Agenda item

To consider a report from the Head of Scrutiny and Member Development providing an update and to consider a range of information associated with NHS England’s ongoing review of quality of children’s heart surgery services at Leeds Teaching Hospitals NHS Trust (LTHT).

The Head of Scrutiny and Member Development submitted a report to help members of the Joint Committee consider an update on the progress of NHS England’s on-going review of quality of children’s heart surgery services at Leeds Teaching Hospitals NHS Trust, following the temporary suspension and recommencement of services in March / April 2013. 

 

The report briefly summarised a range of activity that followed the temporary suspension and recommencement of services in March / April 2013 and introduced a report from NHS England that presented the findings of the Mortality Case Review and the Family Experience Report, published on 13 March 2014.

 

The report also introduced written submissions from the Children’s Heart Surgery Fund and the former President of the British Congenital Cardiac Association (BCCA). 

 

The following supplementary information was also submitted and considered at the meeting (minute 21 refers):

 

·  Quality Surveillance Group (QSG) minutes – 19 February 2014

·  QSG follow-up notes – 26 February 2014

·  QSG minutes – 7 March 2014

·  Risk summit minutes – 7 March 2014

·  LTHT update on progress against recommendations

·  Supplementary information (meeting notes, minutes and letters) relevant to the temporary suspension of services at LTHT (March / April 2013)

 

The following representatives were in attendance to help the Joint Committee consider the information presented:

 

·  Dr Mike Bewick (Deputy National  Medical Director – NHS England)

·  Dr Damian Riley (Medical Director – NHS England (North of England))

·  Andy Buck (Director – NHS England (West Yorkshire Area Team))

·  Yvonne Evans (Head of Quality – NHS Trust Development Authority)

·  Julian Hartley (Chief Executive – Leeds Teaching Hospitals NHS Trust)

·  Dr Yvette Oade (Medical Director – Leeds Teaching Hospitals NHS Trust)

·  Dr Bryan Gill (Medical Director (Quality) – Leeds Teaching Hospitals NHS Trust)

·  Dr Carin Van Doorn (Consultant Surgeon – Leeds Teaching Hospitals NHS Trust)

·  Steven Courtney (Principal Scrutiny Adviser – Leeds City Council)

 

The Principal Scrutiny Adviser briefly introduced the report, summarising the Joint Committee’s previous consideration of associated matters and outlining the information presented for consideration at the meeting.

 

In addressing the Joint Committee, the Deputy National Medical Director (NHS England) reminded Members that the temporary suspension of services in March / April 2013 had occurred in the context of a constellation of issues, which included:

 

·  Concerns regarding an early cut of NICOR mortality data / analysis

·  Concerns identified by clinical peers (external to the Trust)

·  Parental concerns

 

Members were also reminded that services were recommenced on a phased basis following recommendations arising from a rapid review in April 2013.  This had formed Phase 1 of NHS England’s review.  At the conclusion of Phase 1, three specific workstreams were identified where further work was required.  These workstreams, which formed Phase 2 of NHS England’s review, were:

 

a)  A mortality case review

b)  A review of parental concerns

c)  A review of clinical peer concerns

 

The report before the Joint Committee covered workstreams (a) and (b) above. 

 

It was reported that the review of clinical peer concerns (i.e. workstream (c) above) had not been completed and remained outstanding; on completion, a report would be published in due course.  Later in the meeting, it was reported that all interviews would be concluded by mid-April 2014, with a report expected to be published no later than week commencing 19 May 2014. 

 

The Joint Committee proceeded to consider issue related to the mortality case review (workstream (a)) and the review of parental concerns (workstream (b)) – now referred to as the Family Experience Report.

 

It was noted that the author of the Family Experience Report, Professor Pat Cantrill, had declined the invitation to attend the Joint Committee to present the review findings and address any specific matters raised by the Joint Committee.

 

Mortality Case Review

 

Addressing the Committee, the Medical Director (NHS England (North of England)) gave a brief summary and outline of the mortality case review outcomes and process.  It was reported that the review had taken place over June/ July 2013, with a series of draft reports produced.  It was also reported that Leeds Teaching Hospitals NHS Trust had been working on the recommendations since July 2013.

 

Representatives from Leeds Teaching Hospitals NHS Trust outlined the Trust’s progress since the temporary suspension of services and specifically against the recommendations highlighted by the mortality case review. 

 

The Joint Committee discussed aspects of the mortality case review findings and recommendations presented and highlighted at the meeting.  A number of matters were raised, including:

 

·  Queries around how the outcomes of the review were being fed into the new review of congenital heart disease, particularly where there was reference to national protocols and evidence.

·  How any triangulation of the three different workstreams would be undertaken – given the work around clinical peer concerns had not been completed.

·  The priority levels of the identified recommendations.

·  How the learning from the review was being raised and considered by other surgical centres.

·  Confirmation of any plans to undertake similar views within other surgical centres. 

 

Family Experience Review

 

Addressing the Committee, the Director (NHS England (West Yorkshire Area Team)) gave a brief summary and outline of the family experience review outcomes and process.  It was recognised that the report concentrated on a relatively small number of families; however this should not detract from some of the important lessons identified. 

 

In terms of the review process, it was noted there had been no intention to counter-balance or compare the family experience reported with staff views and/or evidence from elsewhere, such as patient notes etc. 

 

Representatives from Leeds Teaching Hospitals NHS Trust acknowledge that for some members of staff the report content had proved difficult to accept.  It was also reported that some members of staff had been concerned that the report did not provide an opportunity for a right of reply, although it was acknowledged that the details represented the reality for some families.  It was reported that the Trust viewed the report very seriously and had offered all the families the opportunity to have some input into improving services at the Trust. 

 

The Joint Committee discussed aspects of the family experience review report presented and outlined at the meeting.  A number of matters were raised, including:

 

·  It was appreciated that any poor family experience and the distress this may cause was a concern:  However, it was important to recognise the context of the family experience report – i.e. that the vast majority of families received good services and had a positive experience.  It was felt this was not adequately reflected in the family experience report.

·  Concern regarding the number of iterations before the final version of the report was published.  Members requested a copy of each iteration of the report, along with a summary of the main amendments and changes between successive versions. 

·  How any triangulation of the three different workstreams would be undertaken – given the work around clinical peer concerns had not been completed.

·  It was felt important that for any similar reviews in the future the methodology should allow all voices to be heard – including that of staff.

·  Some concern that there were no national standards to help compare some of the areas where recommendations for improvement had been identified.

·  Queries around how the learning and recommendations from the review were being shared and acted upon at other surgical centres.

·  Confirming any plans to undertake similar views within other surgical centres. 

·  Confirming the Joint Committee’s desire to invite the National Medical Director (NHS England) to a future meeting in order to discuss specific issues associated with the temporary suspension and recommencement of children’s cardiac surgery services at Leeds Teaching Hospitals NHS Trust in March / April 2013.

 

The Chair reminded those present that due to the timing of receipt of some of the information presented, it may be necessary for the Joint Committee to reconsider some of the information at a future meeting.

 

RESOLVED –

 

(a)  That the various reports and information presented to the meeting be noted.

(b)  That, subject to further information becoming available, it may be necessary for the Joint Committee to reconsider some of the information presented at a future meeting.

(c)  That NHS England be requested to provide a copy of each iteration of the family experience report, along with a summary of the main amendments and changes between successive versions. 

(d)  That the Joint Committee maintain an overview and review progress against the recommendations of each report (i.e. the mortality review and the patient experience report), both in terms of local and national responses.

(e)  That NHS England seek to conclude the third aspect of its review in the very near future (i.e. the review of clinical peer concerns) and present this, alongside any triangulation of issues, to the Joint Committee as soon as practicable.

(f)  That, simultaneously, Leeds Teaching Hospitals NHS Trust present its response to the reports and any associated recommendations relating to (e) above. 

(g)  That the National Medical Director (NHS England) be invited to a future meeting of the Joint Committee in order to discuss specific issues associated with the temporary suspension and recommencement of children’s cardiac surgery services at Leeds Teaching Hospitals NHS Trust in March / April 2013.

 

At the conclusion of the discussion, the Chair thanked all those in attendance for their contribution to the item and specific considerations.