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/08/bullying-stopped-nhs-staff-reporting-heart-surgery-deaths-says-cqc
The article has changed 7 times. There is an RSS feed of changes available.
| Version 0 | Version 1 |
|---|---|
| Bullying stopped staff reporting heart surgery deaths, says CQC | Bullying stopped staff reporting heart surgery deaths, says CQC |
| (35 minutes later) | |
| A culture of bullying prevented staff at an NHS trust from speaking out about the fact too many heart surgery patients were dying, a damning report has said. | A culture of bullying prevented staff at an NHS trust from speaking out about the fact too many heart surgery patients were dying, a damning report has said. |
| Inspectors from the Care Quality Commission (CQC) found major problems with the way Queen Elizabeth hospital in Birmingham runs its heart unit, which has a long history of high death rates compared with other hospitals. | Inspectors from the Care Quality Commission (CQC) found major problems with the way Queen Elizabeth hospital in Birmingham runs its heart unit, which has a long history of high death rates compared with other hospitals. |
| Related: Leading hospital under CQC scrutiny over high heart surgery death rate | Related: Leading hospital under CQC scrutiny over high heart surgery death rate |
| The report comes after concerns about the death rates were revealed by the Guardian last week. Calculations by the Guardian suggest that 17 people may have died over the last three years who should have survived. | The report comes after concerns about the death rates were revealed by the Guardian last week. Calculations by the Guardian suggest that 17 people may have died over the last three years who should have survived. |
| The CQC report published on Tuesday found that the NHS trust ignored repeated warnings about its high death rates and there were a number of “near misses and unexpected deaths” in critical care. | The CQC report published on Tuesday found that the NHS trust ignored repeated warnings about its high death rates and there were a number of “near misses and unexpected deaths” in critical care. |
| University hospitals Birmingham NHS foundation trust, which runs the hospital, has been ordered to make improvements and send weekly surgery results to the CQC. | |
| Inspectors found a series of issues at the hospital such as: | |
| • Staff described a bullying and blame culture in operating theatres and critical care. They found it difficult to raise concerns or challenge poor performance and behaviours. They did not always report incidents. | • Staff described a bullying and blame culture in operating theatres and critical care. They found it difficult to raise concerns or challenge poor performance and behaviours. They did not always report incidents. |
| • Trainee surgical doctors were not always supervised by a consultant in theatres despite needing it. | • Trainee surgical doctors were not always supervised by a consultant in theatres despite needing it. |
| • There were difficulties finding consultants when things went wrong in operations. | • There were difficulties finding consultants when things went wrong in operations. |
| • Some operations took longer than expected and patients were on cardiopulmonary bypass for long periods. | |
| • There was a higher-than-expected rate of blood transfusions, while re-bleeding rates after surgery were higher, and the number of patients needing to go back into surgery was “much higher” than the national average. | |
| • Consultant cardiac surgeons did not consistently undertake ward rounds on the cardiac surgery ward. They were also not in theatre “at appropriate times” and did not communicate effectively with staff in critical care. | • Consultant cardiac surgeons did not consistently undertake ward rounds on the cardiac surgery ward. They were also not in theatre “at appropriate times” and did not communicate effectively with staff in critical care. |
| • There was a high rate of surgery cancellations, with some patients’ operations being cancelled several times. The “institutional behaviour” of surgeons contributed to this, including late starts to operations, extended length of operation times, and waiting for confirmation of a bed in intensive care often resulting in the cancellation of subsequent operations. | • There was a high rate of surgery cancellations, with some patients’ operations being cancelled several times. The “institutional behaviour” of surgeons contributed to this, including late starts to operations, extended length of operation times, and waiting for confirmation of a bed in intensive care often resulting in the cancellation of subsequent operations. |
| • There were vacancies in theatres that resulted in operations being cancelled or staff working extra shifts. Nurses expressed concern that they had no specific training in looking after heart patients or using specialist equipment. | |
| • Medical staff in critical care were not all cardiac-trained and at night there were difficulties accessing the on-call surgeon or the consultant anaesthetist. There had been a number of near misses and unexpected patient deaths in critical care. | • Medical staff in critical care were not all cardiac-trained and at night there were difficulties accessing the on-call surgeon or the consultant anaesthetist. There had been a number of near misses and unexpected patient deaths in critical care. |
| • Cardiologists at the trust were increasingly referring patients to other local hospitals for surgery where there were shorter wait times, fewer cancellations and good patient outcomes. | • Cardiologists at the trust were increasingly referring patients to other local hospitals for surgery where there were shorter wait times, fewer cancellations and good patient outcomes. |
| • The heart surgery service was not well led and was “fragmented and dysfunctional”. Delays to making decisions had a negative impact on patient care. | • The heart surgery service was not well led and was “fragmented and dysfunctional”. Delays to making decisions had a negative impact on patient care. |
| • A surgical checklist aimed at preventing harm to patients was not always used. | • A surgical checklist aimed at preventing harm to patients was not always used. |
| Related: The Guardian view on heart surgery failings in Birmingham: disdain for the data | Editorial | Related: The Guardian view on heart surgery failings in Birmingham: disdain for the data | Editorial |
| The report said the trust had only recently started a quality improvement programme (QIP), despite concerns being identified in 2013 and consultants approaching the executive team in 2014 with concerns about patient deaths and outcomes. | The report said the trust had only recently started a quality improvement programme (QIP), despite concerns being identified in 2013 and consultants approaching the executive team in 2014 with concerns about patient deaths and outcomes. |
| The trust was also told its death rates were outside the national average in March 2015. | The trust was also told its death rates were outside the national average in March 2015. |
| England’s chief inspector of hospitals, Prof Sir Mike Richards, said: “When we inspected cardiac surgery at the Queen Elizabeth medical centre we found a lack of strong leadership and a staff team with low morale that felt unable to raise concerns or report incidents. | England’s chief inspector of hospitals, Prof Sir Mike Richards, said: “When we inspected cardiac surgery at the Queen Elizabeth medical centre we found a lack of strong leadership and a staff team with low morale that felt unable to raise concerns or report incidents. |
| “Initial data regarding surgery outcomes in the months since our inspection show an improvement, but we need to continue to monitor the service. | |
| “I have made it clear to the trust that it must continue its work to develop a culture of strong team-working and improve staff training as it addresses the wider issues identified on inspection.” | “I have made it clear to the trust that it must continue its work to develop a culture of strong team-working and improve staff training as it addresses the wider issues identified on inspection.” |
| According to the Guardian, data posted on the Society for Cardiothoracic Surgery website last September – the most recent available – shows the hospital has been a “red outlier”, with heart surgery death rates outside an acceptable range, over the three years from April 2011 to March 2014. In that time, the unit operated on 1,713 patients.. |