St George’s Hospital: Patient Deaths

Question

Asked by

To ask Her Majesty’s Government what assessment they have made of the coroner’s ruling on patient deaths at St George’s Hospital which found that deaths were “unnecessary” and the result of “inadequate” NHS-led investigations; and what steps they will take to prevent such failings in future.

My Lords, I beg leave to ask the Question standing in my name on the Order Paper and in so doing declare an interest as a member of the GMC.

NHS England and Improvement will review the coroner’s prevention of future death reports and respond within the agreed timescales. The coroner’s investigations are ongoing. The Government are committed to improving the standard of investigations into serious patient safety incidents in the NHS to create a culture of learning from mistakes and to improve patient safety.

I am grateful to the Minister. This is a serious issue. An independent review into cardiac surgery at St George’s Hospital found evidence of shortcomings and a number of avoidable deaths. This finding has been totally contradicted by the senior coroner for inner west London, who found the methodology used in the review completely flawed and said of a particular case that the coroner was dealing with that the doctor’s approach had been without reproach. Given the review that will now be undertaken, does the Minister accept that, if the coroner is right, the whole method used by the NHS for these reviews will come under question?

I understand the premise behind the assertion and the Question but, as I explained to the noble Lord yesterday, a number of issues are ongoing—the coroner’s inquest, an employment tribunal and a number of other reviews—which, sadly, I am not allowed to comment on. However, I can say at the moment that we are committed to improving the standard of patient safety investigations. We have set up the independent patient safety investigation service and HSSIB to look at this, as the noble Lord will know from the Bill, and we have a number of independent investigations guidance for standard operating procedures by NHS England and Improvement for teams to use.

In the light of the criticisms levelled by the coroner over the structured judgment review in particular, will the Government undertake to require the royal colleges and the new bodies set up to look at the procedure used? Although it looked at case notes, it included neither full oversight of previous medical history nor direct observation of clinical procedures, surgical technique—including anaesthesia—and post-operative nursing, all of which have an impact on outcomes. We all know that clinical opinion varies; the point at which a procedure is judged as high risk versus futile varies from centre to centre and can vary within them from one surgeon to another.

The noble Baroness clearly draws on her own experience of this. First, we have to wait for all the coroners’ inquests to finish; I think 36 have been completed at the moment. There will then be reviews, to which there is a statutory guideline on when they have to be responded to. However, it is also important to recognise the differences between the coroners’ inquests and the work of the independent mortality review, which was not undertaken to determine the cause of death in individual cases or attribute blame to individual clinicians—it was looking at a number of procedures.

My Lords, it is nice of the noble Lord, Lord Hunt, to put this Question to the House. It is a very serious matter that patient deaths at St George’s Hospital were unnecessary. Having digested the comments, we must take the appropriate steps so that such negligence is not repeated. Hospitals are meant to save the lives of patients, not end them. Human life is very important.

My noble friend makes very important points which I am sure many noble Lords will agree with. It is about understanding what went wrong in places and learning from that. NHS England and Improvement is committed to improving the standard of patient safety investigations. It set up a new patient safety investigations team; as many noble Lords will know, HSSIB and a number of other panels and investigations are also looking to learn. In addition, NHS England and Improvement will have to respond to the coroners’ reports.

My Lords, we have a virtual contribution from the noble Baroness, Lady Brinton.

My Lords, the coroner noted that the NHSI investigation had not used expert investigators and in some cases used only desktop research, looking at case papers, failing to interview key staff witnesses and take a longer view. Given that HSIB uses independent specialist teams and provides a safe space for staff and whistleblowers to talk, is there not a case for asking HSIB now to do its own investigation into this?

The noble Baroness raises a very important question, and it was one of the questions I asked when I was being briefed on this. Unfortunately, when HSIB was established, it did not investigate to historical cases. The future HSSIB will also not be able to investigate such cases; it will undertake only cases that are brought to it in the future.

My Lords, I draw noble Lords’ attention to my registered interests. The Minister rightly identifies that the NHS, and indeed all healthcare systems, must be committed to ensuring the best clinical outcomes and securing patient safety. Clinical failings are subjected currently to a number of different potential investigations, such as local employer investigation, professional regulatory investigation, systems regulator investigation, civil litigation and potential criminal prosecution and interrogation. How do Her Majesty’s Government ensure that these multiple routes for investigating a clinical failing are properly co-ordinated to ensure that immediate learnings from such failings are applied to drive system improvement?

The noble Lord raises a very important point about the complexity of having a number of investigating bodies. When I was being briefed yesterday, I was surprised by the number of ongoing investigations. We acknowledge that there needs to be a consistent approach to establishing and running investigations and inquiries. We are currently looking to develop an effective and user-friendly guide to handling inquiries and involving DHSC policy procurement IT colleagues in the development of a framework. We are working also with the Cabinet Office to ensure consistency across government, so that whatever we do in health is consistent with other investigations.

My Lords, the murder of Stephen Lawrence really caused a lot of trouble. The Met had a review and another review—and another review. The last person to do an apparently thorough review, Sir William Macpherson, turned up at the inquiry and said, “Your evidence is so awful we cannot listen to it any more.” Kent Constabulary carried out a review, but it did not uncover all the stuff that the Stephen Lawrence inquiry found. It was therefore suggested that there must be an independent police inquiry body so that the police are not marking their own homework. I wonder whether the same thing is happening here and whether this new independent review will uncover all that is required.

The noble and right reverend Lord raises a number of important points about consistency and the number of investigations. Their remits are often different, which can confuse the picture, and sometimes some of the investigating bodies are seen to extend beyond their remit, causing further confusion. In this case it is important to recognise the difference between the coroner’s inquest and the work of the independent mortality review. Coroners’ inquests are different, and an independent mortality review was not undertaken to determine the cause of death in individual cases or to attribute blame. It was all about processes, procedures and culture.