Oxford paediatric cardiac surgery services review finds serious deficiencies in risk management and clinical governance

It is, perhaps, noteworthy that the origins of the development of ‘clinical governance’ lie in the well known inquiry into paediatric surgery carried out at the Bristol Royal Infirmary between 1984 and 1995. The Bristol inquiry published its report in 2001 and here we are, almost 10 years later, with a report on a review of paediatric surgery at Oxford Radcliffe Infirmary following the death of four babies within three months of each other that cites, amongst other things, deficiencies in clinical governance arrangements within the trust.

Whilst all findings of the review are important to Healthcare Governance Review readers, there are two key findings that are of particular relevance:

1. The clinical governance structure within the trust was found to be “complex and fragmented.” In particular, “the review team found it difficult to grasp the entire number of committees and their respective reporting lines……[which] lays itself open to confusion and there is  significant risk that key risks get missed and are not escalated in a timely manner to ensure appropriate action is taken.”

2. In relation to the preparation of a business case to expand paediatric surgical services, based principally on appointment of a new, full time paediatric cardiac surgery, “The risks inherent in the strategy were not properly recognised and….there was insufficient consideration of how to mitigate risk.”

Both these finding serve to reinforce guidance that has emanated from the Department of Health, and elsewhere, since 1999 that trusts need to simplify their risk reporting structures and need to carry out robust risk assessments, including consideration of so-called ‘clinical risks’ when preparing business cases.

Recommendation 6 in the review report states that “The Trust should implement new clinical governance systems without delay that set out explicit responsibilities service by service with a single line of accountability to the Trust board.” Whilst boards are there to govern, and not to manage, what goes on in healthcare organisations, it is important that there is a single line of accountability from services through the CEO to the board.

The trust is now facing a trust-wide investigation by the Care Quality Commission. Cynthia Bower, Chief executive of the CQC, is quoted in the Telegraph (30 July 2010) as saying: “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.”

Download the report on the review of paediatric cardiac surgery services at Oxford Radcliffe Hospitals NHS trust here.

Read the Telegraph article here.

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