The death of 67 cardiac surgery patients has been linked to a hospital’s “significant shortcomings,” according to a new report.
The Independent External Mortality Review, released Thursday, documents historical care failures in the cardiac surgery unit at the NHS Foundation Trust of St. George’s University in South London between 2013 and 2018.
It emerged that there were “significant deficiencies” in the care of 102 patients and that 67 of them probably or most likely contributed to their death.
The review was carried out by an independent group of medical and surgical experts and examined the death of 202 patients undergoing cardiac surgery at St George’s Hospital in south London.
The review included a series of case studies of patients who had died during the Trust’s care, with examples of poor care in those cases including inaccurate surgical risks cited to patients, ongoing “inadequate and unnecessary” procedures and misinformation given to coroners .
In one case, in which the patient died six days after surgery, the review noted that there was “post-operative” evidence of a dysfunctional team functioning “between cardiac surgeons and ICU consultants, including” angry notes with capital letters and many exclamation marks “medical team in” a very difficult position “.
The Trust Foundation of St. George’s University Hospitals offered an unreserved apology for “serious treatment failures”.
Its medical director, dr. Richard Jennings said, “We fully accept the panel’s findings and apologize for the serious treatment failures identified by the review.
“The care we have provided in the past did not live up to the high standards our patients deserved.
“We have disappointed these patients and their families, for whom I am deeply sorry.”
The Trust claimed to have established a Cardiac Surgery Task Force in 2017 to address long-standing problems within the unit and a number of changes, and improvements in working practices have been introduced as a result.
By March 2018, cardiac surgery mortality rates in St George had returned to the “expected range” where they have remained since then, he added.
Dr Jennings said the improvements were confirmed by the Care Quality Commission (CQC) in her latest inspection report published in December 2019.
He added: “The cardiac surgery service at St George’s is now secure and the current service is very different from what confidence has taken urgent measures to improve in 2017.”
The changes introduced in San Giorgio over the past two years include the appointment of a senior cardiac surgeon from outside the organization to guide the service and all new cardiac surgery cases are reviewed by a multidisciplinary team of healthcare professionals, the confidence said.
NHS Improvement said the report was formally addressed to the medical profession’s regulatory authority, the General Medical Council (GMC), which is asked to assess whether regulatory action is needed.
The review, announced by NHS Improvement London in January of last year, followed two previous reports on the assistance provided by the trust.