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

James Morris Excerpts

Monday 18th July 2022 Commons Chamber

[The Parliamentary Under-Secretary of State for Health and Social Care (James Morris)]

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.