Surgeons blame pressure from management for poor safety at Lincolnshire trust

BMJ 2013; 346 doi: (Published 19 February 2013) Cite this as: BMJ 2013;346:f1094
  1. Clare Dyer
  1. 1BMJ

A patient died after a surgeon was pressurised into carrying out three radical procedures in a day as part of a lengthy list because of waiting time target pressures at United Lincolnshire Hospitals NHS Trust, a leaked letter suggests.

The trust, one of 14 under investigation by the NHS’s medical director, Bruce Keogh, because of high mortality rates,1 is in the news after its former chief executive Gary Walker spoke of a “culture of fear.”2 Walker broke a gagging clause in the compromise agreement that he signed after he was forced out of his job in February 2010, accusing the trust of putting targets ahead of the safety of patients.

The surgeon’s letter is one of three letters dating back to 2010 from doctors at the trust, leaked by independent Lincolnshire councillors on the local news website The Lincolnite ( The letters include concerns that the pressure of meeting targets was compromising safety.

The surgeon, whose identity is redacted, sent the letter to someone at the trust in February 2010 “in the immediate aftermath” of the “tragic death” of an “otherwise well patient” two days after an operation performed by another surgeon.

“The patient’s operation occurred on a day upon which, unusually, three radical procedures were undertaken by the same surgeon on a single extended list. Habitually, one or two procedures would be performed within this session and the additional case was required due to target pressures,” said the letter.

It described “enormous pressure” exerted by targets, resulting in ad hoc arrangements for surgery at short notice, outside surgeons’ normal working hours and at weekends, including operations on patients with whom surgeons had had no prior contact. “This is not only prejudicial to ongoing patient care, but presents enormous and unsustainable pressure on the operating surgeons,” the surgeon wrote.

The same month, a second consultant surgeon wrote about pressure to perform a complex, 10 hour operation shortly before he was due to go on holiday and when he would be unable to provide postoperative care. The consultant said that patient safety was the “absolute paramount consideration” and added, “I do not think there would be any defence either in court or in front of the GMC [General Medical Council] if I put the trust’s target in this instance above the patient’s welfare.”

A third letter from a clinical director to the trust’s chairman, dated March 2010, read, “I feel I must make you aware of my concerns about the balance between patient safety and targets and inform you that in my view the current bullish and sometimes ruthless pressure from above on the management team in my directorate is unfair and unacceptable.

“Such a culture that has evolved over the last few months has caused a subtle but significant shift in the balance between achieving targets and the quality and safety of our service to patients.”

The trust said that its mortality figures had improved in the past year and that it had made significant improvements in all areas of patient safety.


Cite this as: BMJ 2013;346:f1094