Special Assurance Review of CardiacSurgery at Swansea NHS Trust

December 2006

Healthcare Inspectorate WalesUnit 3cCaerphilly Business ParkVan RoadCAERPHILLYCF83 3ED

Tel: 029 2092 8850Fax: 029 2092 8877

www.hiw.org.uk

i

Contents

PageNo

Chapter 1: Arrangements for the Review ........................................... 1

Chapter 2: The Provision of Cardiac Services in Swansea ................ 3

Chapter 3: The Background to the Review......................................... 7

Chapter 4: Findings ............................................................................ 13

Chapter 5: Summary and Recommendations..................................... 31

Postscript: Postscript to Healthcare Inspectorate Wales’s Review 37

Annex A: Healthcare Inspectorate Wales ......................... 41

Annex B: Acknowledgements .......................................... 43

Annex C: References........................................................ 45

ii

1

Chapter 1: Arrangements for the Review

1.1 Healthcare Inspectorate Wales (HIW) came into being on 1 April 2004.

Its role is to undertake inspections and investigations of healthcare bodies in

Wales. HIW aims to provide public assurance as to the efficiency,

effectiveness and safety of NHS services. In this role it has a responsibility to

follow up past problems with Welsh NHS services to ensure that these

difficulties have been dealt with effectively in the best interests of the service,

patients and the public1. There have been ongoing personal difficulties within

Swansea NHS Trust Cardiac Surgery Unit for some years. Difficulties with

cardiac services have been reported in the Board Meetings held in public of

the Swansea NHS Trust and there have been extensive and ongoing reports

in the press.

1.2 The difficulties recorded at Swansea included allegations of bullying

and harassment, withdrawal of one of the senior clinical staff, temporary

closure of the unit due to staff exhaustion and complex team working issues

within the cardiac surgical service. HIW decided to include in its 2006-07

programme a special assurance review of cardiac surgery at Swansea NHS

Trust in order to ascertain the extent to which those difficulties had been

resolved and to assess the extent to which further work might be necessary to

enhance patient safety.

1.3 The following Terms of Reference were established:

To undertake a review of Cardiac Surgery at Swansea NHS Trust to:

• “validate the clinical information that is generating morbidity and

mortality statistics;

1 See Annex A for a full description of HIW’s duties and responsibilities.

2

• ensure that the level of care provided by the cardiac services

directorate, including the Cardiac Intensive Care Unit is in line with

national guidelines and standards;

• ensure that the previous difficulties in relationships between cardiac

surgeons, cardiac anaesthetists and theatre staff have been

resolved or are not impacting on patient care;

• determine whether actions taken by Swansea NHS Trust have been

sufficient and appropriate.”

To achieve the above objectives the following approach was adopted:

• Relevant legislation, policy, procedures and other authoritative

documentation was reviewed and evaluated;

• Systems and supporting records were reviewed and tested;

• Interviews were undertaken with key staff.

1.4 HIW appointed a team of reviewers including professional advisers with

relevant experience of cardiac surgery, cardiac anaesthetics, nursing within

cardiac units and management within the NHS2. In addition to examining

initial documentation, the review team conducted interviews with Board

members and Trust staff in June 2006 over a period of five days, with some

follow-up interviewing during July and August. In total 66 interviews were

undertaken. Additional documentary evidence was provided by the Trust and

a number of individuals provided the team with documents relating to matters

under review.

1.5 For ease of reference, the findings and recommendations of the special

assurance review are set out under the headings of the Terms of Reference.

2 See Annex B

3

Chapter 2: The Provision of Cardiac Services in Swansea

Swansea NHS Trust

2.1 Swansea NHS Trust was established on 1 April 1999 following the

merger of Morriston NHS Trust, the previous Swansea NHS Trust (based at

Singleton Hospital) and parts of Glan-y-Mor NHS Trust (Community and

Mental Health Services). It provides a comprehensive range of hospital and

community health services for Swansea’s population of approximately

250,000. The Trust also provides some local general hospital services for a

wider population (Neath/Port Talbot),a range of specialist services for people

across south and mid Wales (cardiac services providing for a population of

933,000) and some specialist services for the whole of Wales. Services are

provided from nine hospitals with over 1,800 beds and in a range of

community premises. These include psychiatric day centres and resource

centres, health centres and health clinics. The Trust is one of the largest in

Wales with an annual income in excess of £350 million. Approximately 8000

staff are employed by the Trust.

2.2 The Swansea Cardiac Centre, within which cardiac surgery is located,

is housed at the Trust’s Morriston Hospital site.

2.3 Morriston Hospital itself currently has 850 beds, the majority of which

are housed in modern accommodation which has been built since 1981. The

specialist services provided at Morriston Hospital include Renal Medicine,

Neurology and Neurosurgery, Neurorehabilitation, Oral and Maxillofacial

Surgery, the Welsh Centre for Burns and Plastic Surgery, and Palliative

Medicine These services are supported by critical care facilities, which

include a Cardiac Intensive Therapy Unit (CITU), a Cardiac High Dependency

Unit (CHDU) and a full range of diagnostic and therapeutic services. The

District General Hospital (DGH) component encompasses a Coronary Care

Unit, several General Medical sub specialties, a well-developed Trauma and

Orthopaedic service and a range of General Surgical specialties.

4

2.4 Morriston Hospital is also the site of Swansea’s major Accident and

Emergency Department.

Cardiac Centre

2.5 The Swansea Cardiac Centre was opened in 1997 as Wales's second

Cardiac Centre and is one of the smaller units in England and Wales. The

centre employs approximately 230 whole time equivalent staff in the following

areas:

• The Cardiac Catheter Suite consists of two Cardiac Catheterisation

Laboratories providing diagnostic and interventional cardiology procedures

which are associated with a pacing room where the insertion of permanent

pacemakers is undertaken;

• The Cardiac Intensive Therapy Unit (CITU) provides an eight-bedded

intensive care unit caring for approximately 750 cardiac surgery patients

each year. Patients are directly admitted there following cardiac surgery

and later transferred to the eight-bedded Cardiac High Dependency Unit

(CHDU). The CHDU also admits patients from theatre following thoracic

surgical procedures.

• The Cardiac Outpatients Department cares for cardiology and cardiac

surgery patients during both initial and follow up consultations, pre-and

post-operatively and whilst undergoing non-invasive cardiac investigations.

A pre-admission clinic is held to assess patients prior to admission for

surgery, to carry out screening and blood tests as well as giving pre-

operative information in conjunction with other multi-disciplinary team

members.

• The outpatient Cardiac Rehabilitation programme at Morriston Hospital

was established in 1993 with the objective of improving the quality of life

for patients with cardiac disease. The operating department consists of

5

two designated Cardiac Theatres and anaesthetic rooms, which are in

close proximity to the CITU/CHDU, catheter laboratory and main theatre

complex. Procedures undertaken include coronary artery bypass grafts,

valve surgery and other cardiothoracic surgery.

• The Coronary Care Unit has eight beds, a procedure room and chest pain

assessment area. Swansea NHS Trust provides local DGH services. The

unit serves the population of north Swansea and admits patients with

acute coronary syndromes, cardiac arrhythmias and acute heart failure.

The unit also provides tertiary care for patients in south-west Wales who

require interventional cardiology. The annual throughput of patients is

approximately 1000.

• The Cyril Evans Ward is a 21-bedded cardiothoracic surgery ward where

patients are cared for pre-and post-cardiothoracic surgery.

• The Dan Danino Ward is a 18-bedded cardiology ward incorporating a six

bedded high dependency area. There is a separate 12-bedded cardiac

short-stay unit adjacent to the cardiac catheterisation suite.

6

7

Chapter 3: The Background to the Review

3.1 The need for a second Welsh Cardiac Centre was identified in a report

commissioned by the Welsh Office in 1994. In order to provide total of 1400

open-heart procedures in south Wales, it was concluded that a Cardiac

Centre at Morriston should provide 600 cases supporting the continued

provision of 800 cases in Cardiff. A specification to provide this level of

surgery and associated cardiology for the population of south west Wales was

developed by the Welsh Office. The Welsh Office opened the provision of this

service to competitive tender and the contract was awarded to the Swansea

NHS Trust.

3.2 When it opened in 1997, the Cardiac Surgery Unit within the Cardiac

Centre comprised of one theatre, a cardiac intensive care unit, a high

dependency unit, and a new pre- and post-operative ward. The Trust

recruited a lead surgeon, and a second surgeon joined shortly after the unit

opened. Anaesthetic support was provided by two consultant anaesthetists

already working at the Trust, and two new appointees. The unit was led by a

Clinical Director. The two surgeons had good clinical expertise but limited

management and organisational experience. Nevertheless the hard work and

enthusiasm of the pioneers produced good results.

3.3 There were difficulties from the outset. As a relatively small unit, it was

vulnerable to problems with staff turnover. Some staff of the Trust questioned

the extent to which the business plan itself appeared to have underestimated

staffing requirements. There were disagreements about levels of anaesthetic

cover and payments for anaesthetic staff. There were no clear lines of

operational management established or boundaries of expertise agreed.

There were tensions between the cardiac surgeons and some cardiac

anaesthetists and between newly appointed cardiac anaesthetists and the

existing consultant anaesthetist body. In order to meet the commissioned

workload, it was necessary to operate on three patients per day as soon as

the unit opened. Further, there was considerable pressure to tackle waiting

8

lists. Establishing and maintaining this level of throughput placed very heavy

demands on staff which were more challenging in the existing circumstances

of disagreement and less than optimal team working.

3.4 There also appear to have been disputes over private practice

arrangements between the cardiac surgeons and the anaesthetists. Theatre

staff worked voluntarily at weekends for agreed overtime rates. Given their

emergency on call responsibilities and the long hours they were already

working, this put great pressure on the theatre staff. In 2003 the Trust

management suspended private work during weekdays and in March 2004

private patient work at weekends was stopped.

3.5 In 2001, an additional cardiac theatre was added to the existing

complex in order to increase capacity to 750 cardiac surgical cases per

annum. As part of this expansion, an additional consultant cardiothoracic

surgeon was appointed and funding made available for a further two

consultants in cardiac anaesthesia with supporting middle grade staff.

3.6 In June 2002, the Trust, with very limited consultation with staff, and at

extremely short notice, changed the theatre management arrangements so

that the cardiac theatre nursing staff and the operating department assistants

(ODAs) were placed under the direct management of the cardiac surgery

Clinical Director (then one of the two original cardiac surgeons). Some staff

who were transferred were very dissatisfied with these changes and there

was a meeting of staff in July 2002 involving both the (then) Medical Director

and the (then) Director of Nursing (but not any of the cardiac surgeons) to try

to resolve the matter. There were no agreed notes of the meeting and the

apparent outcome (ie for the theatre staff to revert to previous management

arrangements) was disputed by one of the cardiac surgeons on his return

from leave. In November 2002, the newly appointed Medical Director

commissioned an external review, by Mrs B Owens from The Royal Hospitals,

Belfast, to advise upon theatre management arrangements for cardiac

surgery. The report, published in February 2003, recommended:

9

• the recruitment and appointment of a new senior clinical leader for

nursing staff and ODAs;

• improvements to nurse theatre staffing establishment;

• that the two cardiac theatres should be managed as part of the

Anaesthetics and Theatres Directorate;

• improvements to team-working and communication.

Subsequently, staff reverted back to the Anaesthetics and Theatres

Directorate and improvements were made to the nurse staffing establishment.

3.7 In November 2003, 15 members of staff from different disciplines

approached the Medical Director with allegations of bullying and harassment

by two of the surgeons in the unit. The Trust Executive decided that there

should be an investigation under the provisions of the Trust’s ‘Dignity At Work’

policy. A senior manager from within the Trust, Mr Chris Jones, was

appointed to conduct this investigation. Individual statements were taken, but

counter accusations and allegations against the original complainants were

also made.

3.8 In March 2004, during this investigation, individual relationships and

staffing levels deteriorated to the point where the Trust took the

unprecedented step of suspending non-emergency cardiac surgery for one

week. The public explanation given was “staff exhaustion”. Mr Bowen-

Simpkins, a recently retired Consultant Obstetrician and Gynaecologist

provided some support to staff. He reported verbally to the Medical Director.

3.9 The investigation by Mr Chris Jones was suspended and the Trust

subsequently employed the occupational psychologists, Edgecumbe Group,

to help diagnose and resolve the problems. In consultation with Edgecumbe

Group, the Trust Executive decided that the formal procedures of the ‘Dignity

at Work’ policy would not resolve the basic problems in the unit and no

disciplinary or other action was taken as a result of the original allegations of

bullying and harassment.

10

3.10 The exact brief or terms of reference for this intervention are unclear,

but Edgecumbe Group worked with individuals and the staff group to try to

resolve the problems. As a result of this process the Trust made

arrangements for one surgeon to withdraw from the team at Swansea for six

months whilst he undertook some personal development work and the rest of

the team worked with the Edgecumbe Group to develop better working

relationships. It should be noted that there were no questions as to the

individual clinical competence of any surgeon during the course of the

Edgecumbe work. There appears to be no documentary evidence relating to

the Trust’s closure of its work with Edgecumbe. A Cardiac Leadership Group

was established to provide a bridge between the two divisions and ensure that

all views were represented. That group agreed a ‘Cardiac Code of

Behaviour’, advised upon the return to the team of the cardiac surgeon, and

introduced new arrangements for working practices, for example, for

anaesthetic cover in CITU. The group met less frequently as time

progressed, although some staff did not express confidence in its work.

3.11 In February 2005, national targets required the Trust to reduce its

maximum waiting times to 12 months before 31 March. In light of the ongoing

difficulties with staff within cardiac services, arrangements were made to sub-

contract some operations to the private sector at the Wellington Hospital in

London. It was arranged that, during periods of annual leave, some Swansea

surgeons (and the surgeon who had withdrawn from the Swansea team)

would be amongst those to perform these operations. This offered continuity

of care to patients in the south west of Wales and ensured that there was no

delay during transfer of care to another surgeon. They received payment for

these operations as part of their ‘fee for service’ appointment to the Wellington

Hospital. Swansea anaesthetists were not involved in this arrangement as

the Wellington Hospital used its established cardiac anaesthetists from the

London hospitals. This relieved the workload pressures on theatre staff, but

threatened relationships between surgeons and anaesthetists at a critical

moment in the reconciliation process established by Edgecumbe.

11

3.12 Poor relationships continued between some medical staff and on two

occasions led to individual consultants involving solicitors in taking forward

issues concerning colleagues. While in both cases solicitor’s action was

withdrawn, not all parties appear to have been satisfied by the outcomes and

there were still considerable tensions between the medical staff concerned.

One of the issues has been investigated by the Trust and resolution is still in

progress.

3.13 There has been an increased turnover of senior cardiac anaesthetist

staff during these difficulties.

12

13

Chapter 4: Findings

4.1 Since the cardiac surgery unit opened, several thousand operations

have been undertaken successfully, and many patients have benefited

significantly from its activity. We found staff at all levels working extremely

hard, sometimes in difficult circumstances, to ensure the best possible care is

delivered to patients. Nursing staff in CITU and CHDU have become the first

unit in Wales to gain Practice Accreditation via the Leeds University School of

Nursing Practice Accreditation programme. This is a significant achievement.

Is clinical information reliable?

4.2 The clinical data at Swansea is mostly collected and compiled on the

Patient Analysis and Tracking System (PATS), which holds a number of other

important clinical registers and data sets not directly connected with cardiac

surgery. However, data capture arrangements for PATS were found to be

weak. In 1999, the unit lost its audit support and data collection arrangements

became chaotic. Junior medical staff were supposed to input data into PATS

after each operation, but other clinical responsibilities may have interfered, so

that some data was not properly entered, or entered retrospectively.

Recently, there has been some effort to validate the data, and ensure its

accuracy and completeness, but there are many gaps in the dataset and

individual responsibilities for data ownership, data management and system

management are unclear. Cardiac staff have sought additional external

resources above the current arrangements for a dedicated Audit Clerk and a

recent appointment of an IT PACS/ PATS Manager.

4.3 The system security arrangements are not adequate and a system

upgrade which provides an audit trail which helps to ensure the integrity of the

data has not been installed. There was a reported instance of individuals

swapping passwords, but we found no evidence of wilful manipulation of data.

The Trust has invested in a new image archiving system (GE Centricity) in

14

which came online in March 2005. That system has a database facility which

the Trust plans to use to replace the PATS system.

4.4 Many clinical staff expressed concerns that the data was not reliable

because of incomplete data capture and the lack of systematic data

management arrangements. Aware of some of the limitations of the data,

Trust managers have made efforts to ensure that mortality rate data is as

accurate as possible, however we are concerned that all weaknesses are

exposed and addressed and believe that further work is necessary to meet

the known future requirements which will fall upon the information systems.

4.5 There was a clear separation between corporate information systems

such as the Patient Administration System (PAS), and departmental

information systems such as Patient Activity Tracking (PATS). While

demographic information is transferred from PAS to PATS, the two systems

do not interact in any other way and in particular there is no automatic

auditing of one system against the other. The present Information

Management and Technology strategy does not address this matter.

4.6 The timeliness of the entry of clinical data (principally diagnosis and

operation codes) on the PAS system has historically been poor, principally

because clinical coders have not had timely access to medical records. A

recent initiative to send the coders to the cardiac unit to inspect the notes is

designed to address this.

4.7 There have been attempts in 2005-06 to reconcile the PAS and PATS

data, but there are complications with data structures and definitions that

make this a difficult exercise. Other data sets and registers on the PATS

system appear to be better managed than the cardiac surgery register.

4.8 Efforts have been made to validate mortality data, for example by

reference to death certificate information held by the patient services

manager. Morbidity data has received less attention and there is no single IT

15

system that enables surgeons to access details of complication rates following

surgery or the extent of problems with airway management.

4.9 In the NHS, cardiac surgery has led the way in publishing clinical

outcome data. There have been a series of national initiatives requiring

cardiac units to submit clinical data for publication. Most recently, in April

2006, the Society for Cardiothoracic Surgery and the Healthcare Commission

launched a new public portal with information on mortality rates for each

cardiac unit in England and Wales (Healthcare Commission, 2006). Initially,

along with two English Trusts, Swansea did not submit its data within the

submission deadline, but in June 2006, its complete data was supplied

following retrospective analysis of patients’ case notes. We were surprised by

the limited forward planning to meet these requirements for national data

submission.

4.10 Whilst knowledge of the inadequacies of some of the Trust’s data was

widespread on the ground, senior Trust management have continued to

believe and assert both internally and externally that clinical outcomes are

good. To be assured of the quality of its data, the Trust needs to give

attention to the matters set out above and is making arrangements for a fuller

audit of its data arrangements as recommended below.

Recommendation 1: Data capture, data validation, data ownership, datamanagement, data security and system management standards andresponsibilities should be thoroughly reviewed. Standards should bemade explicit and consistently monitored, and individual responsibilitiesfor data built into job descriptions, job plans, and annual objectives.

Recommendation 2: The Trust should seek an immediate external auditof their data arrangements from the Society for Cardiothoracic Surgery,and implement the resulting recommendations.

Note: The Trust has already acted upon recommendation 2 and anindependent data validation exercise was conducted through the NHSInformation Centre for Health and Social Care and the Society ofCardiothoracic Surgeons' quality accreditation programme to validate the datasubmitted to the Central Cardiac Audit Database. This exercise wascompleted in October 2006 and the final report will be considered by HIW aspart of the action planning process to ensure the integrity of the data for

16

cardiac surgery and that the weaknesses identified during the HIW reviewhave been addressed satisfactorily.

Recommendation 3: The Trust should review its information strategy toensure proper attention is given to improving the timeliness and qualityof clinical information. There should be greater integration andconsistency between departmental and corporate information andinformation systems.

Recommendation 4: Health Commission Wales should work with allWelsh providers of cardiac surgery to ensure consistent approaches todata collection and that plans are in place to meet data requirements fornational audit. The Trust needs to play a full part in these processes.

Is current practice safe and in line with current national guidelines?

4.11 The clinical outcomes (as measured by mortality rates in the latest

national data submission3) of the unit were better than expected.

4.12 There are no specific national guidelines published which detail how

cardiac surgery should best be organised, although the Society for

Cardiothoracic Surgery has published some suggestions for good practice

(SCTS, 2001). We have examined the operations of the cardiac surgery unit

against the clinical governance domains established in Welsh Health Circular

WHC (2003) 69 and documented in HIW’s Acute and Community Trusts

Inspection methodology (HIW, 2005)4. Questions of use of information have

already been dealt with in the previous section, so will not be discussed here.

Patient experience

4.13 An effective and active patient group has been established by staff

within CITU. The local Community Health Council had no specific matters it

wished to bring to our attention.

3 The Society for Cardiothoracic Surgery in Great Britain and Ireland and the

Healthcare Commission http://heartsurgery.healthcarecommission.org.uk.4 The Clinical Governance domains are: patient experience, use of information,

processes for quality improvement, staff focus, leadership, strategy, and planning.

17

4.14 There have been delays and, at times, cancellations of operations

owing to the staffing difficulties at the Trust. Each year until 2006 it had been

necessary to conduct special initiatives to deal with end of year waiting lists.

Processes for quality improvement

4.15 There was little evidence of systematic risk assessment and risk

management, although there were individual examples of staff assessing and

managing risks in their individual practice. The Trust’s performance against

Welsh Risk Pool risk standards that seek to measure both clinical and non-

clinical risk declined from 75% compliance in 2003-04 (Welsh National

Average 82%) to 70% in 2004-05 (Welsh National Average 76%), although

there were changes in the standards themselves that may have contributed to

this decline. In 2005-06 the Trust raised its performance to achieve 72%

against the Welsh National Average of 74%.

4.16 Interview evidence suggests that there were doubts amongst staff that

all untoward incidents (and near misses) are captured or properly

documented. There have been recent changes to documentation, but

reporting lines and responsibilities were not always clear to staff. There was

little feedback to operational staff about changes required, or of learning

acquired from incident reporting and investigation. Staff have been trained in

Root Cause Analysis which we were told has been used in the Trust.

4.17 Allegations made by staff of specific incidents of poor clinical practice

were an integral part of the enquiry conducted by Mr Chris Jones. Six of

these which were assessed to be clinical matters were reviewed by the Chair

of the Division of Cancer and Tertiary Services, who reported to us they had

been dealt with at the time by the Medical Director and that there were no

outstanding issues that threatened patient safety. We were unable to locate a

complete audit trail for this work.

4.18 Clinical audit was occurring within the Cardiac Centre. Audit plans

were made and minutes of audit meetings demonstrated the attendance of

18

staff from all disciplines within the Centre. Although audit sessions for cardiac

surgery included all staff working in the surgical environment the review team

questioned the extent to which all disciplines were involved in undertaking and

presenting audits. Anaesthetists and cardiac surgeons conduct their monthly

audit sessions on different days, partly to give anaesthetists an opportunity to

attend the meeting of cardiac surgeons but also to permit surgical Specialist

Registrars (SpRs) to receive dedicated teaching during the period that

anaesthetists are holding their audit. Whilst one anaesthetist regularly

attended Cardiac Centre Audit meetings attendance of other anaesthetists

was limited and irregular. The Trust needs to ensure that full multidisciplinary

audit takes place.

4.19 The CITU nursing practice accreditation was a significant achievement

by the nursing staff, as mentioned above. However, at the same time, there

were no agreements on medical responsibilities for patient management in

CITU. This led to disagreements between anaesthetists and surgeons, and

confused and contradictory instructions to nursing staff. There seemed to be

little evidence of post-hoc discussion and resolution of these professional

disagreements. However the Trust did attempt to resolve issues between

anaesthetists and surgeons by establishing a multi-disciplinary group under

the chairmanship of a consultant anaesthetist to work towards a consensus

taking into account practice in other centres across the UK. The work of that

group needs to be documented in the form of written protocols which reflect

the consensus which it has established.

4.20 There were few agreed integrated care pathways for the cardiac unit to

show what services patients should receive at each stage of their care. CITU

has developed pathways for post-operative care of patients. However in

CITU and CHDU there were no agreed evidence-based protocols for the

management of patients with given conditions, so there were a variety of

different approaches to treating a given problem eg acute renal failure. Some

protocols had been developed by nursing staff, but were sometimes

contradicted or countermanded by medical staff. There was confusion

amongst staff as to the most appropriate course of treatment for a given

19

problem, which could have led to delays in patients receiving treatment or

medication. The absence of clear management protocols created difficulties

for performing good clinical audit and thus, for example, in identifying

morbidity trends within the cardiac surgical patient population. No surgeon

was able to identify their ICU complication rates for patients under their care

in the past year. This makes it more difficult for surgeons, for example, to

identify areas where practice could be improved.

4.21 The arrangements for CITU anaesthetic cover (four or five morning

sessions) were not providing a level of care with which the surgeons felt

comfortable. As a result, each surgeon took individual responsibility for the

post-operative care of their patients 24 hours a day, 365 days a year. There

was no handover of clinical leadership responsibilities from surgeon to

anaesthetist at any point. In the absence of agreed and documented

protocols, this required consultation upon nearly all aspects of ongoing

management of patients, even in those areas in which the surgeons had

limited expertise.

4.22 Research and development priorities reflected individual professional

interests, rather than an agreed strategy for the development of the unit in

relation to the needs of the local population. While reinforcing HIW’s view of

the limited team working within the unit it also suggests that opportunities to

strengthen the work of the unit through research are not being optimised.

Staff focus

4.23 The Trust (in line with many others) has had difficulties recruiting and

retaining experienced cardiac theatre nursing staff, and has sought to address

these with a system of core staff, and staff on rotation from general theatres.

Core staff were supported through appropriate training programmes and a

competency framework. This is discussed later on this report. Staff on

rotation work within the unit for eight months, during which time they are

supported and encouraged to develop the skills required in cardiac theatres

through a competency based programme. Many staff expressed concerns

20

about the availability of experienced and competent theatre nursing staff. The

shortage of theatre nurses can and has led to operations being cancelled at

short notice. The system of rotation has the disadvantage that just as the

nurses gain the necessary experience in cardiac surgical operations, they

revert to working in general theatres, and a new set of nurses requires training

and induction. Prior to cases being undertaken, risk assessments are carried

out to establish if the staffing requirements can be met. However, some

nurses have reported concerns that staffing levels in theatres have been

dangerously low. On-call arrangements for emergencies have put additional

strain on the small number of core cardiac theatre staff, and lead to cancelled

operations the next day when they have been called-out. Although there was

some recognition of the problem and the Trust had taken initiative in relation

to theatres as a whole (eg open days), we did not find any evidence that the

Trust had made serious and sustained attempts to tackle this issue, for

example, through special recruitment or training initiatives. The high numbers

of staff leaving posts and the relatively high levels of sickness and absence

are indicators of the stress that some staff were experiencing. During

May/June 2006 the sickness rate for theatre staff was 3.85% and for

anaesthetic assistants 10.42%.

4.24 At the time of the HIW visit, there were fewer core theatre nursing staff

than surgeons. We were so concerned about the absence of experienced

theatre nursing staff that we raised it with the Trust during the visit as a matter

that required immediate attention. Should the situation persist and trends in

relation to core staff continue then that might call into question the viability of

running more than one theatre.

4.25 There were serious weaknesses in basic staff management practices,

especially in theatres. Staff were not always clear about their line

management responsibilities and appraisals and personal development

planning were haphazard. Induction arrangements were weak and exit

interviews were not conducted. The appointment processes for some locum

medical staff had not always been transparent to staff and as a result, medical

staff expressed concern to HIW about a particular appointment. The Trust

21

needs to ensure that its appointment policy and procedure are clear to all

staff.

4.26 Some individuals were pursuing relevant professional development and

qualifications, and the Trust has invested in practice development nurses in

each Division, but the absence of good appraisal and personal development

by line managers limited its overall contribution and effectiveness. Some staff

had difficulty accessing education and training because of workload. There

were few examples of multi-disciplinary education or training.

4.27 The Royal College of Anaesthetists has expressed concerns about the

training placements within cardiac surgery, and this has led to the withdrawal

of anaesthetic trainees from the CITU and the provision of close consultant

supervision in the cardiac theatres. Similarly, concerns have been expressed

over the training arrangements for surgical specialist registrars which were

being followed up by the Deanery as part of its wider work in Wales. The

committee had visited the Trust about that in May 2006 and was to follow up

the issues by a further visit at the invitation of the local Deanery.

Leadership, strategy, and planning

4.28 The current management structure in the Trust was implemented in

April 2003, and provided for six Divisions, and for clinical directorates within

each of those divisions. The cardiac theatre staff form part of the Theatres

Directorate, and the anaesthetists and operating department practitioners are

managed as part of the Anaesthetics Directorate. Both these directorates are

within the Division of Surgery and Anaesthesia. On the other hand, the

cardiothoracic surgeons, perfusionists, the CITU, the CHDU and the cardiac

ward are part of the Cardiac Unit within the Cardiac and Tertiary Services

Division. Thus responsibilities for the main service elements are split across

three Directorates and two Divisions, which does not help with clarity of

managerial, governance, and financial responsibility. There is little

documentary evidence of discussion and decisions in relation to the cardiac

surgery difficulties having been taken forward within these management

22

structures, and it appears that they were often by-passed or ignored. Despite

the efforts of the Cardiac Leadership Group, much remains to be done to unify

the work of the unit and encourage a team approach.

4.29 There were clear weaknesses in the implementation of the Trust’s

clinical governance strategy. The Trust has recognised the need to develop

this strategy and embed it at operational level by seeking the support of the

Wales Clinical Governance Support and Development Unit. Similarly, the

Trust Non-Executive Directors have recently sought to strengthen their own

involvement in, and scrutiny of clinical governance. There are now five non-

executive directors, including the Chairman, on the Trust Clinical Governance

sub-committee.

4.30 There appears to have been no agreed vision and plans for the

strategic development of the cardiac surgical service between Swansea NHS

Trust and the healthcare commissioners.

4.31 Learning from practice elsewhere is important for all healthcare

providers. The Trust participates in tri-partite meetings with Health

Commission Wales and the University Hospital of Wales and among the

proposals for joint work have been arrangements for visits to peer trusts and

sharing of experience between the two Trusts. This is still to be taken

forward. Reviewers considered that it was in the interests of all parties to

ensure that proposal was actioned.

4.32 The planning and scheduling of admissions, operating lists, and patient

progression through post-operative care and discharge is complex, and

critical to ensure good use of resources and to make progress with tackling

waiting lists. We were not able to quantify these issues, but many staff

reported dissatisfaction with late cancellations, late starts in theatre, theatre

sessions over-running, and other operational mishaps. There were underlying

tensions between the cardiac surgery staff, anxious to ensure recognition of

their particular requirements, and general theatre management who were

concerned that cardiac surgery staff were receiving “special treatment”.

23

These tensions have been exacerbated by the staff shortages in cardiac

theatres and by theatre management that appeared to be remote from day to

day decision-making. In May 2005, the Trust employed a cardiac co-ordinator

to help improve this, and some progress seems to have been made.

However, in June 2006, the cardiac co-ordinator arrangements were changed

with little consultation with key stakeholders - this may threaten further

progress.

4.33 The basic clinical processes require very close co-operation, and team-

working from different disciplines, often in quite critical occasions. This close

co-operation was evident on many occasions, but there have been important

exceptions. In general, staff are focussed on improving their professional

practice in their professional domain, rather than considering how all

professions can best organise and co-operate to improve the care of the

patient.

Recommendation 5: The Trust should urgently review its nurse staffingarrangements in cardiac theatres, and develop and implement robustplans to recruit, train and retain sufficient skilled staff.

Recommendation 6: The Trust should ensure that staff understand theprocedures followed for all medical appointments, including locums, inthe interests of transparency.

Recommendation 7: The Trust should ensure that basic clinicalgovernance processes especially risk management, incident reporting,and staff management are embedded at operational level, and that apositive patient safety culture is engendered. The Trust should ensurethat the communication and dissemination mechanisms arestrengthened, so that learning and improvement occurs, and thatprogress is effectively monitored.

Recommendation 8: The Trust should ensure that all clinical incidentsare properly reviewed and, where appropriate, investigated. Theoutcomes of these reviews and investigations must be properlydocumented.

Recommendation 9: The Trust should develop and implement acomprehensive audit strategy and plan for cardiac surgery,concentrating initially on improving data quality, and strengthening andensuring multidisciplinary audit.

24

Recommendation 10: The Trust should review the levels of medicalcover in CITU, and HDU. The recommendations of the Intensive CareSociety should be followed.

Recommendation 11: The Trust should develop, document andimplement an agreed care pathway and agreed patient managementprotocols for patients in CITU and CHDU. There should be propermechanisms for professional differences on individual patientmanagement to be properly discussed and speedily resolved using thebest evidence available.

Recommendation 12: The Trust should review managementarrangements for cardiac services to clarify individual responsibilities,and avoid structural splits wherever possible.

Recommendation 13: The Trust should review the recommendations ofthe Owens report on theatre management arrangements, to see howclinical leadership and theatre management could be improved. Cleartheatre utilisation protocols should be developed to ensure that all theparticular requirements of cardiac surgery are met, and to ensureeffective resource utilisation. Further external assistance to improveoperating theatre leadership and management may be required.

Recommendation 14: The Trust should review its mechanisms toensure that the cardiac surgery unit keeps abreast of best practice in theorganisation, management and delivery of cardiac surgery. With thesupport of its commissioners the Trust should establish formalbenchmarking or peer review arrangements with other cardiac units inWales and England.

Have the previous difficulties in relationships been resolved? Are theystill impacting on patient care?

4.34 Some staff reported that working behaviours and relationships have

improved after the Edgecumbe process, and that there were fewer arguments

and disagreements. However, others were concerned that the problems had

not been resolved, but had gone underground. Similarly, some staff said they

were now unwilling to raise issues or problems, given past failures to resolve

them fairly. They also spoke of their fear of victimisation or retribution.

4.35 Some staff reported incidents during the course of these difficulties.

Police were asked to investigate one incident, believed to be malicious. The

police were not able to establish the cause and there appear to have been no

further similar occurrences. No recent incidents were reported to us.

25

4.36 The Cardiology Code of Behaviour was not a sophisticated document.

Even though the team had developed the Code themselves some staff felt

that they had been excluded from the process and few expressed ‘ownership’

or faith in its content. Some staff interpreted its existence as suggesting that

normal Trust policies and rules did not apply to the cardiac unit.

4.37 Many staff, especially junior staff, have experienced considerable

stress and difficulties throughout this process and yet remained highly

professional. They have put patients’ interests first and found creative ways

of ensuring that a good quality of care was maintained.

4.38 Although the evidence suggests that individual skills and competencies

are good, many risks can best be mitigated by good teamwork with clear

goals that are shared by all team members, and championed by senior

clinicians. The Trust has had a Cardiac Surgical User Group in place since

the unit opened. The group meets monthly and all members of the multi-

disciplinary team are invited. Issues arising from that meeting can then be

addressed directly by the Service Manager or through the Consultant

Management Meeting. This is useful, but the review team found no clear

evidence of shared goals or new team-working cultures developing as a

result.

4.39 Given the weaknesses in the quality of information on clinical outcomes

and the weaknesses in other information systems eg incident reporting, it is

difficult to form definitive judgements about the precise impact of the

difficulties in working relationships. We did not find evidence of untoward

outcomes for patients in the past. However HIW takes the view that among

the factors minimising risks to patients, there is good team working built upon

respect among colleagues. Enhancing the experience of patients in the future

is dependent upon continued improvement in the working relationships in the

unit.

26

4.40 Problems and difficulties in working relationships are often a product of

underlying structural problems and difficulties that have not been tackled.

These must be resolved – as suggested in the next section.

Recommendation 15: The Trust should ensure that the standards andbehaviours it expects of staff, including staff in cardiac surgery areunderstood by all staff.

Recommendation 16: The Trust should examine carefully howmultidisciplinary team working can be developed and supported, boththrough formal and informal structures and processes. Investigationsof multidisciplinary team working practices elsewhere (not necessarilyjust cardiac units) should be undertaken.

Was the Trust response sufficient and appropriate?

4.41 The Trust made many attempts over a long period of time to resolve

these difficult issues, and ensure the continued provision of a high quality

service. It invested a large amount of time, effort, resources, and external

expertise over a long period. The problems occurred when the Trust as a

whole had significant challenges in bringing the two main hospitals (Morriston

and Singleton) together into a coherent and effective whole. Similarly, there

were considerable pressures for the unit to respond to the high levels of

demand for cardiac services, and avoid long waiting times. There was

significant press coverage, much of it adverse, which was harmful to the

reputation of the Trust.

4.42 Although a number of the original problems that were inherent in the

service in the early days of the unit have been resolved, there are still serious

issues that need to be tackled:

• ensuring that the levels of experienced theatre nurses to support

two full cardiac theatres were appropriately resourced;

• reviewing sessional cover for Anaesthetic Consultants to the CITU;

• improving upon present confused management arrangements and

the Trust’s approach to strategic and operational planning;

27

• improving patient management responsibilities and protocols;

• ensuring consistency and transparency in arrangements for

financial remuneration for medical staff;

• ensuring that revisions to the rudimentary clinical governance

processes that were in place lead to improvements in the

monitoring and performance management of clinical governance

within the Trust;

• ensuring that changes made to organisation management in the

Trust lead to improved clinical and organisation leadership.

4.43 We identified one internal and three external investigations or

interventions. We were unable to identify fully documented responses to

these and among staff there were differences as to the outcome and effect

that these initiatives had produced. In these circumstances it was difficult for

the Trust to convince us that sufficient determination to confront and resolve

the chronic difficulties had been demonstrated.

4.44 Many staff complained that management were unwilling to take notice

of their problems, and that the management responses were slow and

ineffectual. It was not always clear who was being identified by the term

“management”. There were several significant changes in management

structures, clinical leaders, and senior management personnel over the

course of these problems.

4.45 We found little evidence of constructive attempts to resolve problems at

the Clinical Directorate or Divisional level, and little coherent leadership from

those involved. Members of the Trust Executive were involved almost

immediately and many divisional and directorate managers and clinicians

were only tangentially involved in resolving the position. The divisional and

clinical directorate arrangements had only just come into being as the

operational problems were escalating in 2003 and precise responsibilities

were confused. Informal communication channels and networks appear to

have been used more than the formal managerial mechanisms. Front line

28

managers had little support to resolve problems and issues quickly escalated.

Devolved budget arrangements had been introduced in 2004 and as more

experience is gained in the operation of this arrangement further devolving of

financial responsibilities may become possible. The Trust was still developing

its the operation of these arrangements. Successful devolution of budgets

should facilitate the ability of managers to resolve problems more rapidly.

4.46 The Trust Executive informed the full Trust Board of the situation as it

developed, through Board briefing sessions and the confidential section of the

Board meeting. This is proper given the nature of some of the problems.

However, any concerns or issues raised by Non-Executives were not

recorded in the confidential Board minutes or elsewhere, and individual Non-

Executives were not clear about whether the problems had been properly

resolved. The Trust Executive and Board accepted the re-assurances about

good clinical outcomes at face value, when knowledge of weaknesses in the

quality of some of the data was widespread at operational level.

4.47 Some staff were directly involved in the investigations and resolution

processes, others felt they should have been. There was little communication

to all staff about what was happening, or of the outcomes of these

investigations and interventions. Many staff reported that their major sources

of information about the situation were press reports and rumours. Many staff

were concerned that the management response was not robust enough and

that senior clinicians behaved in ways that would not have been tolerated in

more junior staff.

4.48 The Edgecumbe process focussed on individual and team behaviours.

Breaches of policies that would, if proved, normally warrant disciplinary action

appear, in the absence of documentation, to have been left unresolved.

4.49 Although senior clinicians were involved within the cardiac surgery unit

and as clinical directors, divisional chairs, and ultimately, medical director,

they have been ineffective in establishing a clear direction for the unit, in

embedding clinical governance, in ensuring proper patient management

29

protocols and in resolving disagreements and differences amongst medical

staff fairly, transparently and speedily.

4.50 In dealing with issues like these we would expect management

responses that were fair, robust, transparent, and timely. There were failures

on all counts, and this led to problems and difficulties escalating.

Recommendation 17: The Trust Board should satisfy itself that knownproblems are properly investigated and resolved, and ensure that theBoard’s concerns are properly recorded in Board minutes. The findingsand outcomes of investigations and interventions should be properlydocumented, and the Board must be clear about the actions it takes inresponse – and whether these are successful.

Recommendation 18: The Trust should consider carefully how todelegate authority, responsibility and resources so that lowermanagement levels are empowered, and properly supported so that theyare able to resolve problems rapidly and effectively.

Recommendation 19: The Trust should strengthen its communicationsystems so that staff are fully informed and able to convey their issuesand concerns, particularly in difficult situations which are attractingadverse external publicity.

Recommendation 20: The Trust should strengthen its clinicalleadership at all levels, through the appropriate mix of newappointments, and single and multidisciplinary education anddevelopment programmes. All clinicians must be fully engaged inpromoting and enhancing good clinical governance.

Recommendation 21: The Trust should work with its partners toproduce a comprehensive action plan by the end of February 2007 toaddress all of the recommendations in this report. This should be donein consultation with its external partners, and report on its progress andeffectiveness in July 2007.

30

31

Chapter 5: Summary and Recommendations

5.1 The purpose of this special review was to ensure that the past and very

public difficulties amongst staff within the Cardiac Surgery Unit at Swansea

NHS Trust had been resolved. Our review concluded that while there is a

positive commitment amongst both clinicians and managers at the Trust to

delivering good patient care, difficulties remain and the body of this report

catalogues many failings in the Trust over several years. It is critical that in

recognising these failings the Trust addresses all of them and the

recommendations made in this report fairly, robustly, transparently, and in a

timely manner. Healthcare is changing rapidly, and the development of

cardiac surgery in Swansea depends on the ability to learn from past failings.

This will involve co-operation with, and learning from, outside agencies and

partners.

5.2 Individual clinicians and managers also have professional and ethical

responsibilities to learn from these experiences, to confront the problems, and

to take responsibility for helping to resolve them. This report is not designed

to provide justification to entrenched positions and outlooks. In carrying out

their evident commitment to good patient care, clinicians and managers have

a duty both to challenge professional practices about which consensus has

not been established and to resolve differences which may arise between

them. Good healthcare depends on good teamwork.

5.3 There is considerable work for the Trust to do, and the Trust must, with

the help of its external partners, develop and implement a comprehensive

action plan to respond to the recommendations. Final resolution of these

problems will depend on staff at all levels in the Trust recognising the scale of

the challenges, and pursuing their solution with determination.

32

33

Summary of Recommendations

Rec No Recommendation Page

1 Data capture, data validation, data ownership, datamanagement, data security and system managementstandards and responsibilities should be thoroughlyreviewed. Standards should be made explicit andconsistently monitored, and individual responsibilities fordata built into job descriptions, job plans, and annualobjectives.

15

2 The Trust should seek an immediate external audit of theirdata arrangements from the Society for CardiothoracicSurgery, and implement the resulting recommendations.

15

3 The Trust should review its information strategy to ensureproper attention is given to improving the timeliness andquality of clinical information. There should be greaterintegration and consistency between departmental andcorporate information and information systems.

16

4 Health Commission Wales should work with all Welshproviders of cardiac surgery to ensure consistentapproaches to data collection and that plans are in placeto meet data requirements for national audit.

16

5 The Trust should urgently review its nurse staffingarrangements in cardiac theatres, and develop andimplement robust plans to recruit, train and retain sufficientskilled staff.

23

6 The Trust should ensure that staff understand theprocedures followed for all medical appointments,including locums in the interests of transparency.

23

7 The Trust should ensure that basic clinical governanceprocesses especially risk management, incident reporting,and staff management are embedded at operational level,and that a positive patient safety culture is engendered.The Trust should ensure that the communication anddissemination mechanisms are strengthened, so thatlearning and improvement occurs, and that progress iseffectively monitored.

23

8 The Trust should ensure that all clinical incidents areproperly reviewed and, where appropriate, investigated.The outcomes of these reviews and investigations must beproperly documented.

23

34

Rec No Recommendation Page

9 The Trust should develop and implement a comprehensiveaudit strategy and plan for cardiac surgery, concentratinginitially on improving data quality, and strengthening andensuring multidisciplinary audit.

23

10 The Trust should review the levels of medical cover inCITU, and HDU. The recommendations of the IntensiveCare Society should be followed.

24

11 The Trust should develop, document and implement anagreed care pathway and agreed patient managementprotocols for patients in CITU and HDU. There should beproper mechanisms for professional differences onindividual patient management to be properly discussedand speedily resolved using the best evidence available.

24

12 The Trust should review management arrangements forcardiac services to clarify individual responsibilities, andavoid structural splits wherever possible.

24

13 The Trust should review the recommendations of theOwens report on theatre management arrangements, tosee how clinical leadership and theatre management couldbe improved. Clear theatre utilisation protocols should bedeveloped to ensure that all the particular requirements ofcardiac surgery are met, and to ensure effective resourceutilisation. Further external assistance to improveoperating theatre leadership and management may berequired.

24

14 The Trust should review its mechanisms to ensure that thecardiac surgery unit keeps abreast of best practice in theorganisation, management and delivery of cardiac surgery.The Trust should establish formal benchmarking or peerreview arrangements with other cardiac units in Wales andEngland.

24

15 The Trust should ensure that the standards andbehaviours it expects of staff, including staff in cardiacsurgery are understood by all staff.

26

16 The Trust should examine carefully how multidisciplinaryteam working can be developed and supported, boththrough formal and informal structures and processes.Investigations of multidisciplinary teamworking practiceselsewhere (not necessarily just cardiac units) should beundertaken.

26

35

Rec No Recommendation Page

17 The Trust Board should satisfy itself that known problemsare properly investigated and resolved, and ensure thatthe Board’s concerns are properly recorded in Boardminutes. The findings and outcomes of investigations andinterventions should be properly documented, and theBoard must be clear about the actions it takes in response– and whether these are successful.

29

18 The Trust should consider carefully how to delegateauthority, responsibility and resources so that lowermanagement levels are empowered, and properlysupported so that they are able to resolve problems rapidlyand effectively.

29

19 The Trust should strengthen its communication systems sothat staff are fully informed and able to convey their issuesand concerns, particularly in difficult situations which areattracting adverse external publicity.

29

20 The Trust should strengthen its clinical leadership at alllevels, through the appropriate mix of new appointments,and single and multidisciplinary education anddevelopment programmes. All clinicians must be fullyengaged in promoting and enhancing good clinicalgovernance.

29

21 The Trust should work with its partners to produce acomprehensive action plan by the end of February 2007 toaddress all of the recommendations in this report. Thisshould be done in consultation with its external partners,and the Trust should report on its progress andeffectiveness in July 2007.

29

36

37

In the intervening period since completion of the Review by HealthcareInspectorate Wales (HIW), a number of developments have been progressedby the Swansea NHS Trust that respond to matters raised in the HIW’sReview Report. Collection of evidence by HIW was completed in August2006. To allow the report to reflect these changes, HIW is supplementing thereport with this postscript provided by the Trust.

Reliability of clinical information

The report drew attention to the need for the Trust to address a number ofissues relating to the use of information. Recommendation 2 of the reportcalls for the Trust to seek an immediate external audit of its dataarrangements.

This has been done. External validation of the clinical information systemsstatistics was carried out by the Society of Cardiothoracic Surgeons QualityAccreditation Panel and the NHS Information Centre. Their report comparesthe record of patients who died following cardiac surgery, with independentlycollected data from the Office of National Statistics (ONS).

It clearly shows that the mortality statistics are 100 per cent reliable andidentical to the ONS figures.

The Panel’s report shows:

• That the mortality statistics are 100% accurate.• The case-mix of patients treated by Swansea NHS Trust is more

complex than the average for the UK.• Yet the outcomes for patients are: “better than expected”; (source:

Healthcare Commission Heart Surgery in Great Britain.)*

The Trust has concluded therefore that survival rates published by the Trustare accurate and (as per Healthcare Commission report) that they areperforming better than expected, given the case-mix of the patients treated.

The Trust is confident that the Morriston unit is, and continues to be, one ofthe best performing units in the UK with regard to the clinical outcomes forpatients that undergo cardiac surgery.

(* Healthcare Commission Heart Surgery in Great Britain is available on itswebsite www.healthcarecommission.org.uk It shows the survival rate for onegroup of Morriston cardiac patients was 98.7 per for the three years to March2005. The expected rate, taking into account the health of patients treated,was between 91.9 per cent and 95.8 per cent. In a second group of patients

Postscript to Healthcare Inspectorate Wales’s Review ofCardiac Surgery at Swansea NHS Trust undertaken May2006 – December 2006.

38

the survival rate was 97.9 per cent. The expected survival rate on healthcriteria was between 90.6 per cent and 97.3 per cent. The report saidMorriston’s survival rates in both categories were “better than expected.”)

In addition, the Quality Accreditation Panel report commented on datacollection within the Trust. It said:

“In comparison to other units….the Cardiac Centre at Morriston Hospital issignificantly under-resourced”.

The Panel’s visiting team was also:

“Very impressed with the extent, detail and rigor with which a dynamiccohesive and forward-looking team is addressing datamanagement…..Realisation of these ambitions will require sufficientinvestment.”

Other HIW recommendations

Clinical Governance

HIW’s report draws attention to matters relating to Clinical Governance.Recommendations 7 and 8 refer to the reporting of untoward incidents.

During the course of 2006 the Trust has introduced a new Clinical IncidentReporting System which has led to improved practice.

The Trust has also established dedicated IT support for the CardiacInformation System through the appointment of Cardiac Information SystemManager.

Theatre staff nursing levels

At the time of the HIW inspection, concern was expressed about core cardiactheatre staff nursing levels. Recommendation 5 addresses this matter.

The Trust has strengthened core nursing levels in cardiac theatres byappointing more staff into permanent posts following a successful recruitmentcampaign. The Trust has also been able to encourage more staff toexperience and work in cardiac theatres within its existing establishment

All the posts within the establishment are now filled, with the exception of theteam leader post. Applications have been received for that post, andinterviews will take place in January.

39

General cardiac staff relations

HIW’s report draws attention to the difficulties which have been experiencedbetween staff. Recommendations 12, 13, 15 and 16 refer.

Changes have been made to the clinical management team and medical andnursing leads. Management arrangements have been strengthened, and agreater focus placed on the relevant directorate/divisions.

Conclusion

The Trust will endeavour to maintain its excellent clinical results whilecontinuing to develop a culture of better team-working and embedding ofclinical governance at a day-to-day operational level.

There is clearly more work to be done and the Trust will be seeking supportinternally and with its external partners to implement these.

40

41

Annex A

Healthcare Inspectorate Wales

Healthcare Inspectorate Wales (HIW) was established on 1 April 2004 by the

National Assembly for Wales to discharge the responsibilities specified for the

Assembly in the Health and Social Care (Community Health and Standards)

Act 2003. HIW has been established as a Unit within the Assembly with a

formal independence provided through delegations made under the 2003 Act

to the Chief Executive of HIW.

HIW’s core responsibility is to undertake reviews and investigations into the

provision of NHS funded care either by or for Welsh NHS organisations in

order to provide independent assurance about and to support the continuous

improvement in the quality and safety of Welsh NHS funded care. In doing

so, HIW must play particular regard to:

• the availability of and access to healthcare;

• the quality and effectiveness of healthcare;

• the management of healthcare and the economy and efficiency of its

provision;

• the information provided to the public and patients about healthcare

and;

• the rights and welfare of children.

The frameworks of Clinical Governance and Healthcare Standards set by the

Welsh Assembly Government are central to the way in which HIW assesses

Welsh NHS organisations and Welsh NHS funded care.

In this respect, HIW is committed to:

• strengthening the voice of patients and the public in the way health

services are reviewed;

42

• working with others to improve services across sectors and agencies;

• working with other regulators/inspectorates to ensure that the public,

NHS organisations and the Assembly receive useful, accessible and

relevant information about the quality and safety of Welsh NHS funded

care and;

• developing more effective and co-ordinated approaches to the review

and regulation of the NHS in Wales.

On 1 April 2006, the responsibility for the regulation of independent healthcare

transferred to HIW from the Care Standards Inspectorate for Wales under the

remit of the Care Standards Act 2000. Independent healthcare settings

include acute hospitals, mental health establishments, dental anaesthesia

settings, hospices, private medical practices, and clinics where prescribed

techniques include class 3b and 4 lasers.

In addition on 1 April 2006, following the abolition of Health Professions

Wales, HIW assumed responsibility for the statutory supervision of midwives

and also entered an agreement with the Nursing and Midwifery Council

(NMC) to conduct annual monitoring of higher education institutions in Wales

which offers approved NMC programmes.

43

Annex B

Acknowledgements

Healthcare Inspectorate Wales would like to acknowledge the assistance of

the following in the production of this report.

James Roxburgh, Consultant Cardiothoracic Surgeon;

Jean-Pierre van Besouw, Consultant Anaesthetist;

David Purdue, Clinical Nurse Manager; and

Graham Jones, Peer Inspector with management experience in NHS,

Healthcare Inspectorate Wales.

The content of the report is the sole responsibility of Healthcare Inspectorate

Wales.

44

45

Annex C

References

Healthcare Commission (2006)“Heart surgery in Great Britain” public portal athttp://heartsurgery.healthcarecommission.org.uk/ accessed July 06

HIW (2005)“Inspection methodology: Acute and Community Trusts, October 2005”available atwww.hiw.org.uk

SCTS (2001)“Joint Report from The Society Of Cardiothoracic Surgeons and The BritishCardiac Society On Models Of Care For The Delivery Of Cardiac Surgery”London: Society for Cardiothoracic Surgery