Families at Bristol Children's Hospital were let down by over-stretched staff and poor communication, according to an independent review of its cardiac service published today (Thursday 30 June).
It also found hospital management had been unnecessarily defensive in response to criticism, which had created an atmosphere of distrust between families and the hospital.
The Bristol Review, commissioned by NHS England, was prompted by the unexpected deaths of 11 children between 2012 and 2014. All of them had recently had cardiac surgery at Bristol Children's Hospital.
The review found there had been an over-reliance on agency nursing staff, who lacked the skills to deal with such seriously ill children. Time was in short supply too; on occasion nurses were so rushed that parents had to remind them to serve their children meals.
Taking evidence from well over 200 families, the review found that prior to a Care Quality Commission inspection in 2012, senior managers had no idea there were serious problems in the cardiac service.
Here's the review author, Eleanor Grey QC:
The care of 27 children raised particular concerns: their families were provided with individual case reports into their children's care, as part of the review. But many are unhappy with the level of detail, and say a lot of their questions are still unanswered, both in the reports and in the wider review.
Those families have been offered private meetings with review author Eleanor Grey QC, but 10 of them are pursuing legal action against University Hospitals Bristol NHS Trust.
Parents Amy Fenlon and Damian Girling express their unhappiness with the Trust:
The review looked at cardiac care from 2010 to 2014. It has taken two years to publish. It found that despite failings, much of the care was good in that period and that outcomes were comparable with other children's cardiac services: between 2012-15, the cardiac mortality rate at Bristol Children's Hospital was the 6th lowest in the UK, out of the 13 hospitals which have paediatric cardiac units.
The review has made 32 recommendations, to the Trust and to the Department of Health. They include:
- The need for a national review of paediatric intensive care units, which it says are probably over-stretched across the country
- The Trust should streamline its investigations into child deaths
- The Trust should provide clearer information to parents about their child's condition and proposed treatment
- Conversations between staff and parents should be openly recorded, e.g. on mobiles
- The Trust should monitor the experience of children and families
The Trust says it will implement the relevant recommendations as soon as possible, with the help of the families, and that it has already invested millions of pounds in new medical staff and facilities, and made improvements to psychological, family and bereavement support too.
The Chief Executive, Robert Woolley, also issued this message to the parents: