Baby deaths hospital ordered not to resume heart operations

A hospital where four babies died under the care of one surgeon must not resume heart surgery until it improves, a report said yesterday.

The paediatric heart surgery unit at John Radcliffe Hospital in Oxford should remain closed until the right mix of doctors is in place or until it links up with another unit.

All four babies died within a few months of surgeon Caner Salih starting work at the hospital. After the fourth death under his care, in February, he raised the alarm and decided to stop operating, having already complained about the age of equipment and poor working

practices at the unit.

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The investigation, by the South Central Strategic Health Authorit (SHA), said Mr Salih was not to blame for the deaths.

It pointed to issues within the Oxford Radcliffe Hospitals NHS Trust, including a lack of preparation for his arrival and no senior cover to help him.

When the doctor raised his concerns, the trust failed to act for at least 11 days and there was no evidence of a "clear plan of action".

The report said: "On the contrary, there seems to us to have been attempts to minimise the scale of the problem and to restrict knowledge of it."

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It was only when journalists began to investigate the incidents that the trust took action.

Yesterday SHA chairman Dr Geoffrey Harris apologised to the families of those babies who died. "We offer our sincere condolences and we apologise that, in the cases, the standards of care were not what was expected," he said.

The investigation reviewed death rates and found that among 15 babies operated on by Mr Salih, the death rate was 4.8 times higher than would be expected from a national rate.

However, "all the cases were complex and surgery was high risk".

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The report said: "In Mr Salih's four cases, we found no evidence of poor surgical practice, but that he would have benefited from help or mentoring by a more experienced surgeon."

It said it was "an error of judgment for him to undertake the fourth case" but the baby was so poorly it would have been very likely to die anyway.

The paediatric unit, which was temporarily suspended in March, is the smallest in England, carrying out just 120 or so operations a year.

Surgeons need a high enough caseload to maintain expertise but at Oxford there was a "fragile" situation, just one surgeon handling the cases and leading a team with a low workload.

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Furthermore, when less common procedures were carried out, the results were "significantly poorer than expected".

The panel noted that as soon as Mr Salih started work the unit's other surgeon, Prof Stephen Westaby, took holiday.

It was clear "the two had not satisfactorily discussed the matter" of what would happen during his absence.

The report added: "Mr Salih had insufficient time to familiarise himself with the unit's staff, facilities and equipment, all of which were geared to working with Prof Westaby."

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He arrived from one of the world's leading heart centres and was used to new techniques but no preparation had been made to accommodate his preferences, the report said.

The report pointed to an "error of judgment" among the clinical team in deciding that Mr Salih, "as a new surgeon working with a team not yet used to his methods, should undertake some of these procedures without assistance from another consultant cardiac surgeon".

The report set out several recommendations, including an overhaul of the system for dealing with serious adverse incidents and better monitoring of death rates.

The panel "also recommends that paediatric cardiac surgery remain suspended in Oxford until or unless the service can safely be expanded".

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