‘Significant risks to patient safety and trust’s reputation’ uncovered by external review

The problems in the service at Salisbury Foundation Trust, Wiltshire, were so severe that the Royal College of Physicians suggested it should consider transferring key services such as management of GI bleeds and the care of hepatology patients to other hospitals.

The service was struggling with poor staffing which had led to increased reliance on a partnership with University Hospital Southampton Foundation Trust, outsourcing and the daily use of locum consultants, according to the report (see attached below). The trust board had identified “inability to provide a full gastroenterology service due to lack of medical staff capacity” as an extreme risk.

The report said: “This review was complex and necessary as the gastroenterology service is in a very poor state with significant risks to patient safety and the reputation of the trust. We found a wide range of problems which now need timely action to ensure patients are safe.”

The district general hospital trust was part of a sustainability and transformation partnership with hospitals in Bath and Swindon (now an integrated care system), but the review found links were much stronger with Southampton and the Royal Bournemouth Hospital. “The STP currently adds little value to the gastroenterology services at SFT,” the reviewers said.

The invited review by the Royal College of Physicians – conducted early last year, completed in September, and just released to HSJ  under a freedom of information request — highlighted:

• Some members of staff would rather seek advice from gastroenterologists at other trusts after raising concerns about one individual and being uncertain whether they had been acted on. There were complaints that one person had been given too much leeway; and the gastroenterology service – but not GI surgery — was seen as having a “toxic” reputation which had affected recruitment.
• Gastroenterologists cared for a large number of medical patients with concerns that this was potentially unsafe. One consultant had a ward round over 50 patients and said “decision fatigue” would creep in towards the end.
• Concerns about assessment, initial treatment and transfer of patients with GI bleeds including a case where a patient died of a GI bleed in the endoscopy suite. There were also concerns about patient selection, consent and review of histopathology results in the endoscopic mucosal resection service, where a patient had died from a perforation.
• Hepatology was described as “an extremely disjointed service” with long waiting lists. In at least one case hepatocellular cancer was diagnosed at a late stage due to long waiting times. Histopathology patients were being recalled after several significant errors, which staff felt were due to outsourcing,
• Some staff members were critical of senior leadership and in particular the medical director’s leadership, with unsatisfactory responses to concerns, leaving them unresolved. This was identified as a “potential patient safety issue” with staff having lost faith in the value of raising concerns. The medical director at the time of the RCT visit, Christine Blanshard, was seconded to a role at NHS England/Improvement south west in August 2020. 
• A previous attempt to improve staff relations which involved bringing in a consulting firm was said by staff to have made matters worse and was described by some as a “a painful experience” to the extent that it contributed to some consultants leaving. Teamwork had slightly improved after one consultant, who was viewed as a disruptive influence, had left. However, one clinician was said to have a number of outside business interests which means he was sometimes preoccupied and took phone calls during working hours.
• There had been multiple grievances and claims of bullying, harassment, alleged racism and concerns about unprofessional behaviour.

The review made 20 recommendations which needed to be completed within six months. A follow up report, apparently completed early this year, suggested that most of these had been acted on, with an out of hours rota for GI bleeds with Southampton, an increased focus on raising concerns, and attempts to recruit, as well as setting up a combined GI unit led by the GI surgeons. Previously the management of the service was spread across three different directorates.

Trust chief executive Stacey Hunter — who joind the trust in September last year — said: “The whole team has been working to deliver the action plan and are confident in assuring the board and the public that the service is safe. I was in the department a couple of weeks ago and was pleased to hear from long serving and respected staff that the atmosphere had improved considerably.

“The team are focussed on restoring services that were disrupted by the pandemic and recruitment is ongoing.”

There is growing pressure for findings of invited reviews to be made public and sent routinely to regulators, after HSJ revealing multiple instances where this has not been done in recent years.