Report to NHS England and NHS Improvement and St George’s University Hospitals NHS Foundation Trust of the Independent Scrutiny Panel for Cardiac Surgical Services at St George’s University Hospitals

Appoint a new, external Clinical Lead for the Unit.

Progress all outstanding legal claims where patient safety was not an issue to an appropriate conclusion.

Act to ensure all surgeons were clinically safe and met nationally accepted standards.

Establish an oversight mechanism for clinical performance with: o Standard operating protocols o Networked audit system put in place o Regular minuted mortality and morbidity meetings

Establish processes to work with and understand the findings of the Independent Mortality Review of Cardiac Surgery commissioned by NHS Improvement reviewing all deaths of patients who were operated upon in the Unit over the period of the two NICOR alerts (April 2013 – September 2018).

Consolidation of good clinical outcomes on the lower risk population in the first half of 2019.

Put in place a clinical governance bundle for the Cardiac Surgical Unit, to include: o Pooling and an allocation mechanism for all theatre cases irrespective of to whom the patient has been referred o Sub-specialisation (i.e. only nominated surgeons performing mitral valve and aortic surgery) irrespective of to whom the patient has been referred o Documented job planning o Equal access to theatre time for all surgeons

Effective implementation of the protocol for transferring high risk patients to other units and the establishment of a local and regional network to support this.

Establish a mandatory behaviour agreement, to include adherence to the clinical governance bundle and appropriate professional conduct.

The appointment of a substantive surgical team in line with national guidelines, to include a designated mitral valve surgeon.

Establish a decision-making group with experienced external support for the Director of Human Resources and Chief Medical Officer, to support appropriate use of disciplinary procedures such as Maintaining High Professional Standards (MHPS).

Each of the cardiac surgeons should be offered an individualised developmental feedback meeting with clinical representatives from the Independent Scrutiny Panel and Independent Mortality Review, with the Clinical Lead/Associate Medical Director and/or Medical Director as required.

The Trust should review the Cardiothoracic Surgery GIRFT report and the Cardiology GIRFT report when published in 2020 and implement their recommendations.

The Trust should develop and use evidence-based peri-operative protocols for the management of routine care and frequent complications including bleeding.

The Trust should continue to implement and further strengthen safety and governance structures throughout the organisation.

The Trust should develop integrated specialist teams, so that the St George’s Cardiac Unit functions as a team and not as a collection of individual practitioners. An integrated specialist team should: • Include a minimum of two cardiac surgeons with sub-speciality interests, a mixture of imaging and interventional Cardiologists, specialist nurses and therapists. Examples of sub specialties need to include mitral valve disease, aortovascular disease and revascularisation. The mitral valve disease team would require two surgeons from the Trust, the aortovascular team would require two (different) surgeons from the Trust and the revascularisation team should include all cardiac surgeons. • Hold regular minuted Multi-Disciplinary Team Meetings (MDTs). • Develop links with cardiologists in referring hospitals, rather than there being relationships with individual cardiac surgeons

The Trust should ensure the appointment of a substantive surgical team with the relevant sub-specialisations in line with national guidelines (see Appendix Three).

The Trust should appoint a Deputy Clinical Lead in cardiac surgery to support the existing Clinical Lead/Associate Medical Director.

The Trust should continue to ensure robust consultant appraisal and job planning is in place for every consultant working in the Cardiac Surgical Unit.

The Trust should develop a protocol of care for urgent inter-hospital transfers to the Unit. This should include the work-up of patients and medications, in line with best practice as highlighted by the national GIRFT Cardiothoracic Surgery report. A suggested example is at Appendix Two, where daily MDTs are held to discuss referrals for urgent surgery.

The Trust should ensure all referrals for cardiac surgery whether generated internally or externally, are made to the relevant sub-specialist MDT. The MDT should: • Review the clinical data, decide treatment advice, allocate the surgeon and oversee the delivery of integrated care in line with established and agreed pathways. This should be the clinical pathway for all patients undergoing cardiac surgery at the Trust. • Ensure referring cardiologists are encouraged to attend the MDT, either in person or via IT link to present the patient. • Allocate a surgeon taking into account factors such as case complexity, risk and waiting times irrespective of which surgeon the referral was made to in the first instance.