Bullying culture stopped staff speaking out over heart surgery unit, says report

A culture of bullying prevented staff at an NHS trust from speaking out about the fact too many heart surgery patients were dying, a damning report has found.

Inspectors from the Care Quality Commission (CQC) found major problems with the way Queen Elizabeth Hospital in Birmingham runs its heart unit after a long history of high death rates compared with other hospitals.

The report says the NHS trust ignored repeated warnings over its high death rates, while there were a number of “near misses and unexpected deaths” in critical care.

University Hospitals Birmingham NHS Foundation Trust, which runs the hospital, has now been ordered to make improvements and send weekly surgery results to the CQC.

Inspectors found a series of issues at the hospital, including:

:: Staff described a bullying and blame culture in theatres and critical care. Staff found it difficult to raise concerns or challenge poor performance and behaviours. They did not always report incidents.

:: Trainee surgical doctors were not always supervised by a consultant in theatres despite needing it.

:: Difficulties in locating consultants when things went wrong in operations.

:: Some operations took longer than expected and patients were on cardiopulmonary bypass for long periods. There was a higher-than-expected rate of blood transfusions, while re-bleeding rates post-surgery were higher and the number of patients needing to go back into surgery was “much higher” than the national average.

:: Consultant cardiac surgeons did not consistently undertake ward rounds on the cardiac surgery ward. They were also not in theatre “at appropriate times” and did not communicate effectively with staff in critical care.

:: There was a high rate of cancellations, with some patients’ surgery being cancelled on multiple occasions. The “institutional behaviour” of surgeons contributed to this, including late starts to operations, extended length of operation times and waiting for confirmation of a bed in intensive care often resulting in the cancellation of subsequent operations.

:: There were vacancies in theatres that resulted in operations being cancelled or staff working extra shifts. Nurses expressed worry that they had no specific training in looking after heart patients or using specialist equipment.

:: Medical staff in critical care were not all cardiac-trained and at night there were difficulties accessing the on-call surgeon or the consultant anaesthetist. There had been a number of near misses and unexpected patient deaths in critical care.

:: Cardiologists at the trust were increasingly referring patients to other local hospitals for surgery where there were shorter wait times, fewer cancellations and good patient outcomes.

:: The heart surgery service was not well led and was “fragmented and dysfunctional”. Delays to making decisions had a negative impact on patient care.

:: A surgical check list aimed at preventing harm to patients was not always used.

The report said the trust has only recently started a quality improvement programme (QIP), despite concerns being identified in 2013 and consultants approaching the executive team in 2014 with concerns around patient deaths and outcomes.

The trust was also informed that its death rates were outside the national average in March 2015.

England’s chief inspector of hospitals, Professor Sir Mike Richards, said: “When we inspected cardiac surgery at the Queen Elizabeth Medical Centre we found a lack of strong leadership and a staff team with low morale that felt unable to raise concerns or report incidents.

“Initial data regarding surgery outcomes in the months since our inspection show an improvement but we need to continue to monitor the service.

“I have made it clear to the trust that it must continue its work to develop a culture of strong team-working and improve staff training as it addresses the wider issues identified on inspection.”

According to The Guardian, data posted on the Society for Cardiothoracic Surgery website last September – the most recent available – shows the hospital has been a “red outlier”, with death rates outside an acceptable range, over the three years from April 2011 to March 2014.

In those three years, the unit has operated on 1,713 patients, the website showed.

Calculations by The Guardian suggest 17 patients over the period should have survived surgery but did not.

A spokeswoman for University Hospitals Birmingham NHS Foundation Trust said: “We welcome the CQC report in the interests of delivering the safest possible care for our patients.

“None of the cardiac surgeons currently working at UHB are outliers for mortality outcomes and we are confident they will continue to offer the highest standards of care and expertise in delivering their service.

“The trust established a quality improvement plan (QIP) for the cardiac surgery service in July 2015, which is ongoing and subject to external review. At the time of the CQC inspection in December 2015, the QIP had already improved outcomes and internal issues within the service. The subsequent report has added awareness and pace to what is considered a valuable exercise to enhance both staff and, more importantly, patient benefit.

“Patient safety remains our number one priority.”

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