John
07-29-2010, 02:01 PM
A major report on children's heart surgery at John Radcliffe Hospital in Oxford 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).
Its chairman, Dr Geoffrey Harris, apologised to the families of those 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 cease. The report does not criticise Mr Salih, but all four baby deaths occurred under his care shortly after his appointment at the unit.
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 panel 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 sets out several recommendations, including an overhaul of the system for dealing with serious adverse incidents and better monitoring of death rates.
The panel "also recommends that paediatric cardiac surgery remain suspended in Oxford until or unless the service can safely be expanded". There needs to be an adequate caseload so surgeons "can maintain their expertise".
Dr Bill Kirkup, chairman of the independent review panel, told a board meeting of the strategic health authority in Newbury, Berkshire, that there were "serious shortcomings" in the care given to the babies. It was recognised that the babies were "very ill", he said, adding: "There are no guarantees about the outcomes of these procedures and deaths occur despite the best efforts of surgeons."
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." Caner Salih was duly recruited, but Dr Kirkup said the risks of doing that were "insufficiently recognised", while the planning process for the arrival of the new surgeon was not adequately carried out.
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).
Its chairman, Dr Geoffrey Harris, apologised to the families of those 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 cease. The report does not criticise Mr Salih, but all four baby deaths occurred under his care shortly after his appointment at the unit.
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 panel 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 sets out several recommendations, including an overhaul of the system for dealing with serious adverse incidents and better monitoring of death rates.
The panel "also recommends that paediatric cardiac surgery remain suspended in Oxford until or unless the service can safely be expanded". There needs to be an adequate caseload so surgeons "can maintain their expertise".
Dr Bill Kirkup, chairman of the independent review panel, told a board meeting of the strategic health authority in Newbury, Berkshire, that there were "serious shortcomings" in the care given to the babies. It was recognised that the babies were "very ill", he said, adding: "There are no guarantees about the outcomes of these procedures and deaths occur despite the best efforts of surgeons."
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." Caner Salih was duly recruited, but Dr Kirkup said the risks of doing that were "insufficiently recognised", while the planning process for the arrival of the new surgeon was not adequately carried out.