Commission finds that trust failed to look into high death ratesBMJ 2004; 330 doi: https://doi.org/10.1136/bmj.330.7481.8-c (Published 30 December 2004) Cite this as: BMJ 2004;330:8
The Healthcare Commission, an independent body that monitors standards in the NHS, has taken unprecedented action against a Yorkshire hospital for its poor management of gastroenterology and related surgery. It has called on the secretary of state for health, John Reid, to put the trust “under special measures.”
Meanwhile the clinicians involved—who are not named in the report and who remain in post—should have their skills reassessed and should, where appropriate, receive extra training, it recommends.
The commission (formerly known as the Commission for Health Improvement) launched its investigation into Mid Yorkshire Hospitals NHS Trust and in particular the Pinderfields General Hospital in Wakefield in February 2004.
The investigation came after a series of allegations and counter-allegations made over several years by doctors working in the trust.
In 2000 and 2001 three surgeons raised concerns about the high mortality and numbers of complications from a procedure, known as an endoscopic retrograde cholangiopancreatography, carried out by a single handed consultant gastroenterologist. The consultant, in turn, said he had been unhappy for some time with the poor quality of equipment at the hospital. He subsequently made allegations about the performance of the surgeons who had criticised him.
An investigation was carried out by the Royal College of Physicians, which reported problems in the department, and suggested a further, independent investigation, which reported in September 2002. This criticised aspects of the consultant gastroenterologist's care in some of the cases but was also concerned about the practice of the surgeons in some of the cases.
The consultant gastroenterologist then asked the Healthcare Commission to investigate how the trust handled allegations of clinical malpractice. This investigation alerted the commission to the high mortality.
The commission found that the trust specifically failed to investigate properly the high death and complication rates for some procedures in gastroenterology and related surgery, despite concerns being raised over a five year period.
It says that there was a breakdown in the working relationship between clinicians in gastroenterology and related surgery at Pinderfields General Hospital. “Some staff behaved inappropriately to such an extent it posed a potential risk to patients,” says the report.
Their findings also catalogue much wider, systematic management failings over a number of years, from the most senior level down.
A new chief executive, John Parkes, has been in post since April 2004, and the trust has set up an out-of-hours rota for endoscopy and recruited two additional gastroenterologists, one in February 2004 and the other in April 2004. It has also invested in new high tech equipment to support the endoscopy service.
Investigation into Mid Yorkshire Hospitals NHS Trust 2004 is accessible athttp://www.healthcarecommission.org.uk/