Three patients who died after routine surgery at a privately-run treatment centre in Hertfordshire were given satisfactory care, an independent probe has concluded.

However, commissioners said the independent review’s findings did not address their concerns about management and leadership at the Surgicentre, which is based at the East and North Hertfordshire Trust’s Lister Hospital.

The centre in Stevenage is run by Clinicenta, a wholly-owned subsidiary of outsourcer Carillion, and carries out routine surgery.

In addition to the three deaths, a fourth patient suffered “permanent harm”, according to NHS Midlands and East. All the four cases took place last year.

The review by Alan Fletcher, a medical examiner, was commissioned by the strategic health authority cluster and written in November, but published earlier this month.

While it proposed improvements, it concluded patients were given an acceptable level of care.

Dr Fletcher said: “I do not believe the care these patients received is substantially different to that provided to many, many patients in the UK in similar circumstances.”

The author said it was “not the intention of the report to apportion blame”.

Among the improvements the report called for were more clinical supervision for Clinicenta junior medical staff; a review of working hours and a surgical review of patients at Lister Surgicentre.  

East and North Hertfordshire Clinical Commissioning Group chief executive Lesley Watts, said there had been “on-going and continuing concerns” about the centre’s leadership.

She said the centre’s failure to provide assurance about waiting times for outpatient and routine surgical procedures led the CCG to direct ophthalmology referrals to alternative providers in August 2012 and “this remains the position”.

Ms Watts added that GPs had not been making new referrals for orthopaedic joint replacements to the Surgicentre and that NHS Hertfordshire and the CCG had “put a number of measures in place to intensively monitor management of services” at the centre. 

Surgicentre medical director Mark O’Flynn said action had already been taken to speed up responses when specialist care was required. There had also been changes to patient record systems to make it “easier to identify entries by different health professionals”.

East and North Hertfordshire Trust medical director Jane McCue said most of the areas for improvement highlighted by Dr Fletcher had already seen improvements.

See full statement by Mr O’Flynn attached.


Improvements for Clinicenta and East and North Hertfordshire Trust include the requirement for:

  • More clinical supervision for Clinicenta junior medical staff and a review of working hours
  • Better access to full medical records between the Lister Surgicentre and the Lister Hospital
  • Clearer arrangements for escalation and access to senior medical staff
  • A surgical review of patients at Lister Surgicentre
  • Further education for medical staff (and to a lesser extent of nursing staff)
  • Further clarity regarding clinical decisions and investigations of patients prior to the embarkation of surgery
  • Increased and timely information sharing between the Lister Surgicentre and East and North Hertfordshire Trust
  • Increased adherence to clinical protocols and best practice