A probe into five patient deaths at a hospital in Kent has identified that “dysfunctional” working relationships in a surgical team had hampered “intimidated” staff from raising concerns.
The Royal College of Surgeons review, the full version of which was only released this week, provides further details of its investigation into the deaths of five patients at the trust following unusual complications.
It concludes that the deaths were “probably” due to a keyhole techniques used by surgeons which have now been stopped.
The full report into upper gastrointestinal cancer surgery was made public after solicitors for families of some of the patients who died called for the trust to be more open. Maidstone and Tunbridge Wells Trust had previously only published its recommendations.
The trust admits the five patients died from “potentially avoidable” complications in 2012 and 2013, leading to the suspension of some surgery in July 2013.
The report, which was written in December, revealed that:
- Staff reported concerns about both the complications and the defensive reaction of some surgeons.
- Staff had particular concerns about the hospital’s laparoscopic services.
- Its four upper GI surgeons were repeatedly described by staff as a “dysfunctional” team.
- The management of complications was sometimes “poor” and occasionally “haphazard and even illogical”.
- Three of the four surgeons involved showed “poor insight” into the deficiencies of the service they provided.
- Staff were not always clear which surgeon would be operating and patient would see different ones at various on their care pathway. This led to changes in management plans with surgeons not knowing details of the patient they saw.
- Attendance from the three surgeons at multi-disciplinary meetings was poor, with them sometimes leaving after half an hour.
- When staff raised concerns, senior management failed to show “sufficient responsiveness to the breadth of concerns raised by staff”. Some appeared to have been “brushed aside too readily”.
The trust’s medical director Dr Paul Sigston said: “I would again like to apologise to the families involved.
“We are now able to share this report with them that forms part of an in-depth organisation carried out by the trust.”
He added that the trust had reviewed the general surgical outcomes for the consultants concerned and had found good outcomes and mortality rates.