Laurence Vick letter to IRP and Lord Ribeiro
Letter dated 15 January 2013 to IRP/ Lord Ribeiro
REVIEW OF PAEDIATRIC CARDIAC UNITS
I am writing in connection with the IRP review of the JCPCT decision on the future configuration of children's congenital heart services made in July last year.
I have been following developments closely on the basis of my experience of acting for families whose children died or survived with serious injury at the Bristol Royal Infirmary in the 1980s and 1990s and my representation of those families as part of the legal team at the Bristol Royal Infirmary public inquiry chaired by Professor Sir Ian Kennedy. Regrettably, I am currently acting in a number of cases concerning recent failed cardiac operations performed at what is now Bristol Children's Hospital. These include the cases of Sean Turner and Luke Jenkins who died within three weeks of each other - Sean on 15 March 2012 at the age 4 and Luke on 9 April 2012 aged 7 and both are the subject of a forthcoming inquest.
A crucial aim of the families who suffered so grievously from the earlier Bristol scandal was that lessons would be learned so that a similar disaster would never be allowed to happen again. For these reasons I have maintained a close interest in the implementation of the Kennedy recommendations of 2001, which were specifically intended to improve clinical outcomes and help save the lives of more children undergoing complex paediatric cardiac procedures in the future.
In the IRP's press release dated 6th November 2012, after the IRP had been appointed to review the JCPCT's decision you stated that;
"During the course of the review we will gather evidence from a range of people and listen to all interested parties to ensure that the recommendations we make are in the best interests of the children - and their families - across England that need to access these services."
My concern is that the Safe and Sustainable decision was said to have been made without reference to any mortality data. If this is correct, I fear that your review of that decision will also ignore the available data and expose your review to further challenge and debate.
As the various professional associations and Royal Colleges confirmed in a joint letter to the Times on 6 July 2012 after the JCPCT closure recommendations, maintaining the status quo is not an option. They pointed to the fact that surgical expertise has been spread too thinly across too many hospitals and it was imperative that paediatric cardiac surgery is to be provided in a smaller number of highly specialised centres with the expertise and volume of cases to ensure world class care and patient safety and the best possible outcomes. The JCPCT decision rightly envisaged 'joined up' services and networks of care meeting new quality standards and allowing for services to be continually reviewed and improved.
We are still some way from hit squads marching into problem hospitals the instant a unit's mortality rates deviate from current SMRs as envisaged by Professor Kennedy in 2001. We also still have no publication of morbidity rates and no recording or explanation of deaths occurring after 30 days post-operatively. It cannot be acceptable, however, to make crucial decisions over the future of children's heart services without reference to the data that has become available in the post-Bristol era.
When Oxford's John Radcliffe had its paediatric cardiac services suspended in 2010, the South Central Strategic Health Authority (SHA) commissioned an independent review of paediatric cardiac surgery at the Oxford Radcliffe Hospitals NHS Trust. The review panel then commissioned Professor David Spiegelhalter, the lead statistician at the original Bristol Royal Infirmary Inquiry, to produce a statistical analysis of mortality rates - not just at Oxford but at all units, using data from the CCAD so that comparisons could be made.
As laid out in the 'Review of paediatric cardiac services at the Oxford Radcliffe Hospitals NHS Trust' (July 2010), statistics featured highly in the methodology of the review. As this statistical analysis was evidently taken seriously, which would infer its depth and reliability, we are concerned that the Spiegelhalter methodology appears to have been ignored in subsequent reviews of paediatric cardiac units.
I have added a link below to the Daily Telegraph article of 18/9/2010 for reference in order to remind you that the data which the Telegraph obtained (following an FOI request) showed the following analysis carried out by Professor Spiegelhalter in 2009 using data from 2001-2008.
The four underperforming units and percentages of observed deaths over expected deaths (where 100% is the expected amount) were as follows:
1. Guys (Evelina) - 127%
2. Leicester (Glenfield) - 154%
3. Leeds - 142%
4. John Radcliffe (Oxford) - 159%
I am concerned as to what this new review by the IRP will be based on; whether it will be subjective or objective. If mortality and morbidity data is not used, the Safe and Sustainable final decision will inevitably be challenged. Basing your recommendations on a day visit by the IRP and interviews with families and staff will, I feel, render the final decision subject to argument ad infinitum, with the suspicion that the panel has bowed to pressure from MPs and PR campaigns launched by the units earmarked for closure. Obtaining opinions from employees and parents may be a necessary part of the process, however, without vital information, the majority of 'interested parties' will understandably have loyalty towards their local unit/employer. Further, the final closure decision would be better understood by those who will inevitably be unhappy with the outcome and would not be open to challenge if it were based on up to date mortality rates for all units, including those to remain open under the future reconfiguration plans. The review surely must be based on empirical evidence.
Last year's JCPCT decision as to the centres to be closed and those to expand almost exactly matched Spiegelhalter's statistical analysis carried out in 2009-2010 and thus three out of four of the 'to be closed' units were also the ones found to have the highest mortality rates.
A coincidence seems unlikely, hence our surprise when it was announced that mortality data would not be used in the JCPCT's decision . We question, then, was statistical analysis of CCAD data appropriate in the decision leading to Oxford's closure but not in the JCPCT's when it was relevant to all units, not just Oxford?
My question therefore is, will the IRP consider mortality data in its review and if not, why not? Obviously all such data is highly complex and includes many variables but if it was adopted in the Oxford review then it follows that a statistical analysis of fully up to date data should be employed in the review now being finalised.
The Spiegelhalter analysis was far greater in depth than other studies such as the Dr Foster Hospital Guide data, which gave a good all round view of hospitals but did not touch specifically upon paediatric cardiac surgery. Thus, there needs to be a consistent methodology to prevent continual conflicting reports. I strongly believe that allowing the review process to become any more convoluted than it already is will only serve to lessen the support for any reconfiguration.
LAURENCE VICK - PARTNER
Signed for and on behalf OF MICHELMORES LLP