This article is from the source 'guardian' and was first published or seen on . It last changed over 40 days ago and won't be checked again for changes.

You can find the current article at its original source at http://www.theguardian.com/society/2016/mar/03/queen-elizabeth-hospital-heart-surgery-data-kennedy-report

The article has changed 2 times. There is an RSS feed of changes available.

Version 0 Version 1
The history of heart surgery failures: tragedies born of arrogance not malpractice The history of heart surgery failures: tragedies born of arrogance not malpractice
(6 months later)
In July 2001, a report was published into one of the biggest scandals the NHS had known – the tragic and unnecessary deaths of babies who had heart surgery in a Bristol hospital. Up to 35 children under the age of one need not have died, said Sir Ian Kennedy, who led the inquiry and wrote the report. It was regarded as one of the great watershed moments for the NHS.In July 2001, a report was published into one of the biggest scandals the NHS had known – the tragic and unnecessary deaths of babies who had heart surgery in a Bristol hospital. Up to 35 children under the age of one need not have died, said Sir Ian Kennedy, who led the inquiry and wrote the report. It was regarded as one of the great watershed moments for the NHS.
Related: Leading hospital under CQC scrutiny over high heart surgery death rate
The tragedy happened not because of malpractice but because of arrogance. The Bristol surgeons were not good enough at the complex operations on tiny hearts that could have saved lives. But they did not know that, because they made no attempt to compare their own performance with that of surgeons elsewhere. If those babies had gone to other heart units in other hospitals, they might have lived.The tragedy happened not because of malpractice but because of arrogance. The Bristol surgeons were not good enough at the complex operations on tiny hearts that could have saved lives. But they did not know that, because they made no attempt to compare their own performance with that of surgeons elsewhere. If those babies had gone to other heart units in other hospitals, they might have lived.
Kennedy’s report was a searing indictment not just of the individual surgeons but the entire medical establishment. “We cannot say that the external system for assuring and monitoring the quality of care was inadequate. There was, in truth, no such system,” it said.Kennedy’s report was a searing indictment not just of the individual surgeons but the entire medical establishment. “We cannot say that the external system for assuring and monitoring the quality of care was inadequate. There was, in truth, no such system,” it said.
The systems that were set in place as a result of the damning Kennedy report have picked up exactly the same issue at the Queen Elizabeth hospital in Birmingham, 15 years on. This time it is adults, not babies, but the bottom line is the same: there have been too many deaths.The systems that were set in place as a result of the damning Kennedy report have picked up exactly the same issue at the Queen Elizabeth hospital in Birmingham, 15 years on. This time it is adults, not babies, but the bottom line is the same: there have been too many deaths.
Thanks to Kennedy, heart surgeons’ mortality rates are now centrally recorded. They are required to submit data that is published so that other surgeons can compare how well they are doing and – an important demand from Kennedy – so that the public can know how good their doctors are and decide whether they will be in safe hands.Thanks to Kennedy, heart surgeons’ mortality rates are now centrally recorded. They are required to submit data that is published so that other surgeons can compare how well they are doing and – an important demand from Kennedy – so that the public can know how good their doctors are and decide whether they will be in safe hands.
Related: Interview with head of Bristol baby scandal inquiry
The data is collected by the heart surgeons’ professional body, the Society for Cardiothoracic Surgeons. It is analysed by the National Institute for Cardiovascular Outcomes Research (NICOR) at UCL. Then it goes to the Healthcare Quality Improvement Partnership (HQIP), which is tasked by government with producing information for professionals and the public on the performance not only of heart surgeons but more recently others too.The data is collected by the heart surgeons’ professional body, the Society for Cardiothoracic Surgeons. It is analysed by the National Institute for Cardiovascular Outcomes Research (NICOR) at UCL. Then it goes to the Healthcare Quality Improvement Partnership (HQIP), which is tasked by government with producing information for professionals and the public on the performance not only of heart surgeons but more recently others too.
The ambition is to achieve complete transparency, so that doctors know how they are doing and patients can choose who they want to care for them.The ambition is to achieve complete transparency, so that doctors know how they are doing and patients can choose who they want to care for them.
But at Birmingham, things seem to have gone badly wrong. NICOR and then HQIP last year told the university hospitals Birmingham NHS foundation trust (UHB) that the death rates at the Queen Elizabeth, which it runs, were too high. In the parlance, they were a “red outlier”.But at Birmingham, things seem to have gone badly wrong. NICOR and then HQIP last year told the university hospitals Birmingham NHS foundation trust (UHB) that the death rates at the Queen Elizabeth, which it runs, were too high. In the parlance, they were a “red outlier”.
The trust argued that the data was skewed by the results of Ian Wilson, a surgeon it sacked in 2013 because he allegedly fiddled his results to make them look better than they were. Wilson told an inquest in October 2014 into the deaths of three patients, where he was severely criticised, that he was simply writing down the details from memory rather than looking at the patient notes.The trust argued that the data was skewed by the results of Ian Wilson, a surgeon it sacked in 2013 because he allegedly fiddled his results to make them look better than they were. Wilson told an inquest in October 2014 into the deaths of three patients, where he was severely criticised, that he was simply writing down the details from memory rather than looking at the patient notes.
And, said the trust, HQIP should have included the results from a private hospital where its surgeons also work. No, said HQIP – Wilson’s data made no difference and the private hospital does not count because it is not run by the trust.And, said the trust, HQIP should have included the results from a private hospital where its surgeons also work. No, said HQIP – Wilson’s data made no difference and the private hospital does not count because it is not run by the trust.
HQIP then referred Birmingham to the Care Quality Commission – the inspectorate. Before Christmas, a team including two surgeons from other hospitals went in. It is understood they were unimpressed, finding there was poor communication between heart surgeons and cardiologists and the intensive care staff. The problems were not just with the data. They had “significant concerns particularly with regard to the safety, effectiveness and responsiveness of the service”, CQC said in a statement.HQIP then referred Birmingham to the Care Quality Commission – the inspectorate. Before Christmas, a team including two surgeons from other hospitals went in. It is understood they were unimpressed, finding there was poor communication between heart surgeons and cardiologists and the intensive care staff. The problems were not just with the data. They had “significant concerns particularly with regard to the safety, effectiveness and responsiveness of the service”, CQC said in a statement.
The inspection team considered closing down planned heart surgery, at least until all of this had been sorted out. Instead, it is requiring weekly reports from Queen Elizabeth on the results of all heart operations, to ensure patients are safe, and has recommended an independent review to decide what needs to be done, to be carried out by the Royal College of Surgeons.The inspection team considered closing down planned heart surgery, at least until all of this had been sorted out. Instead, it is requiring weekly reports from Queen Elizabeth on the results of all heart operations, to ensure patients are safe, and has recommended an independent review to decide what needs to be done, to be carried out by the Royal College of Surgeons.
But more than two months after the inspection, which found a troubled heart surgery unit with issues that could potentially endanger patients, nothing has emerged into the public domain.But more than two months after the inspection, which found a troubled heart surgery unit with issues that could potentially endanger patients, nothing has emerged into the public domain.
It looks like a wrangle over data, but behind the scenes are warring factions, suspicion, bitterness and personality clashes.It looks like a wrangle over data, but behind the scenes are warring factions, suspicion, bitterness and personality clashes.
Some of this centres on the sacked surgeon, Ian Wilson. He was popular and highly regarded among his peers. His friends believe that – under pressure to keep his own mortality rate low – he made a mistake. A GMC hearing is due to investigate whether it was fraud.Some of this centres on the sacked surgeon, Ian Wilson. He was popular and highly regarded among his peers. His friends believe that – under pressure to keep his own mortality rate low – he made a mistake. A GMC hearing is due to investigate whether it was fraud.
But Wilson’s friends feel the trust was wrong to sack him. He should have been given help and support instead, they claim. And some believe he has been made a scapegoat for the heart surgery unit’s poor performance, which the trust denies.But Wilson’s friends feel the trust was wrong to sack him. He should have been given help and support instead, they claim. And some believe he has been made a scapegoat for the heart surgery unit’s poor performance, which the trust denies.
Tim Graham, another heart surgeon who works at the same hospital, is also in the headlights. He is the current president of the Society for Cardiothoracic Surgeons, which collects the mortality data. He has been criticised by his fellow surgeons for allegedly failing to stand up for Wilson.Tim Graham, another heart surgeon who works at the same hospital, is also in the headlights. He is the current president of the Society for Cardiothoracic Surgeons, which collects the mortality data. He has been criticised by his fellow surgeons for allegedly failing to stand up for Wilson.
And then there is Domenico Pagano, a Birmingham surgeon whose results are exceptionally good. But he is currently taking flak, as is medical director David Rosser, because they are joint authors with the NHS medical director, Sir Bruce Keogh, of a controversial paper cited by Jeremy Hunt as evidence that more patients die in all hospitals at the weekend. The health secretary used this as justification for enforcing a contract normalising Saturday working on junior doctors.And then there is Domenico Pagano, a Birmingham surgeon whose results are exceptionally good. But he is currently taking flak, as is medical director David Rosser, because they are joint authors with the NHS medical director, Sir Bruce Keogh, of a controversial paper cited by Jeremy Hunt as evidence that more patients die in all hospitals at the weekend. The health secretary used this as justification for enforcing a contract normalising Saturday working on junior doctors.
Those who are critical of the UHB trust allege it thinks it is untouchable due to having friends in high places.Those who are critical of the UHB trust allege it thinks it is untouchable due to having friends in high places.
Related: Should the NHS publish patients’ death rates? The experts’ view
On the other side of the fence, the trust feels beleaguered, convinced that it is under attack from Wilson’s friends, who are attempting to blame the heart unit as a whole and clear Wilson’s name.On the other side of the fence, the trust feels beleaguered, convinced that it is under attack from Wilson’s friends, who are attempting to blame the heart unit as a whole and clear Wilson’s name.
This is not the first time heart surgery results have become hugely contentious. In March 2013, surgery was suspended at the children’s heart unit of the Leeds General Infirmary because cardiac data from NICOR apparently showed death rates were too high. The unit was already threatened with closure as part of a plan to reduce the number of hospitals carrying out children’s heart surgery in England – something the Kennedy report had recommended.This is not the first time heart surgery results have become hugely contentious. In March 2013, surgery was suspended at the children’s heart unit of the Leeds General Infirmary because cardiac data from NICOR apparently showed death rates were too high. The unit was already threatened with closure as part of a plan to reduce the number of hospitals carrying out children’s heart surgery in England – something the Kennedy report had recommended.
Leeds fought to keep the unit open, supported by parents whose children had successful operations there and by politicians. Investigations found the mortality rate was acceptable after all but that the unit had been red-flagged because it had failed to submit complete data, which meant it could not know whether its operations were safe or not.Leeds fought to keep the unit open, supported by parents whose children had successful operations there and by politicians. Investigations found the mortality rate was acceptable after all but that the unit had been red-flagged because it had failed to submit complete data, which meant it could not know whether its operations were safe or not.
The Kennedy report was a turning point for the NHS, in that it ensured data on heart surgery was collected and shared for the first time. But disagreements over what that data means and conflicts among the very human characters involved mean that there is much to do before patients and the wider public can really rely on it. The decision of where to go for heart surgery could result in a better quality life – or potentially their death.The Kennedy report was a turning point for the NHS, in that it ensured data on heart surgery was collected and shared for the first time. But disagreements over what that data means and conflicts among the very human characters involved mean that there is much to do before patients and the wider public can really rely on it. The decision of where to go for heart surgery could result in a better quality life – or potentially their death.