Child heart surgery at the John Radcliffe Hospital in Headington should remain suspended following the deaths of four babies, a report has said.
The children were all operated on by consultant surgeon Caner Salih between December 2009 and February 2010 shortly after he started work at the hospital, although the independent report by the South Central Strategic Health Authority (SHA) cleared him of any wrongdoing.
Mr Salih, who had previously not had any surgical deaths in his practice, has since left the hospital to take up a role at Guy's and St Thomas Foundation Trust in London.
However, the report concluded that the surgeon had not received an "appropriate level of senior supervision" and that the unit had been "inadequately prepared" for him to start work there. It also found that Mr Salin had "insufficient time to familiarise himself with the unit's staff, facilities and equipment".
The hospital was also criticised for an absence of effective clinical leadership, inadequate mentoring of a new surgeon a lack of transparency in its clinical governance systems. Child heart surgery at the hospital was only stopped when Dr Salih himself decided to stop operating and informed hospital bosses of his concerns about the age of some equipment and the unit's working practices, which the report said was geared towards long-term surgeon Professor Stephen Westaby.
Dr Bill Kirkup, who chaired the report, said: “I am deeply sorry that this review has been necessary because I fully appreciate that it will have caused distress to some families. However, I very much hope that, as a result of the panel’s work, the risks for children undergoing heart surgery will be reduced.
“We recognise that there have already been significant changes in the arrangements for clinical governance at the Oxford Radcliffe, which we very much welcome. However, the panel has formed a clear view that without a critical mass of surgeons, or sufficient workload to maintain expertise, the arrangements for this service at the Oxford Radcliffe are too fragile for safe care to be assured in future without significant change.”
The hospital's children's heart unit only carries out around 120 operations a year, making it the smallest in England. The report recommended the hospital should improve the way it deals with serious incidents, put in place more effective managerial leadership and adopt techniques to spot adverse trends earlier.
Katherine Fenton, the SHA’s Director of Clinical Standards said: “We have to be absolutely sure that children undergoing heart surgery at the hospital are receiving the best possible care and it is clear from the report that we cannot be guaranteed that is the case at the present time.
“We appreciate that the suspension of the service will impact on parents with very sick children who will have to travel further afield for heart surgery, but patient safety has to be our number one priority.”
In a statement, the hospital trust said: "We know that the last few months have been very difficult for the families of the children whose deaths resulted in this investigation, for the families of patients involved with our children's cardiac team, and for staff. Children's heart surgery has been carried out at Oxford since 1986, with good outcomes.
"We want to be clear that where there are things to learn from the report published today, we will develop plans to tackle those issues as a matter of urgency. The Trust's Board will formally consider and respond to the recommendations in the report at the earliest opportunity."
The Trust has until September 17 to report back to SHA with an action plan. The Care Quality Commission, which regulates health and social care in England, said the report raised serious concerns and the hospital's quality and safety standards were to be reviewed.
Cynthia Bower, CQC’s chief executive, said: “While the report does not say that the failings caused any deaths, I am in no doubt that babies were not receiving care that was as safe as it should be.
“The trust did not handle the safety concerns raised by the surgeon in an effective or transparent way. The delay in notifying the board, strategic health authority and regulator was unacceptable. The clinical governance arrangements to identify and monitor safety risks were not up to scratch. Induction and supervision was clearly poor.”
“We will conduct a full review of quality and safety standards across the hospital. This will involve inspections, interviews with patients and staff, and a review of all available data. We won’t hesitate to take action if we find similar problems exist elsewhere in the hospital.”
A helpline has been set up by the hospital trust for patient inquiries, 01865 572900.
