benefitted from help or mentoring by a more experienced surgeon; and that it was an error of judgment for him to undertake the fourth case.

All other aspects of care, including nursing, were at least adequate and were widely praised by the families panel members met.

Arrangements for clinical governance, which the Trust was already beginning to improve, were in the period reviewed less than adequate.

The panel discusses what it believes were the root causes of the problems. These include the decision to appoint a new surgeon; planning for the arrival of the new surgeon; his induction and mentoring; his impact on team working; and the surgical team and clinical leadership.

The panel also considers the Trust’s recognition and handling of the problem; and early warning systems.

The panel makes a number of recommendations for improvement to the paediatric cardiac surgical service at the Oxford Radcliffe including more effective operational planning; new clinical governance arrangements; an overhaul of the system for dealing with serious untoward incidents; more effective clinical and managerial leadership; and the wider adoption of techniques to identify adverse trends in surgical outcome earlier.

It also recommends that paediatric cardiac surgery remain suspended in Oxford until or unless the service can safely be expanded.

UPDATE: The Guardian's Patrick Butler provides a clear and concise summary of the findings here.