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  • University Hospitals Birmingham NHS FT (UHB): Phase 1 Review by IQ4U - Clinical safety (28 March 2023)

    Patient Safety Learning
    • UK
    • Investigations
    • Pre-existing
    • Original author
    • No
    • Professor Mike Bewick (IQ4U)
    • 28/03/23
    • Everyone


    A number of serious concerns have been raised about the University Hospitals Birmingham NHS Foundation Trust, relating to patient safety, governance processes and organisational culture. The Trust has been under review by the Birmingham and Solihull Integrated Care Board (ICB), following a junior doctor at the trust, Dr Vaishnavi Kumar, taking her own life in June 2022.

    In response to these concerns, a series of rapid independently-led reviews have been commissioned at the Trust. This report outlines the outcomes of the first of these reviews, which is focused on clinical safety. It identified a number of issues which require attention, setting out 17 recommendations for further action.


    The review were assured that services at the Trust remain safe and patients and service users should continue to access care as needed with confidence. However, the review found a number of areas of concern, particularly with regards to governance and leadership, culture and staff welfare and has made a series of recommendations for further action.

    The review was commissioned following concerns raised in December 2022 relating to patient safety, leadership, culture and governance. As part of this response, NHS Birmingham and Solihull (ICB) announced three independent reviews focusing on:

    • Patient safety and governance (Bewick Review) - commissioned by the ICB, overseen by experienced senior independent clinician, Professor Mike Bewick, former NHS England Deputy Medical Director.
    • Well-Led review of leadership and governance – in conjunction with NHS England, using established methodology. 
    • Culture - commissioned externally by UHB’s Interim Chair, incorporating findings from above.

    In order to bring the conclusions and recommendations of these two pieces of work together and provide additional independent assurance, Professor Mike Bewick has been commissioned to support both remaining reviews and also return at a later date to update on progress on implementing the recommendations following this report. 

    In the patient safety review, the independent review team set out two concerns and four groups of recommendations. As part of this, they also make clear that their ‘overall view is that the Trust is a safe place to receive care’. 

    The review team have highlighted the need for better understanding of raised Hospital Standard Mortality Rates, concerns regarding levels of staffing, particularly nursing at Good Hope Hospital. The review also finds that ‘any continuance of a culture that is corrosively affecting morale and in particular threatens long term staff recruitment and retention will put at risk the care of patients’. This was supported by feedback from the Trust’s Medical Staff Committee.

    The review team make 17 recommendations (available in the full report) across clinical safety, governance and leadership, staff welfare and culture, including:

    • Haemato-oncology: 
    1. A specific review of mortality should be conducted by an external specialist in this field with support from a governance lead. The terms of reference should include:
    2. An independent retrospective review of all the deaths first analysed by Dr Nikolousis to establish any lessons learned
    3. Consideration as to whether there an outstanding DoC responsibility relating to this patient cohort 
    4.  All deaths in the year 2021/22
    5. An assessment of how integrated the department is following the merger in 2018 with a focus on how leadership and accountability of the service currently functions.
    • That prospective appointments of senior medical, nursing, and managerial leadership are reviewed with a focus on developing core skills, including those required for leadership, collaborative working methods, professional interaction, and disciplinary processes.
    • In light of the tragic death by suicide of Dr Kumar - Together with HEE, a review of the processes to support doctors in training who are concerned about their mental health, ability to speak up freely about concerns with colleagues and a clear message that they will be listened to.
    • That the concerns of senior clinicians, expressed by the Medical Staff Committee in January 2023, are addressed specifically as part of the Phase 2 cultural review.
    • That the Trust commissions a partner to deliver awareness training on how to identify issues of bullying, coercion, intimidation and misogyny.
    University Hospitals Birmingham NHS FT (UHB): Phase 1 Review by IQ4U - Clinical safety (28 March 2023) https://www.birminghamsolihull.icb.nhs.uk/application/files/5316/7994/0284/Phase_1_Review.pdf
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