Independent Mortality Review of Cardiac Surgery at St George’s University Hospitals NHS Foundation Trust March 2020

The Trust should ensure the principles included in the GMC publication, “Effective clinical governance for the medical profession: A handbook for organisations employing, contracting or overseeing the practice of doctors.”30 are implemented. This publication lays out a framework that requires that clinical teams are supported by their employing organisations and boards, in their pursuit of good governance.

Each of the cardiac surgeons, the lead for cardiology, the lead for anaesthesia/ICU and the lead for perfusion should have an individualised feedback meeting with clinical representatives from the Independent Advisory and Mortality Review Panels. These should be confidential and formative. The purpose of these meetings is to allow for an explanation of the Panel findings, to allow for reflection and to form a platform for ongoing mentoring and support. The Trust’s Chief Medical Officer should also be present at these feedback meetings.

A change of working relationships within and between cardiac surgery, cardiology and anaesthesia/intensive care teams should be fostered. This should include a mutually established “heads of agreement” document, outlining standards of inter-professional behaviour and mechanisms to ensure these values are maintained, with oversight from the Board. The document should enshrine the principles outlined in “Duties of a Doctor”.16 New and locum consultants should have formal mentorship arrangements put in place to support their professional development.

The cardiology department should attain full British Society of Echocardiography Departmental Accreditation.

The Trust should develop sub-specialist teams, if appropriate in collaboration with other hospitals in the network, in mitral, aortovascular and revascularisation surgery. The aortovascular and mitral teams should have at least two consultant surgeons in each group and no surgeon should be in both of these teams. The revascularisation team should comprise all cardiac surgeons at the Trust. Each team should have designated interventional and imaging cardiology consultants alongside radiology and anaesthesia/intensive care consultant representation, where appropriate.

All referrals for cardiac surgery should be discussed at the relevant sub-specialist MDT, which should ensure the availability of all necessary data before review of the clinical case. Subsequently the MDT should plan treatment (including an operative plan) and allocate a surgeon. The MDT should have a pre-defined minimal quorum, with full representation from sub-specialist cardiac surgery, interventional and non-interventional cardiology, and radiology. Anaesthetic advice should be available if required. Discussion, as well as decision, of the MDT should be recorded. If plans for treatment change after discussion at the MDT (either through patient choice or change in the clinical situation) then the patient should be re-discussed to ensure full MDT ratification and oversight of the adapted management plans. Any changes to the original plans should be documented clearly. The MDT should have the provision of the very best treatment for the patient as its aim; taking into consideration the full clinical picture. This will include a full review of the surgical, interventional and medical treatment options available.

Risk-scoring, using up to date risk scoring algorithms (for example EuroSCORE II) should be embedded in practice. The team must ensure all risk factors are considered and that data are sought to ensure an accurate risk prediction. This risk prediction must be recorded on the consent form as part of the discussion of the indications, risks and potential benefits of proposed treatments. On occasion, it is justified to include non-scored conditions (e.g. liver or haematological disease) to increase the quoted risk. Conversely, if the risk quoted is less than the calculated risk, then the reasons for this adjustment should be clearly documented in the case record. Consent procedure should follow the guidance laid out in the Royal College of Surgeons England publication, “Consent: Supported Decision-Making. A guide to good practice”31.

Standard referral templates for cardiac surgery should be developed across the London network. Cardiologists referring patients for surgery should include details of the symptomatic status of the patient, investigations (and their interpretation), co-morbidity (and potential subsequent impact on proposed benefit(s) of surgery) and consideration of alternative interventional and medical therapies. For patients referred for revascularisation with intermediate angiographic stenoses, functional/ischaemia testing should be performed as part of the referral.

The following guidelines/standard operating procedures (SOP) for patient care should be developed and implemented: 1. An SOP for the management of urgent inter-hospital transfers. This should include a clear description of joint care (cardiology and cardiac surgery) arrangements and responsibilities. It should delineate necessary investigations and the management of medications, in line with best practice guidelines (for example the GIRFT report28). 2. A guideline for management of myocardial protection. All theatre team members should consider themselves responsible for myocardial protection and there should be establishment of a ”flat” theatre hierarchy to ensure that the heart remains well protected during surgery. 3. A guideline for the management of operative and post-operative haemorrhage. This should include clear indications for when return to theatre is indicated. 4. A multi-disciplinary guideline for post-operative ECG interpretation, particularly focusing on ischaemia. Clear indications for when emergency repeat coronary angiography, or return to theatre, are warranted, should be included. 5. A multi-disciplinary guideline for selection and management of patients requiring mechanical support, including Ventricular Assist Devices and Extra-Corporeal Membrane Oxygenation. This protocol should be developed with guidance from a transplant centre. 6. The Trust should develop a guideline for outreach services for patients who are not in intensive care environments. Rapid, 24/7 expert review should be available to allow timely escalation for patients in need.

The Trust should develop a robust, independent, multi-disciplinary review of mortality with appropriate governance oversight to ensure that lessons are learnt. The SJR structure of mortality review should be utilised. Panel phase of care and avoidability scores should be presented as part of the Mortality and Morbidity review of the case. Given the findings of the mortality review Panel, the SJR should also include assessments of whether the MDT operation plan was delivered and whether it was performed by the right person at the right time. Review of the case should include an appraisal of discussions made with the coroner. The Trust should ensure that it fulfils any responsibility it has under the duty of candour provision of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 subsequent to this review and ensure a robust system is in place for patients who receive care in the Trust going forward.

The Trust should adapt the coroner referral form. There should be only one signatory of the form, which should be that of the responsible consultant.

The Panel recognise the substantial contributions that national audits (such as NICOR) and programmes (such as GIRFT) have made to patient outcomes. It is clear that these oversight and review mechanisms are essential in ensuring patient safety in the UK. Indeed, this review would not have come about without the NICOR alert warnings. The Panel recommend continued funding of these national initiatives. Early warning systems should be developed to allow rapid identification of issues within cardiac surgery units, as they arise. Publication of benchmark outcomes (such as the SCTS “Blue Book”) should be centrally supported.