9:00am Friday 30th July 2010
"WE know that the last few months have been very difficult for the families of the children whose deaths resulted in this investigation, for the families of patients involved with our children’s cardiac team, and for staff.
The Trust paused the children’s heart surgery service in February because we felt there was a need to stop and investigate concerns that had been raised following the deaths of four children in a short period of time.
This was the right thing to do and the review of services that is now reporting, looked not just at the four deaths we had highlighted, but at our processes around clinical governance and service delivery going back to January 2009. The report has found that ‘in no case did they find a clinical decision, untoward incident or other aspect of care that they regarded as having led directly to death or to another adverse outcome’.
The ORH provides care and treatment for children with congenital heart problems from birth through to adulthood. Over 5,000 paediatric cardiology outpatient appointments take place each year and about 100 operations (in addition we would usually refer about 20 children for heart surgery at other specialist centres).
Children’s heart surgery has been carried out at Oxford since 1986, with good outcomes. Professor Stephen Westaby has worked for a significant part of this time to provide the service on a daily basis, and he has rightly earned the trust and respect of patients, their families and the staff he works with.
The report suggests that clinical governance systems within the Trust ‘lacked clarity and transparency’. In April, we started a review of clinical governance and risk management processes within the Trust to streamline our internal systems and reporting lines.
We recognise that in such a large organisation, processes can become over-complex and we are working to address this issue and ensure that we adopt a more uniform approach across the whole Trust in the future.
The whole Trust Board, under the chairmanship of Dame Fiona Caldicott, is committed to working in an open and transparent way, where problems as well as successes are discussed and addressed. The board sees this as a priority for the Trust’s leadership and is determined to ensure that this approach is fed through the organisation.
Many of our non-executive directors have been with us less than 18 months, we have several new executive directors at the top of the Trust’s management team and the whole team is unified in support of this approach.
Some of the families, whose children are patients at our hospital, have been involved in this review of our children’s heart surgery services. We appreciate that this has been a particularly hard time for them.
We want to be clear that where there are things to learn from the report published today, we will develop plans to tackle those issues as a matter of urgency. The Trust’s board will formally consider and respond to the recommendations in the report at the earliest opportunity.
We would like to take the opportunity to thank patients and their families for the support they have given our services and our staff during this difficult period. Our staff do an excellent job and care deeply about their patients.
Our priority, as always, is to make sure patients get the best service available."
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