Care Quality Commission
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Health watchdog responds to independent review of heart transplant deaths at Harefield Hospital

The Healthcare Commission today (Wednesday) welcomed the findings of the independent review of heart transplant services at Harefield hospital.

The review identified no common factors that caused the recent rise in the number of deaths.

The review was triggered in October when the Royal Brompton and Harefield NHS Trust notified authorities that four consecutive patients had died within 30 days of undergoing heart transplants at the hospital.

The Healthcare Commission and the National Specialising Commissioning Team

(NSC) immediately engaged a surgeon and cardiologist, both of whom specialise in heart transplantation.

The review assessed the care of seven patients who died between January and September this year. Four had died within 30 days, two within 90 days and one within 108 days of their heart transplantations.

It also included an analysis of rates of mortality following heart transplants at Harefield Hospital between 1 January 2006 and 31 August

2008 and assessed the trust?s own internal review of its heart transplant services.

Nigel Ellis, the Commission?s Head of Investigations, said:

  • The death of any patient, under any circumstances, is always a tragic event. Heart transplants are inherently risky operations carried out on extremely ill patients and in many cases it is their last resort.
  • This was a thorough and independent review carried out by experts in the field. We are satisfied that their findings are fair and robust.
  • We note that the review did not find evidence of deficiencies in the care given to patients or that the deaths could have been prevented. I?m sure these will be important findings for the family of those patients.
  • The findings echo our recent review of transplant services at Papworth hospital which also experienced a high number of deaths over a seven-month period. The Papworth review led to a series of changes that appear to have had an effect on outcomes.
  • The Harefield review also makes important recommendations for the hospital to further tighten its procedures, particularly around better assessments of whether a patient is well enough to undergo such major surgery. We will continue to monitor the hospital to ensure that these important changes are implemented in full and as swiftly as possible.
  • The trust did exactly what it should have in these circumstances. It kept a close eye on outcomes from surgery, it identified the rise in the rate of deaths and it initiated its own internal investigation. When the trend in mortality rates continued, it notified external bodies and triggered an independent review.?

Mr Ellis added:

  • It?s important to note that when rates of mortality were examined over a longer period of time, Harefield Hospital was found to have a slightly lower rate than the national average. This shows how difficult it can be to apply statistical analysis to small numbers of patients over a short space of time.
  • For this reason, the review makes an important recommendation about revisiting the way in which outcomes of heart transplant surgery should be monitored in the future. It is right to consider whether these changes might bring benefits.
  • The issue of older donors highlights the importance of recruiting more people to be organ donors. This really could save lives.?

Notes to editors:

The Healthcare Commission is the health watchdog in England. It keeps check on health services to ensure that they are meeting standards in a range of areas. The Commission also promotes improvements in the quality of healthcare and public health in England through independent, authoritative, patient-centred assessments of those who provide services.

Responsibility for inspection and investigation of NHS bodies and the independent sector in Wales rests with Healthcare Inspectorate Wales

(HIW). The Healthcare Commission has certain statutory functions in

Wales which include producing an annual report on the state of healthcare in England and Wales, national improvement reviews in England and Wales, and working with HIW to ensure that relevant cross-border issues are managed effectively.

In November 2007, the Healthcare Commission published a report and recommendations following a two-week review of Papworth hospital, looking into the death of seven out of 20 heart transplant patients from January to September 2007. The Commission returned to Papworth six months after the review and found that there had been no deaths of patients following heart transplantation since the review. Further details of the review can be found here.

For more information please contact:

Tony Koutsoumbos for the Healthcare Commission on 0207 448 9210 Jo Thomas for the Royal Brompton and Harefield Trust on 0207 351 8850 Ray Allger for the National Commissioning/NHS London on 07887 683713

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