Heart surgery patients in London have died “unnecessarily” and faced increased risk of death as botched NHS investigations into dozens of deaths reduced a hospital’s ability to treat people, a coroner has warned.
“Unnecessary” patient deaths have occurred as a result of heart surgery at St George’s University Hospital Trust being restricted and emergencies diverted to other “over stretched” hospitals, following investigations by national NHS bodies.
The warning that deaths have occurred and may occur in the future, comes following the conclusion of a series of inquest hearings in March, during which it was found the NHS’ wrongly blamed a team of cardiac surgeons for the deaths of dozens of patients.
Coroner Fiona Wilcox, in a report published on Wednesday, has now said the “inadequate” NHS led investigations, which criticised the care of 67 patients, led to people being put increased risk of death.
It is the latest update in a long running saga over the safety of cardiac surgery at St George’s hospital, which has faced scrutiny since 2018 after reports said the unit had a “toxic environment.
The NHS’ investigations into the deaths of 67 patients ruled there were “shortcomings” in care. It led to complex operations being diverted elsewhere and doctors being referred to the General Medical Council.
According to the coroner’s findings, capacity within cardiac surgery at the unit is down by 60 per cent and staff are becoming “deskilled.”
Coroner Wilcox has said as a result of the restrictions placed on St George’s unit, by the NHS, “emergency patients being diverted away from St George’s Hospital has resulted in unnecessary deaths.”
She said public confidence in heart surgery at the hospital has been “so dented” that patients have been discouraged from going to the hospital and thus increasing their risk of death.
The NHS investigations, called structured judgement reviews, were found to have been based on “incomplete” evidence, without any discussions with the clinicians involved, and looked at for only 10-20 minutes by the experts involved.
The report added: “That this [structured judgement review] process has undermined the department unnecessarily, impacting on morale and the mental health and confidence of the cardiac surgeons and other clinicians and non-clinicians within St George’s Hospital which may translate into a lower quality of care for patients.”
The scathing warning added that the “unfounded” damage to the reputation of the cardiac surgery department at the trust would take “years” to repair, and that the families of patients involved had been put through “immeasurable” pain.
The report said the NHS also failed to identify any issues from which lessons could have been learnt and patient safety improved.
It warned the NHS’ investigations had further undermined “the public confidence in the NHS, which the public may perceive as the NHS being unable to appropriately audit its own work.”
A St George’s spokesperson said in a statement after publication: “We have fully implemented the recommendations of the Independent Mortality Review, which helped improve the quality, leadership and culture in the cardiac unit. Improvements we have made have led to better outcomes for patients and mortality is also now in line with that expected nationally.”
NHS England was been approached for comment.
