• Regulator “not assured” heart surgery has credible and effective leadership or management
  • Very limited evidence of improvement despite problems persisting for over eight years
  • Mortality and morbidity meetings often a way of “shifting blame” not learning
  • Follows years of dispute between surgeons at the “dark forces” unit

Leadership and management problems from service to trust level contributed to failures at a London teaching trust’s heart surgery unit, the Care Quality Commission said today.

The regulator was “not assured there was credible and effective leadership or managerial oversight at service, divisional or trust level” at St George’s University Hospital Foundation Trust.

Its cardiac surgery unit faced severe problems during summer this year, with the suspension then reinstatement of two surgeons, amid intense media interest. In an independent review of the department, revealed by HSJ in July, staff reported “a persistent toxic atmosphere and… a ‘dark force’ in the unit”.

Inspectors visited the trust’s hospital in Tooting, south London, in August – while the row over suspensions was ongoing – and in September.

The CQC report says there was a “lack of effective clinical leadership within the service”. It said the service was safe and highlighted steps taken to improve it, including daily multi-disciplinary meetings with staff from neighbouring trusts.

However, the report repeated issues raised in external reviews from 2010 and earlier this year and found “there was very limited evidence of any improvement”.

The CQC report acknowledged the problems in the unit go back more than eight years and the trust’s senior leadership team has been in place for 18 months. However, “the impact of intervention to address cultural issues had lacked pace and not improved the situation,” the report added.

Inspectors found “a lack of cohesion and poor working relationships between surgeons” and that mortality and morbidity meetings were “more often used as a way of shifting blame onto others, rather than trying to learn from incidents”.

The 2018 review, written by former NHS England deputy medical director Mike Bewick, was precipitated by the unit’s mortality rate rising outside the expected levels and triggering an alert from the national auditor for cardiac surgery.

Dr Bewick said the high death rate was “the ‘smoke’ of a supressed fire” for the dysfunction within the unit. The CQC inspectors said the latest figures in 2018 showed the death rate had improved and said there was “no direct evidence” that poor working relationships between surgeons had “fed through to poor patient outcomes”.

The trust has also commissioned an external review of the culture, which was taking place during the inspection, to understand the issues affecting the unit and consider steps to improve it.

In response to the report, the trust highlighted the appointment of Mr Steven Livesey from University Hospital Southampton as the service’s new leader. It also said a new governance lead has been appointed to oversee the unit and it had installed new software for capturing mortality and morbidity data.

The chief executive, Jacqueline Totterdell, said she was pleased the CQC had declared the trust’s heart surgery unit was safe but added: “Of course, this does not change the fact that significant improvements are required – and significant progress has been made since the CQC’s visit back in August.”