Invited Service Review Report: Report on the General Surgery surgical service at The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust

The Trust should implement a policy or standard operating procedure to ensure that there is an effective handover of patients at all times, including on either side of the weekend. This system should clearly apply to locum as well as substantive consultants and should ensure that every patient is allocated to a named consultant when a locum consultant leaves. Once implemented, this system should be audited.

The Trust should implement a policy that outlines the processes required for patient handovers when consultants take periods of leave, and for ongoing care.

The Trust should ensure that there is a system in place that clearly determines on-call arrangements, clarifying who is responsible for the ongoing management of a patient’s care in cases where the on-call surgeon has operated.

The Trust should review whether appropriate changes can be made to the electronic system to ensure that it holds up-to-date information regarding which consultant is responsible for managing a patient’s care.

With regard to case the review team strongly recommended that the Trust provides feedback to the operating locum surgeon’s agency regarding the unacceptable quality of surgical care provided in this case, if this has not already occurred. The Trust should further consider whether a regulatory referral is required.
a. The Trust should ensure that there is a robust system of feedback in place to ensure that feedback is provided to locum agencies in cases of poor practice.

It is critical that the ongoing dysfunction between the consultant surgeons is resolved. The review team expressed concerns that continued dysfunction would lead to service deterioration and present risks to the provision of safe care.
a. The Trust might consider implementing behavioural contracts with the threat of disciplinary action should the contracts not be abided by.

The Trust should keep RCS England updated in respect of the actions taken in relation to the two ‘whistleblowing’ letters received by RCS England and shared with the Trust in August and September 2025.

The Trust Audit Office should ensure that the service’s consultant surgeons are provided with their NBOCA data, and that this is validated by the consultant surgeons. This should be incorporated as part of the departmental clinical governance.

The Trust should introduce effective leadership to the surgical division. The Trust might consider looking beyond the surgical division for leadership appointments. Individuals within these roles should be supported with training and ongoing mentoring.
a. The review team understood that an individual was to be brought in from Norfolk and Norwich University Hospitals NHS Foundation Trust to support the Clinical Director in their role in the weeks following the invited review. Progress made within this collaboration should be noted and monitored.

The length of robotic and laparoscopic surgeries should be monitored, and discussions had between the relevant staffing groups (surgeons, anaesthetists and theatre staff) about when surgeries should be converted – ensuring all staff are in agreement with the approach taken by the surgeon.

The Trust should implement an operational and governance plan for the ongoing use of robotic surgery at the hospital, in turn, illustrating and utilising its value. A pause in the use of the Robot puts it at risk of being moved to another site, particularly with the proposed merging of services in late 2025.

The review team considered that the consistent and effective use of M&M meetings was necessary to ensure that there was appropriate identification, learning, and action from safety incidents. To improve the efficacy of M&M meetings, Chairing (by a senior medical leader) and adequate resourcing should be agreed and recorded.
a. The attendance of consultant surgeons should be mandated, job-planned, and a register taken, to ensure all consultants are present for discussions at M&M meetings.

With regard to clinical governance meetings, consistent recording of minutes should be carried out.
a. The Trust should re-consider the post holder of Governance Lead for Surgery, until the service culture and divisions are resolved, and adequate training and/or support is in place.

Consultant Meeting attendance should be mandated, and an updated agenda should be used for each meeting. Attendance throughout the entire meeting should be minuted.

The Trust should implement and ensure that there is satisfactory and bespoke mentoring for all new consultant appointments. This needs to be robust and appropriately audited. This mentoring should cover both clinical and leadership skills.

The Trust might consider appointing a Mortality Lead within the Division to support with the timely management of SJRs, moving forward.

The Trust should appoint a senior doctor to hold regular meetings or a forum, with the middle grades across the Trust, to hear their concerns and re-motivate them. Further training opportunities should be provided to resident and SAS doctors, both within theatres, and with regard to a local training programme within the service. Specifically, there should be opportunities for non-consultant grade doctors to develop their operative and endoscopic skills.

Based on the review of case it is recommended that the Critical Care team and theatre nursing staff receive training on the positioning and handling of sedated patients.

Following the review of case it is recommended that the Director of Nursing remind nursing staff of the importance of calculating and recording the risk of thrombo-embolic disease.

Incident investigations did not appear to have been flagged for cases in turn, limiting the learning and actions that could be drawn from these cases. This needs to be addressed to ensure the Trust captures all significant events.

The practice of ‘double counting’ Programmed Activities must cease.