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Secret reviews and lack of candour undermine trust in patient safety

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Since the 2015 Morecambe Bay maternity scandal, in which 11 babies and a mother died, NHS Trusts are supposed to publish summaries of external reviews into sub-standard care and share them with the regulator and more widely if concerns are raised about patient safety.

Reviewing bodies (normally one of the Royal Medical Colleges) work to agreed specific terms of reference which can include interviews with patients or patient representatives and should also consider patient feedback or written patient complaints. Indeed, reviews may also include a lay reviewer with a specific mandate to represent the patient and public interest.

Lack of transparency

Once those reviews are complete, the report becomes the property of the NHS Trust under investigation and it is hoped that the Trust in question will be open and transparent with the regulators, patients and the public about the review, taking into account patient consent and confidentiality. The Care Quality Commission (CQC) does not currently have the legal power to compel Trusts to share those reports or make them implement any recommendations.

Earlier last month BBC Panorama sent Freedom of Information requests to all NHS Trusts in the UK asking for details of any Royal College reviews of services in the last five years. 80 reports were released to the BBC programme. 65 of the 80 contained potential or actual patient safety concerns. In another 22 cases the regulator was only aware of the review or had only seen part of it. The BBC had been told about 111 reports, but the Royal Colleges advised Panorama they had in fact carried out about 260 reviews during that time.

The Academy of Medical Royal Colleges is reported to be ‘dismayed’ that, despite its guidance in 2016, summaries of reports dealing with safety or care concerns were not being made public. Prof Ted Baker, the CQC's chief inspector of hospitals, is equally alarmed by an apparent lack of transparency, insisting that Trusts undertaking invited external reviews have a responsibility to ensure that any serious patient safety issues raised are at the very least shared with the CQC.

Lack of inclusivity

It is also merely a hope that reviews, conducted under agreed terms of reference, will be comprehensive and inclusive, giving due weight and consideration to the views of the patients themselves. However, the Independent carries the story of two patients left with severe injuries after being operated on by Dr Camilo Valero at the Norfolk and Norwich Hospital Trust. It describes a now published, but previously secret, report by the Royal College of Surgeons (RCS) into his actions which has only now been seen by those patients he harmed who claim that it clearly has not taken their views into account.

After being admitted for emergency gall bladder surgery in 2020 both patients were operated on by Dr Valero who mistakenly removed their bile ducts and severed parts of the liver, as well as connections between the liver and intestines. One has been left incontinent and diagnosed with post-traumatic stress disorder while the other has been left with tubes permanently going in and out of his body to recycle bile produced by his liver.

The RCS review found ‘significant concerns’ with Dr Valero’s decision-making after he carried on operating despite getting into problems and did not ask for help but concluded he had demonstrated insight and now acknowledged he would seek help in similar future situations.

However, the review team relied on Dr Valero’s description of how he obtained consent but did not interview any of the patients he harmed who had raised concerns about the surgeon’s communication, attitude and behaviour towards them while in hospital. Indeed, one patient had submitted a 57-page report to the hospital days before the RCS carried out its review, but this was not forwarded to the reviewing team by the hospital.

The case of Mr Stephen Bridgman

A case in point is that of Mr Stephen Bridgman, who was operated on by Mr Hussien Mohammed El- Maghraby at University Hospitals Coventry & Warwickshire NHS Trust. Mr Bridgman, from Redditch was left in a vegetative state after Mr El-Maghraby operated on his benign brain tumour in 2016. His brain had been irreparably damaged following heavy bleeding and he died shortly afterwards. Mr Bridgman’s’ case spurred the Trust to ask the Royal College of Surgeons (RCS) to review four of Mr El-Maghraby’s patients (all of whom are represented by Shoosmiths) in September 2017.

The RCS report was critical of Mr El-Maghraby, concluding that the care provided to Mr Bridgman was “unacceptable”. More worryingly, the RCS review team noted in writing that full copies of the clinical records for the pre- agreed cases were not made available to them. Instead, the Trust relied upon the executive summary of the report, which stated that, despite all the evidence to the contrary, his technical skills had not been the main issue and that his clinical outcomes were comparable with those of his colleagues.

Sharon Banga, a medical negligence specialist solicitor in Shoosmiths Birmingham medical negligence team with over a decade of experience in clinical negligence cases comments:

“At the very least, aside from obviously sharing with the appropriate regulatory body, Trusts should make all information and opinion available to review teams and share and the findings of review reports with those patients whose care is the subject of that review as soon as possible. The fact that a review has been done should never be a secret and a summary of the findings should always be published to ensure patient safety.  Unless the law is changed, as things stand Trusts are under no obligation (other than a moral one) to do just that. This surely cannot do anything other than undermine confidence in their commitment to patient safety and is an issue that ought to be addressed urgently by the government.”

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