Invited Review Case Studies

This review of a combined dental service was requested following a number of patient complaints.

What we concluded:

• There had been inappropriate changes in the modality of treatment from fixed to removable appliances, which was considered not to be in the best interests of these patients.
• There were some cases reviewed in which ‘extraction only’ was offered as part of a range of treatment options. This was considered to be appropriate in the circumstances, provided that the patients concerned were fully informed.
• Reasonable options were recorded as having been discussed with patients and shared with the referring general dental practitioner by letter. However, these letters were not always copied to patients.
• Dental nurses had not been involved in new patient clinics, and therefore were not present to support patients in their understanding of treatment options.
• There were concerns about reports of repeated breaches in hand hygiene practice.
• There were separate leads for orthodontics and oral surgery and therefore no coordinated approach for addressing service issues or delivering improvements.
• There was poor communication and engagement between the oral surgery and orthodontic MDT teams. The absence of team meetings afforded limited opportunities to discuss service issues and share information.
• The service’s clinical governance practices were in need of improvement. There was a lack of sharing of information about complaints, near misses and serious incidents. There had however been a number of audits undertaken to a good standard.

What we recommended:

• The consent process in orthodontics should be strengthened
• A regular hand hygiene audit should be carried out
• The Trust should appoint a clinical lead for the service
• There should be regular departmental and clinical governance meetings
• The Trust should support and encourage all staff to report incidents

Outcome:

After issuing the report, the review team followed-up the Trust’s progress in implementing the recommendations made. This continued until there were actions undertaken or planned to address the issues identified in the report.

The review took place following changes, which meant that the services were being provided across two sites.

What we concluded:

• The review team found that changes to the acute pathway had improved care for patients who required emergency treatment, but that other patients were not being managed appropriately; with reports of some inappropriate transfers between hospital sites of patients with less acute symptoms.
• In terms of post-operative care, there was a lack of assurance that patients were receiving a daily, senior review from a clinician able to make management and discharge decisions.
• There was inadequate supervision of junior doctors due to a lack of availability of surgical registrars and consultant surgeons.
• Clinical governance was found to be deficient in the areas of morbidity and mortality meetings and administrative support for audits.

What we recommended:

• The formalisation of the pathways for the referral of patients to both sites as well as for patients with poly-trauma
• specification of at which site elective colorectal cancer procedures should take place
• increasing consultant surgeon input on the post-operative ward.

Outcome:

• Revised pathways for colorectal and vascular treatments;
• Introduction of face-to-face patient handovers between clinicians;
• Concentration of colorectal surgery at one hospital site;
• Introduction of a joint meeting between general surgery and urology;
• Appointment of a Specialty Lead for General Surgery;
• Introduction of regular morbidity and mortality meetings;
• Pairing of consultants for the performance of post-operative reviews.

The review was requested following a number of serious untoward incidents, including some wrong-level operations

What we concluded:

• There were no ongoing safety concerns identified, with the service’s surgical outcomes found to be in line with national averages.
• The department was compliant with most national guidelines on the prevention of wrong-level procedures, although local policies did not mandate the use of an intra-operative x-ray to confirm the spinal level or joint (consultant surgeon) operating in complex cases to reduce the risk of incidents.
• Difficulties in scheduling emergency procedures at the weekend were identified, indicating issues with weekend theatre lists.
• Data collection and submissions to national audits were found to be incomplete and inaccurate.
• There was some disparity in the decision making of the spinal orthopaedic and neurosurgeons, which had been reinforced by separate multi-disciplinary team and morbidity and mortality meetings.

Outcome:

• Revision of the local ‘correct level’ policy and the introduction of new imaging display systems in theatres during complex spinal surgery;
• Updates to the local dual-surgeon operating policy to include cases at high risk of wrong-level surgery and facilitation of more dual-surgeon operating;
• Equitable access to emergency operating lists for spinal patients and additional input from registrar and junior doctors to the spinal on-call rota at weekends;
• Improved data submissions to external audits as a result of verifying data with M&M records for accuracy;
• Introduction of a joint, complex spinal MDT, a joint spinal M&M meeting and employment of a dedicated spinal nurse to manage complex spinal patients.

The RCS was asked to carry out the review following a local merger of two HPB services.

What we concluded:

• The MDT was found to function mostly very well, although some areas for improvement were identified.
• There was found to be insufficient time allocated to the discussion of the high volume of patients referred, a lack of time to prepare for the meeting as well as insufficient administrative support.
• There was also concern that the impending relocation of the HPB service to another site could cause some disruption.

Outcome:

• Extension of the MDT meeting by 30 minutes and the discussion of benign cases after malignant ones at what was, in effect, a separate meeting;
• Additional appointments, including a Chair and part-time administrator for the benign MDT;
• The introduction of a pre-MDT agenda meeting to review and prioritise the cases referred and an audit of the referrals to monitor their appropriateness;
• Earlier agreement on the cases listed for MDT discussion to allow radiologists sufficient preparation time;
• The commencement of pre-operative anaesthetic assessment clinics for timely anaesthetic input;
• The scheduling of additional actions following the service’s relocation including changing the MDT meeting to a more appropriate day and introducing a dedicated HPB morbidity and mortality meeting.

The RCS was asked to review a vascular surgery service to determine the safety of the current model and to advise how it should be configured in the future.

What we concluded:

• The review team’s conclusion was that the current on call arrangement was unsustainable and that it did not allow for management of two vascular emergencies at once.
• There was also a lack of clarity in emergency patient pathways, making it unclear as to which site patients were to be taken.
• There had also been a failure to support the network MDT arrangement, with no provision made for regular M&M discussion.
• The review team was also concerned to find that a lack of co-operation between the consultant surgeons across all three sites had led to difficulties in patients’ post-operative care.

What we recommended:

• The review team assessed the local geography and other relevant factors and recommended that the development of a single, central hub centre should be the long term objective, with other improvements to be made in the interim.

Outcome:

• After nine months, a rota, designating the consultant surgeon and site for vascular emergencies, was supporting the existing service delivery model.
• Protocols were being developed with the ambulance service for the conveyance of emergency patients between hospitals and network MDT and M&M arrangements (involving video conferencing between the two sites) were being set up.
• A few months later on, a taskforce was established to oversee plans to develop single service on one site with a completion date set.

The review team was asked to consider the clinical practice of a consultant surgeon, including their surgical skills, clinical decision making and whether their training adequately equipped them to undertake the work they had been performing.

What we concluded:

• The review team were satisfied with the surgeon’s performance of routine cases
• They were, however, concerned with their surgical technique in complex cases
• There was also a need for the surgeon to improve their team working and communication with colleagues.

What we recommended:

• Plans were made for one of the RCS’ clinical reviewers to supervise and assess the surgeon in theatre.
• After a year, the surgeon’s operative skills assessment had been completed, but for one particular procedure.
• A report from the clinical reviewer confirmed that the surgeon’s management of complex cases had been largely satisfactory, but that there had been issues with technique for tissue dissection and exposure of the operative site.
• The surgeon was still restricted from performing particular procedures, pending further exposure, and it was agreed that they would cease a specialised procedure due to a lack opportunity to undertake it regularly.

The review was requested in response to concerns raised about the care provided to patients, consent processes and the possibility of the surgeon practicing outside of locally agreed restrictions.

What we concluded:

• The review included consideration of 21 clinical cases, which provided no evidence that the surgeon had operated outside of the restrictions or failed to obtain appropriate patient consent.
• The review team was concerned by the extent of the surgeon’s demanding external commitments and they were recommended to significantly limit these for a period in order to refocus on their clinical commitments.
• A well-structured programme to support the surgeon’s return to full clinical duties was also recommended.

Outcome:

• In response to the review team’s recommendations, within a few months, the consultant surgeon had significantly reduced their external commitments.
• The surgeon was attending the MDT meeting regularly and was fully discussing their patients.
• The surgeon had commenced a logbook to record their activity and outcomes, with relevant cases being presented for discussion at M&M meetings.
• A programme of mentored reintegration was underway: the surgeon had observed and assisted their external mentor with certain procedures, with further visits planned.
• After eight months, the consultant surgeon had restarted (supervised) on-call duties, and was shortly expected to perform these unsupervised. The only restrictions that remained in place related to a few, specialised procedures.

The RCS was contacted after concerns were raised by the surgeon’s colleagues

What we concluded:

• The review team was highly concerned about the care provided to some cancer patients
• The surgeon’s use of a novel technique, rather than the standard treatment, raised questions about their adherence to the MDT’s decisions and their process of obtaining patient consent.

What we recommended:

• The surgeon’s suspension from clinical practice was to be continued
• A referral to the GMC was to be made.

Outcome:

• In response to the RCS’ preliminary feedback, the Trust established a management group to oversee the review of 1,200 clinical records and a separate clinical advisory group to quality assure the process.
• Within a few months, all the clinical records had been reviewed and 28 patients, identified as having been harmed, had been contacted.
• The surgeon had also been dismissed from the Trust and a GMC investigation had commenced.

The College was asked to undertake a review of 142 clinical records, after the Trust had been identified as an outlier for two-year mortality within a national cancer audit.

What we concluded:

• The review team concluded that the majority of patients had presented with advanced and incurable cancer and that their treatment had been palliative rather than curative.
• The reviewers found all aspects of the care to have been acceptable in the majority of cases but also identified some cases where the overall care was not of an acceptable standard and a number of others where it had been inconsistent.
• The reviewers differentiated between those cases where surgical complications may have been expected and the decision-making had been difficult and others where surgery should not have been undertaken. The reviewers identified where mistakes may have been made, but did not directly contribute to a patient’s death and a small minority where the patient’s death was directly linked to technical errors.

What we recommended:

• The review highlighted areas for improvement including the initiation of more timely investigations, better case selection through robust MDT discussion and the provision of earlier surgical treatment for some patients.

The College was asked to undertake a review of three sets of clinical records where surgical complications had arisen. Each of these operations had been performed by the same consultant surgeon and, as a precaution, the Trust had imposed practice restrictions while the review was carried out.

What we concluded:

• The overall standard of care in each case was found to have been acceptable.
• The standard of the assessment and investigation of the patients’ conditions had been high. The procedures had been completed competently and intraoperative complications had been well managed with good team working.
• The reviewer, whilst entirely satisfied with the evidence of communication with all three patients, highlighted individual instances where the documentation for certain procedures had been lacking.

Outcome:

• The Trust shared the report with the surgeon whose cases had been reviewed and lifted the temporary restrictions.

The College was asked to undertake a review of 15 clinical records selected at random from patients who had been under the care of a particular consultant surgeon. Concerns had been raised by colleagues regarding the surgeon’s clinical decision making and the timing of patients’ treatment. The surgeon had been placed under temporary restrictions by the Trust, limiting their patient-facing activities, whilst the review was undertaken.

What we concluded:

• Six of the records reviewed demonstrated the provision of an acceptable level of care, whilst some aspects of the care in the other cases were unacceptable to varying degrees.
• The review did note, however, that only in a minority of cases were the deficiencies solely due to the surgeon whose practice was under review.
• In other instances, delays in patients’ treatment resulted from the involvement of multiple clinicians between whom there was found to have been suboptimal communication and co-ordination.
• The review concluded that the surgeon’s apparently very risk averse approach to surgery had led to avoidable delays in some patients’ treatment.

What we recommended:

• The review recommended consultation of local and national guidelines in regards to treating certain conditions to help reinforce appropriate decision making and avoid delays.
• The review also advised that, as a new consultant, the surgeon would benefit from more direct support from senior colleagues.