Unsafe Cardiac Unit caused death of four babies
An external review published yesterday has found that four babies died within three months of each other after being operated on by a surgeon who was appointed to raise patient numbers at the John Radcliffe Hospital in Oxford. The report has been written by Dr Bill Kirkup, the director of clinical standards at the South Central Strategic Health Authority (SHA).
Out-of-date equipment and poor working practices
Mr Caner Salih, who was left alone on only his second day in the post, complained about the age of the equipment and poor working practices at the children's cardiac unit. He blew the whistle to managers after four of his patients died within three months and asked to stop operating. The doctor’s concerns were ignored and it was only when journalists began to ask questions that the trust managers informed the SHA and the health care regulator, the Care Quality Commission. It may have been up to six weeks after Mr Salih raised concerns that children's heart surgery at the trust was suspended.
Oxford cardiac unit unsafe
The report recommends that operations at the children’s cardiac unit should never take place again because it is unsafe.
Managers at the John Radcliffe Hospital were aware that a forthcoming review of children's heart surgery was likely to recommend the closure of small units which handled few patients the report found. The Oxford Cardiac Centre at the John Radcliffe Hospital is the smallest cardiac unit in the country, treating just 100 patients a year.
In order to try to boost patient numbers, managers took on another consultant surgeon. The job was Mr Salih's first consultant post in the UK after working in Australia.
But the report says he was left alone when senior consultant Stephen Westaby went on holiday for three weeks the day after Mr Salih started. The report does not criticise Professor Westaby directly but refers to him being "idiosyncratic" and that nurses and anaesthetists had adapted to his ways of working.
Four babies died within three months
Four babies on whom Mr Salih operated died between December 2009 and February 2010. The report says that Mr Salih complained to managers after finding it impossible to continue to operate with what he said was out-of-date equipment and working practices.
Mr Salih's competence has not been called into question and there is no suggestion he was in any way responsible for the deaths.
The report examined each of the four deaths in detail and points out that the national mortality rates for the procedures the children underwent were not high. However each child operated on at the cardiac unit in the John Radcliffe Hospital was extremely ill and this increased the likelihood of a poor outcome.
The report states that, in at least one case, it is probable the child would have died anyway. In the other three cases it is "difficult to say".
The first of the babies to die was named in March as Nathalie Lo, who died on 22 December 2009 when she was 23 days old. She had required corrective surgery on a heart valve.
Her mother, Aida Lo, 29, and her father Zeilo Li, 30, who live in Oxford but are originally from East Timor, have demanded to know if her death could have been prevented.
"A mother wants the best for her child and I trusted my baby to the hospital," Mrs Lo said earlier this year as reported by the Telegraph. "What else could I do? I believed Nathalie was in good hands. But finding out that three other mothers have been through this in such a short time is a big shock. Now I'm angry and I just want to know what happened to my baby."
Bad hospital management
The report is highly critical of the hospital's handling of the situation, as managers did not inform the SHA or the Care Quality Commission of the claims made about the cardiac unit by Mr Salih at the time that he raised them. It was not until television reporters began looking into the matter that the trust took action, the report says.
Expert medical negligence lawyer Adrian Desmond comments on the news “This report is reminiscent of the Bristol heart scandal in which 35 babies died. The children died after being treated at Bristol Royal Infirmary's heart unit between 1990 and 1995. It led to the biggest public inquiry ever undertaken into the workings of the NHS. Sir Ian Kennedy, who chaired the inquiry, recommended that children's heart surgery be carried out only in highly specialist centres. This has yet to be acted on.
The Oxford trust was aware that an ongoing review, conducted by Sir Ian Kennedy, was likely to recommend that children's heart surgery be concentrated in fewer, larger units so the motivation of the Trust managers has been called into question.
The Kennedy review is due to be published this month and it is expected to recommend that the number of units offering children's heart surgery be cut from 11 to five or six, so that each one operates on around 400 cases a year and has an establishment of four surgeons. We will cover that review when it is published.”
Consistent with our policy when giving comment and advice on a non-specific basis, we cannot assume legal responsibility for the accuracy of any particular statement. In the case of specific problems we recommend that professional advice be sought.
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