For more information or advice on clinical negligence matters you may have received please contact Cecily Cameron, head of our clinical negligence team.

30 July 2010

Systems failures responsible for the deaths of four children during paediatric heart surgery at the John Radcliffe Hospital   

We have recently reported on the suspension of paediatric heart surgery at the John Radcliffe Hospital while investigations were carried out into the deaths of four children between December 2009 and February 2010.

The report of the investigation, carried out by the NHS South Central Strategic Health Authority, was published yesterday. The report indicated that the treating surgeon, Caner Salih, was not responsible for the deaths of the children. The reported stated that: “In Mr Salih’s four cases, we found no evidence of poor surgical practice, but that he would have benefited from help or mentoring by a more experienced surgeon; and that it was an error of judgment for him to undertake the fourth case.”

Professor Stephen Westaby, who has worked on the unit since 1986, took three weeks leave as soon as Mr Salih started work at the hospital. Mr Salih complained about the poor working practices at the hospital, the age of the equipment, and the need for greater supervision. He even asked for operations at the hospital to cease but inaction was the only response to his comments.

The report concluded that paediatric heart surgery should remain suspended until arrangements are made for improving care. 16 recommendations were made including:-  

• Recommendation 2: the Trust should ensure that there is effective operational planning for clinical service changes that takes account of the expected impact on the capacity and capability of the relevant clinical teams, the level of support services required and the provision and utilisation of facilities such as theatres and intensive care.  
• Recommendation 4: the Trust should ensure that all newly appointed consultant staff have access to an appropriate mentoring arrangement. The nature of this will vary according to the nature of clinical practice, but for technically demanding specialties such as paediatric cardiac surgery must include arrangements that facilitate joint operating.  

www.thisisoxfordshire.co.uk reported on the response of the Oxford Radcliffe Hospitals NHS Trust. The Trust stated, “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”. A patient inquiry helpline has been created on: 01865 572900.

A full copy of the report is available here.  It is our experience that patients have great respect for most of the medical and nursing staff they encounter and admire them for working in often difficult conditions. But they find it very hard to understand why systems should repeatedly fail, with the result that staff are overstretched and distressed and patients are injured or worse.

6 July 2010

GPs to take over responsibility for Oxfordshire’s out-of-hours service?

The out-of-hours services in Oxfordshire is an organisation which provides urgent medical cover for GP practices from 6.30pm – 8am on weekdays, and 24 hours a day on weekends and bank holidays. The running of the out-of-hours services is currently the responsibility of NHS Oxfordshire, and has been since 2004.

The government is discussing plans to hand responsibility for the service back to GPs. Local GPs feel that the out-of-hours service is currently inadequate; the service has had on average one formal complaint every two weeks for the past two years. GPs are concerned that the decision to transfer the responsibility for the service, without providing additional resources or funding, will just shift the blame for the poor service onto them.

www.thisisoxfordshire.co.uk reported that Dr Prit Buttar, a GP at an Abingdon surgery commented: “I’m concerned that unless adequate resources are provided giving us commissioning responsibilities, it will just be giving us the blame”. It remains to be seen whether the responsibility for the out-of-hours service is transferred to GPs and whether this will have an impact on the standards of care provided by the service.   

16 June 2010

Cuts to the NHS Oxfordshire Mental Health Trust  

It has been reported at www.thisisoxfordshire.co.uk and on the BBC news website that, following a review of their mental health day services, NHS Oxfordshire has announced that it intends to cut its yearly budget from £2.1 million to £1.7 million.  

Mind and Restore, the Oxfordshire mental health charities, have indicated that the services that they provide will suffer as a result of the cuts. Stuart Reid, who is head of services at Oxfordshire Mind, reported that the 20% cut had come as a huge shock. There are concerns that the reductions in services will mean that vulnerable people will be at greater risk. BBC news reported that Benedict Leigh of Restore explained: “It’s going to mean we will be able to deliver less service to less people and there will be less support for people with mental health problems in Oxfordshire.”  

The head of integrated commissioning for mental health at NHS Oxfordshire, Fenella Trevillion, said that the cuts did not mean that care could not improve.

14 June 2010

An increase in the number of cancelled operations at Oxfordshire hospitals

www.thisisoxfordshire.co.uk recently reported that the number of cancelled hospital operations at the John Radcliffe Hospital, Churchill Hospitals and the Horton has increased. Between December 2009 and March 2010 252 patients received cancellations for procedures that they were booked in for.  

The Oxford Radcliffe Hospitals NHS Trust issued an apology in October, following a large number of complaints about the cancellation of procedures at the John Radcliffe. In October Elaine Strachan-Hall, the director of nursing and clinical leadership, blamed the cancellations on an unexpected influx of patients who needed emergency treatment. Since that time the number of cancelled hospital operations has increased.  

27 May 2010

Suspension of children’s cardiac surgery at the JR Hospital

Henmans recently reported on the decision to suspend children’s heart surgery at the John Radcliffe Hospital while investigations are carried out into the deaths of four children. There has been a lot of press coverage, both locally and nationally, about the recent events at the hospital.  www.thisisoxfordshire.co.uk recently reported that the articles particularly caught the attention of Shara Vines, whose 11 month old son died at the JR in 2004 whilst he was undergoing heart surgery. Shara Vines brought a clinical negligence claim against the hospital which settled out-of-court last year for £100,000.

Ms Vines is now preparing to submit all her evidence relating to her son's death to the General Medical Council. We do not know at this stage whether Ms Vines’ evidence will be considered in the independent review of children’s cardiac surgery at the hospital.

24 May 2010

Errors at IVF clinics in England and Wales double

An article on the BBC news website recently reported that the number of errors made at IVF clinics in England and Wales has almost doubled in the last year. 

IVF clinics are regulated by the Human Fertilisation and Embryology Association, and a recent study has shown that the number of reported mistakes made a dramatic increase from 182 in 2007/8 to 334 in 2008/9. The mistakes include various incidents from so called “technical failures” to serious errors including the wrong sperm being used to fertilise the wrong egg and embryos “going missing”.

The article notes that an electronic tagging system has been introduced in some clinics to help avoid mix ups. This enables eggs, sperm or embryos to be electronically tagged and linked to a specific patient. The electronic tag is identified by the microscope. If an individual attempts to mix the wrong egg and sperm an alarm will be triggered. However the initial costs of installing the system is roughly £100,000.00 and there are also high running costs. It remains to be seen whether the electronic tagging system is introduced in the majority of fertility clinics. 

19 May 2010

E.coli outbreak at Luton & Dunstable Hospital in 2008

In October 2008 there was an outbreak of antibiotic resistant E.coli at the neonatal intensive care unit at the Luton & Dunstable Hospital. 13 newborns contracted the illness. Some of the children were seriously affected and parents of two of the children are taking legal action against the hospital. It is thought that the children may experience long term health problems as a result of contracting the disease.

A report which was released last month identified failures to comply with very basic infection control measures, such as cleaning equipment and washing hands, as the cause of the spread of the disease.

The mother of one of the children affected told the Daily Telegraph: “It was absolutely terrifying every time we had to leave Lewis because we didn’t know if the nurses would be washing their hands.”

The Divisional Director for Women & Children’s Services at Luton and Dunstable Hospital said: “We are confident that staff adhere to our infection control procedures. However, there may be emergencies during the care of extremely premature or critically sick children when staff have just a few seconds to intervene.”