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St George’s University Hospitals Trust: Cardiac Surgery Mortality Review

Volume 718: debated on Monday 18 July 2022

Motion made, and Question proposed, That this House do now adjourn.—(David Morris.)

I thank Mr Speaker for granting this Adjournment debate. I first want to explain why I have brought it forward. St George’s University Hospitals NHS Foundation Trust is not in my constituency, but Professor Marjan Jahangiri, professor of cardiac surgery at St George’s Hospital, is my constituent, hence my involvement today. I am delighted that my constituent is in the Gallery. I reassure you in advance, Mr Deputy Speaker, that while I may refer to coroners’ inquests, I will refer only to those that have concluded; there are several pending, but I will not refer to them, so my remarks will not be on matters sub judice.

I have secured this debate because I believe my constituent may have suffered a serious miscarriage of justice. There are also major public policy issues, if my conclusion is right that the independent mortality review of cardiac surgery at St George’s is deeply flawed. Let me say by way of background that my constituent is a pre-eminent cardiac surgeon and was the first female professor of cardiac surgery appointed in the UK and Europe.

Let me attempt to summarise a very complex situation. The results of cardiac surgery in the UK are reviewed on a three-yearly cycle. St George’s Hospital went into alert for the periods of 2013 to 2016 and 2014 to 2017, due to excess mortality of 11 to 12 patients. I should state that my constituent’s results have never been subject to an alert or an alarm. There were 202 deaths from approximately 5,200 operations at the unit between 2013 and 2018. NHS Improvement commissioned an independent mortality review of the cardiac surgery unit, which is known as the Lewis review.

The Lewis review panel studied the cases and wrote a one-page report on each patient—a structured judgment review. These were based solely on a review of hospital records. Each case received a score of 1 to 6 for problems in care contributing to death. No medical professional was interviewed, and no risk-adjusted mortality was analysed. This methodology is, I understand, very non-standard and runs counter to the methodology of the National Institute for Cardiovascular Outcomes Research. My constituent highlighted, before publication of the Lewis report, factual errors in the structured judgment reviews, but these letters were ignored.

The review, when it was published, concluded that 67 out of the 202 deaths were avoidable. The figure of 67 is vastly different from the original alert of 11 to 12. As a result of the review, all consultant cardiac surgeons at the unit, including my constituent, were referred to the General Medical Council by NHSI and St George’s. The General Medical Council found “no case to answer”, with no failings in care, and the case was closed.

The 67 cases were referred to Her Majesty’s senior coroner for inner west London, Professor Fiona Wilcox. The coroner has rejected the findings of the Lewis review in all 13 of my constituent’s cases, and no failings in care have been identified. In total, the coroner has rejected the findings in almost 40 cases, and in only one has she concluded that there have been failings in care—a case in which she had already opened an inquest.

I want to give the House a flavour of some of the comments that the coroner has made. I will just choose a few quotations from an inquest on 14 July 2021, which was one of my constituent’s inquests. One quote is:

“I can find no failings of care. I find no criticism of the care delivered by the clinical team. The failings identified in the review have, once again, not been found after consideration of the evidence.”

Another quote from that inquest is:

“I cannot find failings that contributed to the death. On the contrary, I find that the care given by the staff of St George’s was excellent and beyond criticism.”

And another quote from that inquest is:

“There has been enormous damage and suffering as a result of the NHSI Review to the families and St George’s staff, sufferings to relatives who fear that their loved ones died because of lack of care or failures in care, and extraordinary amount of work for this Court.”

On 9 May 2022, the coroner issued a regulation 28 report under the Coroners (Investigations) Regulations 2013, in which she described the failings of the NHSI Lewis review and stated that its implementation has caused deaths and harm. I want to quote just a few quotations from that regulation 28 review. It said that

“when the operative mortality statistics of each of the surgeons is examined across the range of theatres where they work, no surgeon had then or has now an operative mortality rate higher than expected.”

Separately, it said:

“The whole reputation of the cardiac surgery department and the hospital has been damaged with no evidence that this court has so far seen of deficiencies in care.”

Specifically, it was said as a matter of concern that

“the SJR process as deployed in SGH is not fit for purpose, further undermining the public confidence in the NHS, which the public may perceive as the NHS being unable to appropriately audit its own work.”

My constituent finds herself in a position where a review states that her unit caused 67 avoidable deaths, yet she has been exonerated by the coroners’ inquests and the General Medical Council.

This has wide-ranging implications. Not only is my constituent’s medical reputation severely affected, but there are many other consequences. The families of those who died are left confused and troubled as to why their family members died, and it erodes public confidence. As noted in the regulation 28 report, which I mentioned briefly, the restrictions imposed on the unit are limiting its ability to carry out necessary surgeries. The coroner also said that the trust’s cardiac research and training programme had to be disbanded as a result of the review, and surgeons and nurses are losing vital skills. Finally, significant public funds are being spent on the court’s time and legal settlements.

This troubling situation raises significant public policy issues. The situation has been raised in the other place. Lord Kamall said that

“it is also important to recognise the differences between the coroners’ inquests and the work of the independent mortality review, which was not undertaken to determine the cause of death in individual cases or attribute blame”—[Official Report, House of Lords, 18 May 2022; Vol. 822, c. 451.]

and that it was all about processes, procedures and culture. I would argue, however, that that is not the case.

The Lewis review is specifically called a mortality review, and the terms of reference for the review refer nowhere to a review of processes, procedures or culture. Instead they are focused squarely on whether there are

“problems in care that may have or definitely contributed to the death of a patient.”

Furthermore, the terms of reference explicitly confirm that the review was to consider the same issues as the coroner. I therefore ask the following of my hon. Friend the Minister, although I appreciate that he may want to reflect on this: given the rulings of the coroner and the General Medical Council, I ask that the findings of the NHSI/Lewis review be dropped. This was clearly a review into individual deaths rather than a review of culture, and the findings have been discredited by the coroner. I believe it is firmly in the public interest to drop the conclusions of this review. I further ask that that be done quickly, as it is taking a significant toll on all those involved. I would be most grateful if my hon. Friend the Minister gave this issue his full and due consideration.

It is a pleasure to be here in my new role as Parliamentary Under-Secretary responsible for primary care and patient safety, and I start by thanking my hon. Friend the Member for Kensington (Felicity Buchan) and congratulating her on securing this important debate on cardiac services at St George’s Hospital. Before responding to the specific issues that she raised, I wish to extend my sympathies to the bereaved families she mentioned who have been affected by these issues.

It might be useful if I begin by setting out some of the background and history of cardiac services at St George’s University Hospitals NHS Foundation Trust. It is important to consider the mortality review in the context of the growing concerns that there were about the culture that existed across cardiac services at St George’s, and the impact that context may have had on the safety and quality of services and questions over mortality rates. Indeed, a number of reviews of cardiac services at St George’s and a Care Quality Commission inspection were critical of services, and concerns were raised by a large group of cardiologists from the hospital. Following two mortality alerts from the National Institute for Cardiovascular Outcomes Research, NHS Improvement commissioned an independent external mortality review, which my hon. Friend mentioned. The purpose of the mortality review was to verify that the trust had identified and addressed the concerns raised through both NICOR alerts, and to inform the trust’s discussions with the coroner regarding the deaths.

It goes without saying that the review’s aims and methodology differed significantly from those of an inquest. The independent panel for the review was composed of consultant cardiac surgeons, cardiologists and consultant cardiac anaesthetists drawn from across the country. It was chaired by Mr Mike Lewis, and published its report in March 2020. The panel found shortcomings in 102 of the 202 deaths it examined. In particular, it found that problems in care probably, most likely or definitely contributed to the deaths of 67 heart surgery patients. As my hon. Friend mentioned, the structured judgment reviews are a standard way of assessing deaths. There is always learning following such a level of scrutiny of a service, including for the regulators. However, I would argue that it would not have been acceptable for NHSI to have ignored the professional and public concerns that gave rise to the mortality review in the first place. The trust and NHS Improvement jointly referred 67 heart surgery patients identified by the review to the coroner. The coroner decided to hold inquests into those cases, which are ongoing. NHS England received a prevention of future deaths report, dated 9 May 2022, to which my hon. Friend referred.

My hon. Friend has raised serious concerns about the findings of the coroner in relation to the mortality review of cardiac services at St George’s, the subsequent impact on the services available to people in south-west London, and the impact of regulatory action on the professionals involved. I have set out the background to the mortality review and what it found. Since the independent mortality review, St George’s has taken comprehensive action to improve the quality, leadership and culture in the cardiac unit. Importantly, mortality has returned to normal levels, patient care outcomes have improved, and the Care Quality Commission has found that services are safe. The review greatly assisted the trust by making recommendations that helped to improve the service and deliver better outcomes for patients.

NHS England London region is continuing to work with the trust to improve the services and leadership of the cardiac unit. The restrictions that were placed on the cardiac surgery unit’s practice before the mortality review have now been removed, and the unit’s outcomes are now in line with those of other trusts. Enhanced oversight of the unit continues, with a package of support measures in place to ensure that improvements are made.

As my hon. Friend said, on 7 May 2022, the GMC found that the two doctors excluded by the trust had “no case to answer”. It is important to emphasise that the referral of those doctors was not as a result of the mortality review, which considered issues of safety and did not criticise any individual. It would be inappropriate for me to comment on individual cases in relation to that matter because of ongoing legal issues. Finally, NHS England is committed to reviewing the coroner’s prevention of future deaths report of 9 May and will response in due course.

NHS hospitals are working hard to provide the very best care for their patients and families, and they should always seek to learn and take action when they have concerns. The Government are absolutely committed to improving the standard of investigations into serious patient safety incidents in the NHS to create a culture of learning from mistakes and to improve patient safety.

Question put and agreed to.

House adjourned.