Royal College of Surgeons of England: Report on the general surgical service on behalf of University Hospitals Sussex NHS Foundation Trust (17 January 2024)

Summary

On 26 January 2023, University Hospitals Sussex NHS Foundation Trust contacted the Royal College of Surgeons of England to request an invited service review of the Trust’s general surgery department, with a specific focus on upper gastrointestinal surgery, lower GI surgery and emergency general surgery. The request highlighted that the general surgery department was a service which had been under scrutiny for many years, with a history of internal reviews, and concerns being raised by consultant surgeons as well as other members of staff within the department. This report sets out the findings of this review.

Content

This report highlights a number of areas of concern, including:

• The review team identified that the colorectal cancer outcomes appeared to be acceptable, including within the normal range for 30 day mortality. However, they considered that the National Bowel Cancer Audit data showed that there was a disproportionately high rate of urgent or emergency surgery admissions for colorectal cancer patients (54%), which was far higher than the national average (20%) and the regional average.
• The review team considered that the National Emergency Laparotomy Audit data showed a higher than national average 30 day mortality for emergency laparotomy patients, with poor performance for timeliness of arrival in theatre and involvement of geriatricians in the care of high-risk patients. They were of the view that this reflected sub-optimal care for emergency patients, which was a threat to patient safety.
• Major concerns were identified by the review team over high rates of cancellations of elective patients.
• The review team noted that there was a high volume of complaints from patients. The most common theme of complaints was around communication, in terms of patients having a clear understanding of and expectations of their treatment.
• The review team found there was dysfunctional team working and a lack of cohesion and unity amongst the surgical teams and within the general surgery department. They were told that consultant surgeons were dismissive and disrespectful towards other members of staff and displayed hierarchical behaviours towards allied healthcare professionals, particularly junior members of staff.
• Reports of negative culture and behaviours within the general surgery department and wider Trust was of concern to the review team. They heard reports of staff witnessing or hearing about instances of bullying and harassment.
• Serious concerns about a wide disconnect between staff within the surgical teams and the executive leadership within the Trust were identified. The review team found that there was a lack of visible presence of the executive leadership ‘on the ground’ amongst staff, for example on the wards, and a reluctance to engage with the department, and therefore a lack of true understanding of the challenges affecting clinicians.
• The review team were particularly concerned to learn that a ‘culture of fear’ existed amongst staff when it came to the executive leadership team. There were concerning reports of bullying by members of the executive leadership team, with instances of confrontational meetings with individual consultant surgeons, when they were told to “sit down, shut up and listen”, with no ability to express their own concerns, and where they were alone and outnumbered.
• The review team found that staff were reluctant to respond to whistle-blowing requests, given they had experienced instances of other staff members raising concerns through such mechanisms reportedly facing bullying and being dismissed. Whilst the appointment of the Chief of Surgery was found to be positive, as staff felt when they raised concerns they would be taken more seriously, the review team found that the listening stopped at this level, with repeated reports that communication with the executive leadership team was poor.

The report makes a number of recommendations for the Trust to address the patient safety risks that it identifies, including measures to ensure better control over the emergency and elective workload, improve communication, improve the effectiveness of multidisciplinary team working and to break down the disconnect between clinicians and the executive leadership team.

Related Reading

• “Had my concerns been taken seriously by medical staff, Lewis might still be alive today.” Simon Chilcott tells his son Lewis’s story (11 October 2023)
• Mistakes and 'mafia-like' culture at NHS Trust (BBC Newsnight, 29 November 2023)