The first of three reviews carried out at University Hospitals Birmingham NHS Foundation Trust, found concerns around leadership, culture and staff welfare - which if not improved, have potential to put the care of patients at risk.
The NHS Birmingham and Solihull Integrated Care Board was given six weeks to produce the report, carried out by Professor Mike Bewick, former National Deputy Medical Director at NHS England.
Here are 10 issues and topics uncovered in the Bewick report:
Reports of a long standing "bullying and toxic" environment were heard. UHB's approach was first thought to be "firm and fair" but is now more commonly reported as "overzealous and coercive".
The review heard of many examples of concerning comments over a range of subjects including issues over promotion process, bullying of staff (including junior doctors, and a fear of retribution if concerns were raised). All of the issues will be subject to further investigation in the Phase 2 Culture review.
Dr Vaishnavi Kumar's death
Dr Vaishnavi Kumar was a senior doctor in training, approximately one year from qualifying from as a consultant diabetologist. In June last year, she took her own life after feeling 'belittled' at work.
She was still conscious when the ambulance arrived and told the crew "under no circumstances" to take her to the Queen Elizabeth Hospital.
Senior leaders from the Trust failed to attend the funeral of Dr Kumar.
The report believes that opportunities were lost and many felt that the Trust kept itself at arm's length from the Kumar family. No face-to-face meetings were offered to the family by the Trust.
One senior member of staff was unaware of Dr Kumar's death and emailed her personally 26 days after her death, asking why she was removed from her post and if she was still being paid. However, the report does recognise the current interim chair has made progress in reaching out and working with Dr Kumar's father.
Data was provided on 26 Never Events reported between January 8 2020 and November 5 2022. They included:
- 2 operations performed at the wrong surgery- 2 wrong implant/prosthetic surgeries- 8 retained foreign objects post procedure- 7 incorrect operations or procedures- 5 transfusion/transplant of ABO-incompatible blood components or organs- 1 local classification of wrong method of preparation
Blood transfusions 'never events'
Allegations were made that 20 never events occurred in the year from April 2020 and the Trust was responsible for half the total number of transfusion - related errors in England. But, a provisional report from NHS England for the year of April 2020 to March 2021, suggested that there were 12 never events reported - the highest from a single organisation.
7 were regarding ABO incompatible transfusions - this is when people who have one blood type receive blood from someone with a different blood type, it may cause their immune system to react.
2 of the cases were administered because of bedside errors (patient details not checked against the blood bag).
In 5 of 7, the wrong blood was issued by the transfusion laboratory - in 2 cases the Laboratory Information Management system was not updated after patients had undergone transfusions.
The report found that there was a focus on 'human error' rather than human factors or systems-based interventions.
Junior doctor feedback
Doctors in training are giving the chance to give anonymous feedback about their experience of working within the Trust.
Comparing the results from 2018 to 2022 reveals a clear drop in the trainee assessment of working within UHB.
The data is benchmarked against all other training environments, so it shows a decline in the quality of working environment for a key part of the UHB workforce in the last four years.
At a time when recruitment is one of the largest issues facing the NHS, the report stats the Trust is in a position that it cannot afford to be in and a focus on junior doctor working conditions and support is needed to reverse this trend.
Many felt the merger by acquisition in April 2018 between the Heart Of England Foundation Trust (HEFT) and the Queen Elizabeth was not an unqualified success. HEFT had moved into a state of financial failure with a deficit of £90m and there were additional clinical safety concerns with some high-profile cases, not least the cases of Ian Paterson. Some staff at HEFT felt as though the merger was on sided.
The most recent mortality rate is at 110, which is significantly higher compared to other organisations.
It's an indicator of healthcare quality that measures whether the number of deaths is higher or lower than expected.
Lower recruitment levels are associated with increased mortality and worse patient outcome.
Effective team-working leads to higher levels of innovation and a culture of openness has been shown to reduce mortality.
The most recent data on nurse vacancies shows a figure of 13.35% (England average 10%), representing a shortfall against plan of 870 nurses in November 2022.
Although all sites have difficulties maintaining staffing levels currently, Good Hope Hospital is the only one with a CQC regulatory notice at present.
To mitigate this and keep safe staffing levels across the Trust, each ward has a budgetary allocation for additional staff to act as 'floats' who form a flexible workforce.
The Trust should adopt a 'no blame' culture and reinforce when whistleblowers report concerns.
An external review should be made into the Never Events associated with transfusions and should include the views of an independent biomedical scientist.
A close monitoring of future mortality statistics and if these rise persistently - a further external review is commissioned.
In the light of the death of Dr Kumar, there should be a review of the process to support doctors in training who are concerned about their mental health and have the ability to freely speak up and be listened to.
The NHS Birmingham and Solihull Integrated Care Board have said following the review, they were assured that services at the Trust remain safe and patients and service users should continue to access care as needed with confidence.