England's top doctor has ordered an independent review of a hospital where child heart patients died, after he dramatically circumvented NHS complaints procedures to personally meet bereaved families.
Sir Bruce Keogh, the medical director of NHS England, said the independent review should take place after he had a "powerful" meeting with 10 families who said their children were the victims of poor care at the Bristol Royal Hospital for Children, part of the University Hospitals Bristol (UHB) NHS Foundation Trust.
The intervention came after inquests into the deaths of two of the children and a Care Quality Commission (CQC) report failed to satisfy families that their concerns were being listened to. The review will be led by the leading lawyer and health expert Sir Ian Kennedy, who carried out the inquiry into children's heart surgery at Bristol Royal Infirmary, also part of UHB, more than a decade ago.
His report concerned the deaths of children during heart surgery between 1991 and 1995, and led to sweeping reforms in the provision of child heart surgery in England.
The new review will look into the care of patients at the Bristol Royal Hospital for Children's paediatric cardiac unit, and its scope will be determined in consultation with the families involved. It's believed to be the first time such an inquiry has been set up on this basis. Families will meet with Sir Ian in the coming weeks to plan the terms of reference of a review, Sir Bruce said.
The three-hour meeting, which took place at a hotel in Bristol on Friday, was described as "harrowing" by the mother of four-year-old Sean Turner, who died at the hospital in March 2012. It was proposed by Sir Bruce via his Twitter account after Sean's father, Steve, appealed for someone to "pick up the reins, stand to post and sort this out".
Problems at the hospital first came to light in 2012. Inquests have since been held into the deaths of Sean, who died from a brain haemorrhage after complex surgery in March 2012, and seven-year-old Luke Jenkins, who died at the hospital a month later after suffering complications following open-heart surgery.
Both inquests, heard by the Avon coroner Maria Voisin in November 2013 and January this year, found "no gross failures" in the care of the two children.
Seven of the 10 families who met Sir Bruce last week had children who died after being treated at the hospital's heart unit. Among concerns raised were allegations of poor communication between staff leading to delays in crucial interventions, monitoring equipment not working and parents not being properly informed of children's care and treatment.
In March 2012, Ward 32, where Sean was treated, did not have a high dependency unit (HDU) for children with severe conditions, in which nurses would have only two patients to care for each. The CQC inspected the ward in October 2012 and issued a formal warning to UHB over staffing levels which, it said, were not sufficient to meet patients' needs.
The Trust responded by saying it had improved nurse-to-patient numbers on the cardiac ward, and had addressed issues that led to the warning. Changes continued throughout 2013, and an HDU was set up. However, more families have since come forward with concerns. Families also told Sir Bruce of their dismay at what they called the "diabolical" handling of their complaints by the Trust.
Sir Bruce's intervention may be seen as a watershed moment for the NHS. Since the revelations of the Mid Staffordshire Hospital scandal set out in the Francis Report one year ago, it has been under intense pressure to prove that it has become more transparent and responsive to patients' concerns and complaints.
But Laurence Vick, of Michelmores solicitors, who is representing families seeking legal action against the Trust, said he was concerned that lessons had not been learnt in Bristol. He said: "I'm sure the majority of staff at the unit are dedicated, and work to highest standards. They have been let down however by the failings of those in charge."
Sean's mother, Yolanda Turner, said the families now felt they had "a way forward" and hoped that Sir Bruce's intervention would set a precedent for NHS leaders to meet directly with families who had serious complaints.
"The extent of the problems he was hearing were quite shocking and I think his reaction was appropriate," she said. "I don't think he expected it to be quite as harrowing as it was."
In a statement, Sir Bruce thanked the families for "the dignified and powerful way they have talked to us". Mrs Turner said the families wanted the review to go ahead.
Deborah Lee, the Trust's acting chief executive, welcomed the new review, but said the hospital was providing "good clinical outcomes", pointing out that 98 per cent of its patients' parents said in a survey that they had received excellent, very good or good care.Reuse content