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Investigation into the safety of child heart surgery in Leeds – NHS England

The client

NHS England, Healthcare Sector

Challenge

NHS England asked Verita to conclude a series of investigations into the safety of child heart surgery in Leeds. Surgery was temporarily suspended in March 2013 when data suggested that death rates were unacceptably high and concerns were raised by families and from clinicians from a rival service in Newcastle.

Scope

Verita investigated the care and treatment of 14 Leeds patients, and produce an overarching report summarising previous investigations and setting out lessons to be learned.

Process

The Verita team involved associate Lucy Scott-Moncrieff and partner Barry Morris. An advisory panel of four clinicians were recruited to help us formulate and validate our findings about the care of some of the children at the paediatric cardiac surgery unit at Leeds. The panel consisted of clinicians who had expertise in treatment and management of babies, children and young people with serious heart defects and/or more general expertise in high-quality hospital systems and processes.

We identified and reviewed a large amount of documentary evidence including patient case notes from both Leeds and Newcastle, policies from UK cardiac centres, previous reports and reviews, complaints and statements from families.

We also conducted 28 interviews with:

  • families of affected patients
  • individuals and groups of staff at LTHT
  • individuals and groups of staff at the trust raising concerns
  • NHS England
  • NICOR.

The work was undertaken against the sensitive ‘political’ background of a national review of paediatric cardiac services which had recommended some existing services be moved to other centres which would have had a significant impact on both Leeds and the trust who raised concerns about Leeds services.

Findings

Although the Leeds service was found to be safe, we concluded that the national review of children’s heart surgery services had put both Leeds and Newcastle services under threat and had damaged trust between them. We found that everyone expressed sincerely held concerns but they were not always in possession of all the facts.

Outcome

Upon completion of our review we produced two reports that set out:

  • our review of patient cases at LTHT
  • the lessons to be learnt from the management of these cases
  • recommendations for any further actions that could be taken to improve patient
  • management and patient pathways, inter-unit referrals, professional relationships and communications
  • potential wider implications identified for other parts of the NHS

Testimonial/feedback

NHS England’s deputy medical director Mike Bewick said: “Patients should be reassured that this service has been rigorously scrutinised and has improved as a result. Not only have we learnt about services in Leeds, we have learned lessons of relevance nationally.”