• Peer review of Queen Elizabeth Hospital found “complete lack of medical leadership”
  • ENT surgeons refused to travel to the site to perform tracheostomies on critical care patients
  • No ownership of the care of “deteriorating patients” across the hospital, review says

A “complete lack of medical leadership”, low consultant staffing levels, “inadequate clinical governance” and poor culture are among key findings in a damning peer review into a south London intensive care unit.

The report, shared with HSJ, found the unit at Queen Elizabeth Hospital, run by Lewisham and Greenwich Trust, had several problems causing “significant concerns” for reviewers from the South London Critical Care Network.

In their report, they raised fears that care for patients across the trust could be affected because of issues with the critical care service. This included claims that “younger fitter patients with single organ failure” would not be admitted to intensive care until they developed multiorgan failure because of pressures on bed availability.

They also highlighted an increase in non-clinical transfers of patients – with 16 in one month due to a lack of bed capacity, with no clear plans for this to be addressed.

The reviewers said they had “serious concerns regarding the lack of clear medical leadership on the unit. It was apparent that there were longstanding cultural issues that were preventing appropriate development of the medical model. Communication between the consultants was reportedly inconsistent. There were no planned handover conversations, or multidisciplinary team discussions to agree plans for difficult medical decisions.”

A trust spokesman said since the report was given to it in February, it had acted to ensure patients are safe and improve leadership and staffing numbers.

Concerns highlighted by the review were:

  • Staffing levels – there were 19 patients to just one consultant, which exceeded the recommended ratio of between 1:8 and 1:15. The report said: “It was apparent that this is a consistent issue with no clear recognition of the need for extra consultant input, nor any plans to address this.” Only 3.5 full time equivalent consultants were in post with staff working locum shifts to fill gaps.
  • Leadership – there was a “complete lack of medical leadership… There are no regular meetings where all the consultants discuss the care of patients, development of the unit or future strategy regarding bed base, patient case load, recruitment, standards or guidelines.” There was “inadequate clinical governance” and “it was unclear that any actions created by any of the governance meetings were completed or fed back or resulted in any change to practice”.
  • Escalation of deteriorating patients was described as “ineffective” with a high number of peri arrests (where the heart has unusual rhythms that could signal a cardiac arrest) in the hospital with 60-80 a month. The reviewers suggested deteriorating patients were not being identified. “There was no ownership of the care of deteriorating patients in the wider hospital,” they said.
  • Only two out of 12 critical care outreach nurses had critical care training. There was no consultant input to the team and it was not part of the critical care directorate.
  • Handover between consultants after a three or four days on call did not happen except on an “ad hoc basis”.
  • Ear nose and throat surgeons, based in Lewisham, “refuse to attend” Woolwich hospital meaning patients who need surgical tracheostomy have to be transferred to Lewisham for their operation.
  • Poor incident reporting culture – two members of staff were approached by their managers after reporting incidents with one being told “she had created a lot of work” while another was told she should have said something verbally rather than submitting a formal incident form. The ICU is at the centre of Dr Chris Day’s whistleblowing employment tribunal to be heard next year.

The review team praised nurses saying there was clear evidence of teamwork, communication and strong leadership in the critical care nursing team.

Lewisham and Greenwich Trust was formed out of a controversial merger in 2013 after South London Healthcare Trust was put in special measure for financial problems.

A trust spokesman said following the peer review it agreed to work with local clinical commissioning groups to address “all the issues raised in the peer review and we have been liaising closely with the critical care network on progress against the action plan”.

He added: “Since February, we have generally not had more than 15 patients on the ICU requiring intensive care. When we have had higher numbers of patients on the ICU requiring intensive care, we have carried out clinical risk assessments of every patient so appropriate arrangements can be made, including providing additional consultant cover from the ICU at Lewisham. We are also in the process of recruiting an additional four consultants who will start in August to meet the national guidance around consultant to patient ratios.

“We have been recruiting to other key posts, including six additional critical care nurses who support consultant led outreach work on the wards, reviewing patients who may require critical care. We are also increasing the number of junior doctors on the unit from nine to 12.”

Other actions taken by the trust include:

  • appointment of a new clinical director and clinical lead;
  • new consultant outreach ward rounds;
  • new regular clinical multidisciplinary team reviews of all deaths;
  • new processes to reduce delayed discharges;
  • tracheostomies are carried out onsite; and
  • improving responses to early warning scores for deteriorating patients.