We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

The people we spoke to were generally positive about the care and treatment they received, the facilities it was provided in and the staff who delivered it. They said that they were able to make choices about the treatment they received and they could approach staff if they did not understand anything. People told us that the hospital was usually clean, tidy, safe and well maintained. People said they thought staffing levels were “quite good”, although staff were very busy at particular times of the day. People told us that they knew who to speak to if they were unhappy about anything or wanted to make a complaint.

St George's University Hospitals NHS Foundation Trust is a combined acute and community health provider. The trust provides secondary and tertiary acute hospital services and community services to the local population. The trust employs over 8,000 WTE staff and serves a population of 1.3 million across South West London.

This is a report on a focused inspection we undertook of the cardiac surgery unit on 23 August, 13 and 14 September 2018. The purpose of this inspection was to follow up on concerns from the Bewick Report that the cardiac surgery unit was a mortality rate alert outlier, on other concerns raised in the Bewick Report published in July 2018, and on concerns raised to CQC.

The concerns focused on patient outcomes and mortality rates, culture, governance and leadership.

We found the cardiac surgery unit was going through a significant transition. Local governance and leadership were weak and were being revised to help improve the service. The culture was poor. Consultant surgeons mistrusted each other, as well as cardiologists, anaesthetists and senior leaders. Morale amongst several consultant surgeons was low and they told us they were under pressure and scrutiny, both internally and externally. There was a reduction in the number of patients accessing the service, as high-risk patients were diverted to other local hospitals and referrals were reduced. Monitoring and oversight by key stakeholders, meant that several measures had been put in place to assist and improve the service.

Our key findings were as follows:

• There was a lack of cohesion and poor working relationships between surgeons, although no direct evidence that this fed through to poor patient outcomes.

• There was not a culture of learning from incidents, mortality and morbidity amongst consultants.

• The quality of mortality and morbidity meetings were poor.

• There were multiple patient record systems, which meant notes were not centrally recorded and there was a risk of information not being accessible or not being handed over adequately.

• Morale amongst several consultant surgeons was low and they told us they were under pressure and scrutiny, both internally and externally.

• There was a lack of ongoing and regular oversight of some aspects of the cardiac services.

• There was a lack of understanding and insight of the performance within the team and the importance and role of national audits.

• Not all staff understood the duty of candour, when it was clearly indicated.

However:

• Bed occupancy rates were being reduced, due to a reduction in referrals and high-risk cases being diverted to other local NHS trusts.

• Comprehensive risk assessments of patients were carried out.

• There was a hospital-wide standardised approach to the detection of deteriorating patients using the National Early Warning System (NEWS) scoring system and staff knew what action to take when the score went above four.

• There were no immediate concerns with regards to patient safety and patients were well-prepared for surgery.

• Latest available data showed the mortality rate for the unit had reduced to 2.7%.

• Consent to care and treatment was sought in line with legislation and guidance.

• There was ongoing external oversight and monitoring of the cardiac surgery unit by key stakeholders.

• Multidisciplinary (MDT) team meetings, took place daily and involved neighbouring NHS Trusts.

• An independent scrutiny panel for cardiac surgery, set up by NHS Improvement, was appointed to advise, challenge and support the trust.

Importantly, the trust must:

• Review and improve governance systems and processes for the unit.

• Review the quality of mortality and morbidity meetings and include evidence of learning and how this is shared.

• Improve learning from incidents, mortality and morbidity amongst consultants.

• Resolve issues relating to leadership structure and cohesion to support the service to change and improve.

• Address cultural issues within the service to improve multi-disciplinary working and effective governance systems.

In addition, the trust should:

• Review the multiple patient record systems in use, because there was a risk of information not being accessible or not being handed over adequately.

• Ensure all medical staff understand their responsibilities to raise concerns, to record safety incidents, concerns and near misses and to report them internally and externally, where appropriate.

• Ensure all staff understand and apply the Duty of candour procedure, when it is clearly indicated.

• Support staff working in the unit, to improve morale and well-being.

Professor Ted Baker

Chief Inspector of Hospitals