May 24, 2022

Avoidable deaths at St George’s Hospital: the saga continues

I was disturbed to read about the latest developments in the ongoing saga relating to standards in heart surgery at St George’s Hospital in London. This saga has now been unfolding for some years.

The story began with two separate alerts relating to cardiac surgery, which were triggered between 2013 and 2018. In both it was found that survival rates at St George’s Hospital for cardiac surgery fell below accepted safe standards.

The first of the two alerts led to an internal review at the Trust, which identified a “toxic” culture in the cardiac unit. The second led to an external review, published in March 2020 This ruled that there were significant problems with the care of some 102 patients, of whom it was found that 67 died avoidably. The Trust apologised unreservedly for the shortcomings that had been identified, and (other than further assessment of data and working practices to ensure that nothing like this happened again) that should have been the end of the story.

Unfortunately, it isn’t.

It has now emerged that following this review, the Trust’s management put very stringent restrictions into place regarding the types of patient who were eligible for surgery on the unit.

In all surgical specialisms, surgeons submit their results for particular operations and pathologies annually. This data is risk-stratified (a scoring process, which allows units to see where its surgeons sit individually in relation to national averages, and how the unit as a whole is doing in relation to particular procedures and conditions). In theory, this allows early detection of emerging problems. In practice, surgeons in unhappy units may be reluctant to operate on higher-risk patients whose conditions are much more likely to lead to bad outcomes, as those outcomes could push their individual risk scores above acceptable levels. Put bluntly, risk stratification makes risky patients political. St George’s Trust’s management appears to have tried to cut this Gordian knot by saying that virtually nobody was allowed to do risky procedures.

Announcing that a unit which had until recently been a major cardiac hub is no longer going to do complex procedures is one thing. Ignoring the question of what one then does with individuals with (say) severe multiple coronary vessel disease or valve disease at multiple levels is something else again. Such patients don’t cease to exist because you have decided not to operate on them – although they might well cease to exist if you don’t then design a “Plan B”.

In a nutshell, this was the very recent finding of Professor Fiona Wilcox, a senior coroner, who said that “unnecessary” patient deaths had been caused by the restriction of heart surgery at St George’s and the funneling of severely ill patients to other “over-stretched” hospitals. In cardiac cases, time is frequently of the essence if one is to retrieve the position for the patient.

It is very sad to think that a set of management decisions designed to mitigate risk for the unit has instead increased risk in the community, and I very much hope this can be rectified.

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