The deaths of 67 heart-surgery patients have been linked to a hospital’s ‘significant shortcomings’, a new report has found.
The Independent External Mortality Review, published on Thursday, documents historic care failings in the cardiac surgery unit at St George’s University Hospitals NHS Foundation Trust in south London between 2013 and 2018.
It found that there were “significant shortcomings” in the care of 102 patients and that for 67 of them these either probably, most likely, or definitely contributed to their deaths.
The review was carried out by an independent panel of medical and surgical experts and examined the deaths of 202 patients who underwent heart surgery at St George’s Hospital in south London.
The review included a number of case studies of patients who had died while in the Trust’s care, with examples of poor care in those instances including inaccurate surgical risks quoted to patients, “inappropriate and unnecessary” procedures being carried out and misinformation given to coroners.
In one case, where the patient died six days after surgery, the review noted that there was “evidence of dysfunctional team working” post-operatively between the cardiac surgeons and ICU consultants including “angry notes with block capitals and many exclamation marks” putting junior medical teams in “a very difficult position”.
St George’s University Hospitals Foundation Trust offered an unreserved apology for the “serious failings in care”.
Its chief medical officer Dr Richard Jennings said: “We fully accept the panel’s findings, and we apologise unreservedly for the serious failings in care the review has identified.
“The care we provided in the past fell way short of the high standards our patients deserved.
“We have let these patients and their families down, for which I am deeply sorry.”
The trust said that it had set up a Cardiac Surgery Task Force in 2017 to address long-standing problems within the unit and a number of changes and, as a result, improvements to working practices were introduced.
By March 2018 heart surgery mortality rates at St George’s were back within the “expected range” where they have remained since, it added.
Dr Jennings said the improvements were confirmed by the Care Quality Commission (CQC) in its latest inspection report published in December 2019.
He added: “The 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.”
Changes introduced at St George’s over the past two years include the appointment of a senior cardiac surgeon from outside the organisation to lead the service and all new heart surgery cases being reviewed by a multidisciplinary team of healthcare professionals, the trust said.
NHS Improvement said that the report had been formally referred to the medical profession’s regulator the General Medical Council (GMC) which is being asked to consider whether regulatory action is required.
The review, announced by NHS Improvement London in January last year, followed two earlier reports into the care provided at the trust.