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Archive - Tag: Oxford heart inquiry

September 1, 2010

Dr Phil’s Private Eye Column, Issue 1270 September 1

A solicitor writes…

MD has received a disturbing e mail Huw Morgan, a Medical Protection Society solicitor representing a pathologist who has given evidence to the University Hospitals Bristol (UHB) Pathology Inquiry: ‘It has been alleged that it was he who provided you and/or Private Eye with the information regarding such services which appeared in the 2009 issue(s) of that magazine, shortly before the Inquiry was set up. This is not the case; however he is concerned that such any such mistaken belief on the part of Panel members might be an adverse factor in their assessment of the evidence which he has given to them.’

MD has never had any contact with the pathologist, and the public money used to fund the Inquiry (£464,000 to the end of June 2010) would be better spent focusing on the specific allegations of misdiagnosis in specialist adult and paediatric pathology. Equally important is to ascertain whether appropriate action was taken to investigate the allegations. Concerns about the lack of specialist paediatric pathologists date back to 2001: ‘Over the next 2 years paediatric work was done by adult pathologists with disastrous results, particularly in the fields of childrens’ cancers and Hirschsprung disease.’ An overseas paediatric pathologist was appointed but he was reported to the GMC and removed his name form the medical register in 2004 to avoid investigation.

Allegations about the misreporting of specialist adult pathology were first raised in 2004, and NHS Bristol, the lead commissioner for UHB, has known about concerns at least since October 2007. Detailed allegations were put in writing ‘through the correct channels’ in 2007 and 2008, and the Royal College of Pathologists were aware of them long before the inquiry prompted by the Eye’s exposure in June 2009. UHB is a Foundation Trust, largely divorced from central control and supposedly accountable to its patients. It has ordered and paid for its own inquiry, agreed the terms and the statistical analysis and controls how much of the final report enters the public domain. This story is as much a failure of management as of pathology. In the 15 months since the first Eye column, UHB’s chief executive has resigned, the medical director and head of pathology have found jobs elsewhere and the report seems delayed by an ill-advised hunt for the Eye’s source.

Oxford critics beware…

In 2004, a public health specialist wrote a paper published in the British Medical Journal1 which suggested on the basis of an analysis of administrative data that Oxford had high mortality for paediatric cardiac surgery. Well before publication, two letters were sent to the Radcliffe Infirmary giving details of the results, and a reply from the Medical Director of the Trust did not dispute the figures. After publication, 16 doctors from the Oxford unit wrote to the GMC, disputing the figures and asking whether the author had ‘acted unprofessionally in bringing potentially very harmful information into the public domain in this manner.’ The author underwent a very stressful 4 month investigation, before the GMC decided that the publication of a scientific article in a major peer reviewed journal did not amount to a malicious or unfounded criticism of colleagues. Child heart surgery in Oxford is now suspended following the latest independent analysis which revealed long-standing cultural and management problems, and that ‘between 2000 and 2008, 9 deaths occurred in children undergoing less common procedures, 5.29 times the expected death rate.’ This was before a new surgeon arrived in 2009 and suffered four deaths in fifteen operations (4.8 times the expected death rate). (see Eye 1268) The authors are doubtless awaiting their letters from the GMC…..

1 BMJ 2004;329:825-9


July 30, 2010

Dr Phil’s Private Eye Column Issue 1269, August 4, 2010
Filed under: Private Eye — Tags: — Dr. Phil @ 8:00 am

Oxford Heart Inquiry

Ever since exposing the Bristol heart scandal in 1992, the Eye has argued that complex child heart surgery should concentrated in fewer, more specialized centres. Now, thanks to the rank amateurishness exposed in the Oxford heart inquiry, small units may finally have to merge. The report has many echoes of Bristol, where between 30 and 35 children less than one year died than might have been expected at a typical unit at the time. In Oxford, the numbers were smaller, because surgeon Caner Salih blew the whistle himself after four deaths in fifteen operations between December 2009 and February 2010 (4.8 times the expected death rate). But between 2000 and 2008, 9 deaths occurred in children undergoing less common procedures, 5.29 times the expected death rate. In a nutshell, such a small unit should have ceased doing complex paediatric cardiac surgery after the Bristol report a decade ago, and must never be allowed to again.

Prior to the arrival of Mr Salih in December 2009, the Oxford Radcliffe Infirmary had a single paediatric heart surgeon, Professor Steven Westaby, dividing his time between adult and paediatric work. For over four years, Oxford had the equivalent of half a child heart surgeon, on call twenty four hours a day, every day of the year. When Mr Salih arrived from Melbourne, Professor Westaby took a deserved three week holiday. So a new, relatively inexperienced surgeon started on the unit with inadequate induction, no on-site mentoring and no senior operating help for the more complex cases.

Professor Westaby told the inquiry ‘that he did not expect Mr Salih to operate during his absence. On learning from the panel that Mr Salih had operated during that time, he said that he did not expect that the operations were complex.’ Unfortunately, they were. Mr Salih told the inquiry he did not regard Professor Westaby’s absence as ‘relevant to what operations he carried out’, and it was clear that the two had ‘not satisfactorily discussed the matter.’ By the time Westaby returned, Salih had announce his intention to leave his job. Westaby presence didn’t improve matters, because he had an ‘idiosyncratic’ approach to operating and so they worked in isolation, rather than as a team.

Having been promised two operating lists at interview, Mr Salih wasn’t given any to start with, having to cram operations in whenever a slot arose. He was finally given one on a Friday morning, not enough to improve his skill levels, and intensive care was often full and monitoring of sick babies over the weekend harder. There was no dedicated paediatric perfusionist able to offer the life support back-up he was used to, and neither was the surgical equipment he needed available from the start of his appointment. He did manage to find a mentor, over the phone in London, but this was hardly ideal given the complexity of the operations he was attempting. The review concluded that ‘all the cases were complex and surgery was high risk. We found no errors of judgement that directly lead to any of the deaths…. we found no evidence of poor surgical practice… it was an error of judgement for him (Mr Salih) to undertake the fourth case.’

The review found plenty of evidence of the dismal monitoring of safety by the Trust. In December 2009, Mr Salih expressed concerns about the support he was receiving, but by February 2010 he still hadn’t met the Paediatric Directorate manager. On February 19, he informed colleagues that he was ceasing to operate because of the string of deaths, but no formal action was taken to suspend services on that day. Surgery was not officially ‘paused’ until February 24, but no-one considered this warranted reporting a ‘Significant Untoward Incident’ or telling the SHA. Only when a journalist threatened to leak the story was an SUI declared on March 3. Once the story broke, an extraordinary mortality meeting was held to discuss the four deaths, 21 days after the last had occurred. Prof. Westaby didn’t attend and neither did one of the paediatric anaesthetists. Most damning of all is that parents don’t appear to have been told the true, surgeon or unit specific risks of the operations their babies were undergoing but rather national average risks. It’s as if Bristol never happened. Labour ducked the opportunity to safely sort out child heart surgery. The coalition mustn’t make the same mistake.


July 23, 2010

Dr Phil’s Private Eye Column Issue 1268, July 21, 2010
Filed under: Private Eye — Tags: , , — Dr. Phil @ 2:20 pm


Just had a phone call from a very reliable source about the Oxford heart inquiry, due to report on Thursday, I believe. Apparently big failures in clinical governance and oversight at trust level, lessons not learned from Bristol etc but despite that, the Oxford unit has asked to be allowed to continue paediatric cardiac surgery. I strongly believe it should remain suspended pending the findings of the latest paediatric cardiac services review. Decision rests with the SHA. Who will take these decisions when there’s no SHA?

 Medicine Balls: The White Paper

How does Andrew Lansley’s Equity and Excellence: Liberating the NHS compare to White papers past? Frank Dobson’s  1998 bestseller, ‘A First Class Service – Quality in the new NHS’  gave us 191 mentions of ‘quality’ and promised to ‘publish outcomes to end unacceptable variations in health care.’ A decade later, Lord Darzi gave us ‘High Quality Care For All’ with 359 exhortations of ‘quality’ and a warning that the ‘unacceptable variations that have grown up in recent years must end.’ Lansley is also a firm believer that the way to achieve ‘quality’ (110) and to end ‘unacceptable services’ is to publish ‘outcomes’ (85). But after 13 years of Labour, we have precious little access to robust and valid comparisons of different clinical services. And without outcomes, offering patients ‘choice’ (Darzi 62, Lansley 84) is pointless, and you can’t ‘commission’ (Lansley 184) excellent services.

 There will always be variation in healthcare, and collecting and analyzing outcomes to try to understand which variations are due to chance and which to unacceptable practice is both complex and expensive. Labour made little headway and most commissioning was done on the basis of cost. So various PCTs gave Out of Hours Services to a company called Take Care Now because the price was right and they sounded as if they cared. Alas, they employed overseas doctors who didn’t know the patients, didn’t know how the NHS worked and didn’t understand how to use drugs like diamorphine. Dr Daniel Urbani killed David Gray by injecting him with ten times the safe dose because he was exhausted, had poor English and the drug was not routinely used in Germany. Prior to his death, two other German doctors had made similar errors (without causing death) but despite warnings from one of its own doctors that ‘it was only a matter of time before a patient is killed’, Take Care did not take note.

 One way to stop doctors giving ten times the dose of diamorphine is to not allow them to walk around with it in their bags. I’ve only ever carried one 5mg ampoule, so why Dr Urbani had 50mg or more on him is a mystery to most GPs. Lansley said before the election that he was going to put GPs back in charge of commissioning out of hours care, and it makes sense that clinicians should help commission and manage the services they know most about. Indeed Lansley is very big on services being ‘clinically commissioned, credible, approved, led and justified.’

 But just who are these clinicians? Midwives get 1 citation in Liberating the NHS, nurses 2, pharmacists 2, consultants 5 and GPs….. 75.  ‘Manage’ gets 43 citations but ‘manager’ only 3. GPs, apparently, can do it all by organizing themselves into ‘consortia’ (new entry, 64). Lansley has picked up the Tory baton from where it was discarded 13 years ago, just as fund-holding GPs were pooling themselves into multifunds, only to be scrapped by Labour and replaced by PCTs. In seven years as shadow health secretary, Lansley has had his ear bent incessantly by GPs complaining about the control-freakery and lack of clinical understanding of PCTs. So he’s calling their bluff, taking out the Strategic Health Authorities and the PCTs, and giving GPs the responsibility for commissioning nearly everything, while saving £20 billion and making sure the mighty Foundation Trusts don’t hoover up what’s left.

 GPs have always seen themselves as NHS gatekeepers, managing as much illness as possible in the community to present precious NHS resources being squandered in expensive hospitals. But emergency admissions to hospital are up by 12% and unless GPs can put a brake on this, they’ll be taking on an impossible job. It’s a bit like being handed the steering wheel just as the runaway coach approaches the cliff edge. And amidst all the financial pressure, it’s hard to see who will find the money to collect and analyze comparative outcomes in a meaningful way to guide commissioning and choice. Lansley’s catch phrase of ‘no decision about you without you’ sounds great for patients (217). But when they ask me which of my local hospitals is best for, say, hip replacements and which is ‘unacceptably poor’, I haven’t got a clue. And I’m supposed to be in charge. Now I must find out which consortium I belong to.


March 22, 2010

Dr Phil’s Private Eye Column, Issue 1258, March 17, 2010
Filed under: Private Eye — Tags: , , — Dr. Phil @ 10:02 am

 Labour’s dead babies

‘The death of a child is an unbearable sorrow that no parent should have to endure’ said Gordon Brown a year ago. And yet Labour’s record in providing safe services to critically ill babies is lamentable. Whatever cause the current inquiry finds for the deaths of four babies following heart surgery in Oxford, it’s patently clear that the unit simply isn’t fit for purpose. With just one dedicated paediatric cardiac surgeon (now departed) and one surgeon mixing adult and paediatric work, it beggars belief that – after the Bristol scandal – Labour could have allowed such a small unit to carry on performing such complex surgery.

This is not a new argument. Since exposing the Bristol scandal just 18 years ago, MD has argued ad nauseum that highly specialised healthcare must be concentrated in fewer units that are safely staffed and equipped. Hardly rocket science. The Kennedy Inquiry reached the same conclusion in 2001 and triggered an expert review, chaired by cardiac surgeon James Munro, which recommended that the number of child heart surgery centres be reduced to six. Labour ignored the recommendations. NHS Medical Director and cardiac surgeon Bruce Keogh realised that another disaster was imminent, and instigated a second service review last year, saying that ‘Failure to reconfigure child heart surgery will be a stain on the soul of the specialty and will compromise the treatment of the most vulnerable members of the next generation.’ (Eye 20.1.10).

This review will shortly recommend that each unit must have a minimum of four surgeons and perform at least 400 procedures a year. Oxford did less than a hundred, but at least surgeon Caner Salih realised he worked in an unsafe environment and reported the run of deaths himself before leaving for another job. Labour should have decommissioned the Oxford unit back in 2003, along with several others with only two surgeons. But that would have been politically awkward. As MD predicted in January 2004,  ‘All the units will continue to provide a miraculously safe service with inadequate staffing until one cracks under the pressure… The seeds have already been sown for another Bristol, and the blame lies firmly with this cowardly government.’

Eye reader Joanne Ferguson is equally unimpressed with Labour’s failure to adequately fund neonatal care. The NHS Neonatal Taskforce was set up in February 2008, prompted by a National Audit Office report criticizing the organisation of neonatal services and staff shortages. Last November, the taskforce launched a Toolkit for High Quality Neonatal Services, describing it as ‘the best opportunity in 30 years to raise special care baby services up to the standard that babies and their families deserve.’ Alas, there is a shortfall of over 2,700 nurses and 300 supporting therapists that are needed to give premature babies one on one care. Labour has done very little to reverse this shortfall in paediatric intensive care, and labour wards are also perilously understaffed with 500 potentially preventable deaths a year still occurring in childbirth (see Eye November 2009).

Mrs Ferguson has set up a website1 linking expert recommendations that Labour hasn’t funded with harrowing stories of unsafe care. Brown may claim he wants no parents to endure what he has, but plenty still are thanks to a lack of courage from his government. And if he bumps into Mrs Ferguson on the stump, he’ll get some tough questions. Such as why, if £105 billion goes into the NHS, is she reporting the story of a premature baby lying all day in shit?



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