A worried manager voiced her concerns about Oxford Heart Centre a year ago. Some of those involved have left, but no-one has been fired. Laura Donnelly and Claire Laurent report

Oxford Heart Centre is 'on its knees and riven by internal conflict'. Its culture is characterised by arrogance, complacency and secrecy. So says the long-delayed independent report commissioned by South East regional office.

Surgeons are feuding. During the review, vacancy rates for nursing staff reached 'crisis levels' of 60 per cent.

The review says a 'drinking club culture' at the centre undermined its management. Loyalties were deeply divided, with a group of supporters for one surgeon described as the 'rat pack'.

Service delivery manager Colette O' Keefe, who drew attention to problems within the unit, remains on sick leave, a year after she made allegations - backed by the Royal College of Nursing - against one of the centre's surgeons, Ravi Pillai. He is back at work, while an internal inquiry decides whether he behaved in 'an intimidatory manner towards all or some staff within cardiac services'.

The report found other concerns, too - the absence of proper audit, allegations of fraud, which were upheld, and operating systems in which private patients 'always appear to be put first on the list'.

What is a chief executive to do?

Some might be tempted to watch the heads roll. Not David Highton, chief executive at Oxford Radcliffe Hospital trust since May, who has the unenviable task of clearing up the mess. Instead, he has put out an action plan (see panel).

The review, run by Stephen Bridge, chief executive at Papworth Hospital trust, Jules Dussek, president of the Society of Cardiothoracic Surgeons, and Wilma MacPherson, director of nursing at Guy's and St Thomas' trust, had a strangely worded remit which put tight limits on the issues which could be examined: it wasn't allowed to look at patients' complaints. Some inquiry experts have suggested there was sloppiness in the failure to specify which period of time should be investigated.

Perhaps as a result, the review limits its detailed investigations to the period surrounding the loss of accreditation in 1998, the suspension of two of the cardiothoracic surgeons inside two years, and the attempts of Ms O' Keefe to bring her concerns to the attention of senior managers in autumn 1999.

The panel found the five surgeons in the unit worked autonomously, with little regard for the others. There was no common policy and no protocols among them, leading to confusion and placing huge stress on junior medical staff and nurses. Nurses were often unclear about who should be called out of hours, due to a belief by some staff that surgeon 'x' would only allow surgeon 'y' to treat his patient 'over his dead body'.

The centre rose to international eminence during the early 1990s when the number of open heart operations increased from 150 a year to peak at 1,400 cases a year by the end of the decade.

However, such throughput was unsustainable, says the report. It relied on patients being seen pre and post-operatively by cardiologists, not the surgeons, on parallel operating theatre lists, with one surgeon running operations in two theatres simultaneously.

It also required fast-tracking: the use of a cardiac recovery unit (CRU) instead of an intensive care unit. The CRU's success was largely due to the skill of the nurses, especially Ms O'Keefe, says the report.

'Things began to change from about 1993, ' says the report. By November 1995 the Royal College of Surgeons of England had found 'significant deficiencies' in training. In June 1998 accreditation was lost.

In July 1998 the centre agreed, among other measures, to cease use of parallel operating lists. A month later this agreement was being ignored by one of the consultants. Ms O'Keefe notified the medical director, Dr Chris Bunch, in writing of this, on two separate occasions. The review found that his response gave the impression that the trust was not 'unduly concerned'.

In May 1999 Mr Pillai was reported to have been drinking while on call. A letter from Dr Bunch to Mr Pillai 'failed to spell out the very serious consequence' which was that Oxford potentially had no paediatric cardiac surgeon cover that evening, says the review. In autumn 1999 Ms O'Keefe met separately with chair Peter Bagnall and John MacDonald, then chief executive, to raise concerns about clinical standards and the difficulty she was having in getting the trust to investigate.

The review says she had practically 'begged for an audience with the director of nursing' (Tricia Hart), but a meeting was cancelled at the last minute by Ms Hart. The report comments: 'The support, supervision and guidance of the director of nursing has been found lacking.'

In December 1999 the RCN, acting on behalf of Ms O'Keefe, presented the trust with a series of allegations concerning the heart centre. The panel heard Ms O'Keefe's claims that in late November she received abusive and threatening telephone calls at home and that on 6 December 1999 a brick was thrown through her children's playroom window.

The trust suspended Mr Pillai in December 1999 while the allegations were investigated.

Three of the five allegations were not pursued any further. The other two were the subject of an intermediate, internal inquiry, now concluded.

One of those not pursued concerned making decisions while under the influence of alcohol. In reaching this decision, events going back three and seven years were regarded as time expired and inadmissable, while the incident in May 1999 was considered to have been 'dealt with' and therefore inadmissable.

However, when Mr Pillai was informed his suspension was to be lifted it was subject to two conditions: to meet monthly with the occupational health physician for the next six months 'and to seriously consider' discontinuing the so-called Friday night drinking club arrangements.

Speaking at the launch of the review report, Mr Highton said that Mr Pillai had been required to meet the physician because deputy medical director Dr James Morris (now acting medical director) hoped to establish 'whether there was any alcohol dependency'. Mr Highton said that one visit took place and 'it became clear that that was not the case'. No further visits took place. He said the Friday night drinking club had ceased.

Issues about patient outcomes remain largely unresolved due to the poor levels of clinical audit.

Annual operation throughput is down to 800. Cancellation rates on day of admission for operations were 20 per cent.

Oxfordshire community health council deputy chief officer Val Garner believes current methods of clinical audit potentially lack independence and objectivity.

For now, no one will be fired as a result of the review. Two of the directors have since left the trust but the three others implicated in the report - Ms Hart, Dr Morris and director of personnel Mike Fleming - will remain in post. At a public meeting last week, the CHC demanded their resignation.

But the previous day, at the launch of the report, Mr Highton said: 'These three directors have been critical to me in delivering the agenda in the last six months.

I don't believe criticisms in the report mean they need to leave.'

He said 'there may well be issues of professional conduct if [the surgeons] continue to be unwilling to work together'.

Ms O'Keefe remains on sick leave. Tom Bolger, assistant general secretary of the RCN, is shocked: 'Colette O'Keefe was brave, she was professional and she has used all of her experience to bring to bear that things were wrong in this heart centre. 'She was rebutted at every turn. The responsible thing for the trust to do is to create an environment where Colette can returrn to work.'