Experts have decided that the ban on all children’s heart surgery at a troubled trust is to stay in place until further improvements are seen.
An independent panel set up following the deaths of four babies after cardiac surgery at the Oxford Radcliffe Hospital has published its review.
The Review of paediatric cardiac services at the Oxford Radcliffe Hospitals NHS Trust, contains a number of recommendations for improvement, which have all been agreed by the board of South Central Strategic Health Authority (SHA).
The SHA commissioned the independent review after the Oxford Radcliffe Hospitals NHS Trust suspended its paediatric cardiac surgery service in February this year following the deaths of four babies in a 10-week period.
The SHA board has approved the panel’s recommendation that paediatric cardiac surgery at the hospital should remain suspended.
The panel reviewed the clinical notes for babies operated on from January 2009 to February 2010 and identified eight deaths within 30 days of surgery from cardiac causes.
They found that, after a new surgeon took up post, there were more deaths than would be expected from national mortality rates for the procedures undertaken, and that this was unlikely to have occurred through chance alone.
However, they found no errors of judgment that directly led to any of the deaths. All the cases were complex and surgery was high risk. But the panel concluded that several cases might have had a better outcome with different surgical management.
Oxford Radcliffe had been keen to expand its paediatric cardiac surgery service, said the review, but gave insufficient consideration to the risks associated with introducing a second surgeon with different techniques and requirements to the surgeon already in post.
Panel chairman Dr Bill Kirkup said: “I am deeply sorry that this review has been necessary because I fully appreciate that it will have caused distress to some families. However, I very much hope that, as a result of the panel’s work, the risks for children undergoing heart surgery will be reduced.
“We recognise that there have already been significant changes in the arrangements for clinical governance at the Oxford Radcliffe, which we very much welcome.
“However, the panel has formed a clear view that without a critical mass of surgeons, or sufficient workload to maintain expertise, the arrangements for this service at the Oxford Radcliffe are too fragile for safe care to be assured in future without significant change.”
The report makes several recommendations for improvements 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
- the wider adoption of techniques to identify adverse trends in surgical outcome earlier.