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  1. Content Article
    More information about "Top 10 priorities for patient safety in surgery (Royal College of Surgeons of Edinburgh)"
    We asked the Patient Safety Group (PSG) of The Royal College of Surgeons of Edinburgh (RCSEd) to draw up their top 10 priorities for patient safety in surgery. This resource is for surgeons, anaesthetists and other healthcare professionals who work in surgery and contains links to useful tools and further reading. See also: Safety in surgery series Top 10 tips for surgical safety: ‘Think Safety, think SEIPS’ Top 10 patient safety tips for surgical trainees 1. Foster a culture of safety through design Establish a psychologically safe environment, through design, where staff feel empowered to speak up without fear of blame. Promote a Just Culture, balancing personal accountability with systems-based learning from adverse events and near misses. Actively encourage multidisciplinary teamwork and peer support, with support from senior leadership, to enhance safety and well-being. Other useful RCSEd resources: Anti bullying and undermining campaign Sexual misconduct in surgery - Lets remove it campaign Addressing conflict in surgical teams workshop 2. Implement team-based quality and safety reviews Use team-based quality reviews (TBQRs) and structured case analysis to learn from everyday work, incidents and near misses. Translate findings into sustainable improvement initiatives that enhance both patient outcomes and staff experience. Foster a culture of collective learning, ensuring safety insights lead to actionable change. Other useful RCSEd resources: Making sense of mistakes workshop 3. Apply Human Factors principles and systems thinking principles in surgical and clinical practice Design resilient systems that mitigate work and cognitive overload and enhance performance reliability. Use TBQR principles to support this. Standardise workflows, optimise usability of IT systems and medical devices, and integrate cognitive aids (e.g. WHO Safe Surgery Checklists, prompts). Ensure governance processes support safe, efficient and user-friendly surgical environments. Other useful RCSEd resources: Systems safety on surgical ward rounds Improving the working environment for safe surgical care Improving safety out of hours 4. Enhance communication & handover processes Implement structured communication tools such as SBAR (Situation, Background, Assessment, Recommendation) to improve clarity and effective decision-making. Optimise handover processes with digital tools, checklists and standardised documentation. Reinforce closed-loop communication, ensuring critical information is confirmed and acted upon. Other useful RCSEd resources: Consultation Skills that matter for Surgeon (COSMOS) 5. Strengthen leadership & accountability in patient safety Senior leaders must visibly support safety initiatives and proactively engage frontline staff in decision-making. Embed structured mechanisms for raising concerns, including TBQR, safety huddles and escalation pathways. Ensure staff have access to training, resources and protected time for safety and quality improvement work. 6. Minimise medication errors in surgery Implement electronic prescribing and technology assisted medication administration to mitigate errors. Enforce double-check procedures for high-risk medications and standardised drug labelling. Improve intra and peri-operative medication safety with clear labelling, colour-coded syringes and real-time verification. 7. Improve early recognition & response to deterioration Appropriate regular training of teams on processes and pathways supported by good design of staff rota ensuring adequate staffing levels. Implement early warning scores and establish rapid response pathways for deteriorating patients. Standardise post-operative surveillance strategies, ensuring timely escalation and intervention. Other useful RCSEd resources: Recognition and prevention of deterioration and injury (RAPID) course for training in recognising critically ill patients 8. Engage patients & families as safety partners Encourage shared decision-making to align treatment plans with patient expectations and values. Provide clear communication on risks, benefits and post-operative care, using tools like patient safety checklists and focus on informed consent processes. Actively involve patients and families in safety and quality initiatives and hospital discharge planning. Other useful RCSEd resources: Patient/carer/families resources and information Informed consent courses (ICoNS) 9. Standardise, simplify & optimise surgical processes Reduce unnecessary complexity in clinical workflows, making processes intuitive, efficient and reliable. Co-design standard operating procedures, policies and pathways with frontline teams to minimise variation. Implement automation and digital solutions where feasible to streamline repetitive tasks. Other useful RCSEd resources: NOTSS (Non Operative Technical Skills for Surgery) courses for surgeons DenTS courses for dentists 10. Promote continuous learning & simulation-based training Conduct regular simulation training for critical scenarios (e.g. sepsis, airway emergencies, human factors). Use insights from TBQR and incident reviews to target training needs and refine clinical practice. Ensure ongoing professional development by providing staff with time, resources, incentives and institutional support for learning. Other useful RCSEd resources: Education pages Edinburgh Surgery OnLine MSc in Patient Safety and Clinical Human Factors
  2. News Article
    A 15-year-old boy who was operated on twice by a now unlicensed Great Ormond Street surgeon says he is living with "continuous" pain. Finias Sandu has been told by an independent review the procedures he underwent on his legs were "unacceptable" and "inappropriate" for his age. The teenager from Essex was born with a condition that causes curved bones in his legs. Aged seven, a reconstructive procedure was carried out on Finias's left leg, lengthening the limb by 3.5cm. A few years later, the same operation was carried out on his right leg which involved wearing an invasive and heavy metal frame for months. He has now been told by independent experts these procedures should not have taken place and concerns have been raised over a lack of imaging taken prior to the operations. His doctor at London's prestigious Great Ormond Street Hospital was former consultant orthopaedic surgeon Yaser Jabbar. Sky News has spoken to others he treated. Mr Jabbar also did not arrange for updated scans or for relevant X-rays to be conducted ahead of the procedures. The surgeries have been found to have caused Finias "harm" and left him in constant pain. "Every day I'm continuously in pain," he told Sky News. "It's not something really sharp, although it does get to a certain point where it hurts quite a lot, but it's always there. It just doesn't leave, it's a companion to me, just always there." Read full story Source: Sky News. 18 May 2025
  3. News Article
    Hospital bosses were warned about an NHS surgeon almost nine years before she was eventually suspended over botched operations on children. A joint investigation by The Sunday Times and Sky News has discovered a confidential report written for managers at Cambridge University Hospitals Trust in 2016 that identified problems with the surgical technique and practice of Kuldeep Stohr, a paediatric orthopaedic surgeon. A series of recommendations were made in the report but Stohr was allowed to continue operating. Managers at the hospital told staff the investigation into Stohr had not raised any concerns. Almost a decade on, Stohr has been suspended by the trust after a new review identified at least nine children whose care “fell below the standard” expected. The trust has begun a review of 800 other patients, including around 560 children, 140 adults and 100 emergency patients, who were operated on by Stohr. It has also commissioned an investigation into what action was taken after the 2016 report. Read full story (paywalled) Source: The Times, 10 May 2025
  4. Content Article
    More information about "Safety in surgery series"
    Patient Safety Learning asked the Patient Safety Group (PSG) of the Royal College of Surgeons of Edinburgh (RCSEd) to draw up their top tips for patient safety in surgery to share on the hub. They came up with three useful resources for surgeons and surgical trainees: Top 10 priorities for patient safety in surgery Top 10 tips for surgical safety: Think Safety, think SEIPS Top 10 patient safety tips for surgical trainees In this blog, Anna Paisley, Consultant Upper GI Surgeon and RCSEd Council Member and Chair of the PSG, reflects on the process her and the team went through to collate these patient safety resources. We hope you find these resources useful.  When asked to do this by Patient Safety Leaning, we were delighted to contribute. However, what seemed initially to be a straightforward task, turned out to be rather challenging. Patient safety covers such a vast area, and it proved very difficult to select only 10 key tips. Each member of the multi-disciplinary surgical team will have a slightly different outlook and perspective; the safety principles most important to their specific practice will inevitably vary. No one size fits all. Each member of the PSG had a slightly different set of tips based on their experience, skill set and discipline. All submissions were of course valid and we thought it would be helpful to include the three main approaches. 1 Top 10 priorities for patient safety in surgery Manoj Kumar, Consultant General and Upper GI Surgeon in Aberdeen, PSG Educational Lead and Convenor of the RCSEd Team Based Quality Review workshop, spearheaded a comprehensive set of patient safety tips for surgery aimed primarily for surgical patient safety leaders. His strong belief is that improving patient safety in surgery requires more than isolated interventions—it demands a sustained cultural and systemic shift. His top 10 priorities are grounded in evidence-based practice and real-world experience, recognising that safer care emerges when we design systems that support people to do the right thing, every time. This approach combines Human Factors principles, team-based quality reviews and learning, psychological safety as well as leadership engagement to drive improvement from the ground up. It moves beyond reactive fixes to proactive action, reduces unwarranted variation and enables learning across all levels of the organisation. By embedding these principles into daily practice, surgical teams can move toward high reliability environments and deliver safer, more effective care for every patient. 2 Top 10 tips for surgical safety: ‘Think Safety, think SEIPS’” When asked to give her top 10 tips for patient safety in surgery, Claire Morgan, Consultant in Restorative Dentistry, PSG Deputy Chair and Member of RCSEd Dental Council, chose to structure her response using Carayon’s Systems Engineering Initiative for Patient Safety (SEIPS). The SEIPS framework allows us to consider any patient safety issue or question using a systems-based approach. This affords a broad view, including application of a Safety 2 thinking; i.e. why do things normally go well. From Claire’s personal perspective, ’Think Safety, Think SEIPS’ ensures a constant recheck of all factors that might contribute to any patient safety incident. SEIPS is a relatively simple tool to use with consideration of six contributory systems to patient safety: tasks tools and technology person organisation internal environment external factors. However, it does not stop there, as it is the interaction between all these systems and then processes that determines outcomes. This approach produced a visual map demonstrating the complexity of the socio-technical systems involved in surgical safety from a human factors perspective. 3 Top 10 patient safety tips for surgical trainees As a consultant Upper Gastro-intestinal surgeon from Edinburgh, RCSEd Council Member and PSG Chair, I compiled a simple list with trainee members of the surgical team in mind. Introducing key patient safety principles early in a training pathway is crucial to helping develop an appropriate patient safety culture in any workplace. I wanted to highlight the principle that patient safety is everyone’s responsibility, and not just that of the quality improvement team. I also wanted to emphasise the crucial point that all members of the team have an important voice and should feel empowered and able to speak up if they feel something is not right. So, the RCSEd PSG have used three separate approaches in defining our top ten tips for patient safety in surgery. I hope that you find them useful and that one will resonate with you from your own individual perspective. Share your resources and top tips What more is needed to support surgeons and trainees? Do you have a tool or policy, a personal reflection, peer-reviewed literature that we could share and highlight on the hub. What other top tips would be useful to surgeons, students and patients? Share your ideas in the comments below (you will need to be a hub member, sign up is free and easy) or contact our editorial team at [email protected].
  5. News Article
    A hospital trust has been criticised for its “poor” and “defensive” investigations into three deaths, which a coroner has linked to care by a single surgeon. Heidi Connor, senior coroner for Berkshire, investigated three deaths that occurred within three months at Royal Berkshire Foundation Trust. Each death followed surgery by consultant colorectal surgeon Daniel McGrath, whose “management” of each case was criticised by experts cited by the coroner. The coroner’s prevention of future deaths report about the death of Lorraine Parker, who died most recently of the three on 30 March 2024, was published last week and examined the trust’s death investigations processes across each of the three cases. Ms Connor found the trust’s structured judgement reviews - which investigate care failings following a patient death - to be “at best, poor” and “at worst, defensive”, and warned the trust that its overall death investigation process “is not working well”. In addition, the coroner questioned “whether the trust has done enough to deal with the concerns about this particular surgeon” following the three deaths. There is no note of a restriction on Mr McGrath’s practice according to the General Medical Council register. However, Royal Berkshire told HSJ it has “worked closely with the coroner and the GMC” on measures to oversee his work. He has also been removed from surgical duties. Looking at how the trust handled investigations into the three deaths, the coroner’s report noted the trust did not carry out a “detailed [Patient Safety Incident Response Framework] report”, which supports responses to patient safety incidents, into any of the deaths. Read full story (paywalled) Source: HSJ, 1 May 2025
  6. Content Article
    Lorraine Parker’s death was the third within three months at Royal Berkshire Foundation Trust following surgery by the same consultant colorectal surgeon.   With the permission of both families, the coroner referred to two previous inquests – Mr MR (date of death 4 March 2024), and Mr ME (date of death 28 December 2023) – to focus on the trust’s death investigation processes, and how efficient they have been in terms of picking up issues following each of these deaths. The coroner instructed independent colorectal surgery experts to comment on the management, using two different experts for the three cases. The coroner made the following findings: In the case of Mr ME, a significant surgical error was made when a healthy part of the bowel was removed instead of the area with the cancer, resulting in a much more extensive operation and Mr ME dying around 5 weeks later. This was discussed in a morbidity and mortality meeting, which ends with the simple phrase “await coroner’s report”. A structured judgment review was carried out by a consultant colorectal colleague on 4 May 2024, over four months after the death. According to this review, all of the care given to Mr ME was either “good” or “excellent”. A further structured judgement review took place. It would appear that none of the colorectal surgeons was willing to carry this out, resulting in the need for a gastroenterologist to conduct a second review in July 2024, by which time the surgeon had already been suspended from major operative work. It is important to note that in a clinical governance meeting in February 2024 (ie before either of these structured judgement reviews) it was noted that there were “no learning points identified” in relation to Mr ME’s case. In the case of Mr MR, a structured judgement review took place conducted by a consultant surgical colleague. This report was poor and the coroner wrote to the Chief Medical Officer about it after the inquest. It has the look of the briefest of reviews and tick box exercises. Again, all of the management is referred to as “good”. Mr MR’s case was not discussed during the March 2024 morbidity and mortality meeting, despite the fact that a later death (Lorraine Parker’s, on 30 March 2024) was discussed then. Mr MR’s case did not go to a morbidity and mortality meeting discussion until May 2024. The reasons for this remain unclear. In Lorraine’s case, there was a morbidity and mortality meeting discussion in March 2024 (or perhaps shortly thereafter). The April clinical governance meeting minutes refer to Lorraine’s case and again state “no learning points”. None of these three cases has been the subject of a detailed PSIRF report. Matters of concern On the evidence from the three inquests referred to, the Royal Berkshire Hospital’s death investigation process is not working well. Evidence of delayed morbidity and mortality meetings with no clear system for ensuring that these discussions happen timeously. There is little (if any) record of areas of concern identified at meetings – whether at morbidity and mortality meetings or clinical governance meetings. There is delayed escalation of concerns. Structured judgement reviews are at best, poor, and at worst, defensive. Delayed or no scrutiny of cases being reported to the coroner because the cause of death is unnatural, given that medical examiners are not funded to scrutinise those cases. Opportunities for early learning are therefore being lost. Systems of collating and providing medical records and clinical governance records to the coroner (and presumably to others involved in death investigation) are unreliable. The coroner is concerned about whether the trust has done enough to deal with the concerns about this particular surgeon, not just in the Berkshire area, but more widely.
  7. News Article
    Hundreds of patients treated by a spinal surgeon who was found to have caused them serious harm could have their cases reviewed. NHS England has confirmed it will look back into two hospital reviews into John Bradley Williamson, who worked at Salford Royal Hospital and the Royal Manchester Children's Hospital from 1991 to 2015. It comes after former patients, who said they had experienced problems linked to his surgery, said they believed the previous reviews were too limited. Mr Williamson said he has "always strived to provide the very best care for patients" and would cooperate with any patient care investigation. A report into the surgeon's care between 2009 and 2014 found he had caused "severe harm" to seven patients at Salford Royal Hospital. Some screws were poorly placed, and some patients suffered heavy blood loss, the report found. One former patient, treated by Mr Williamson when she was 11, said she had been living in "agony" after the surgery at the former Pendlebury Children's Hospital, now Royal Manchester Children's Hospital. Campaigners, including the sister of a teenager who died during spinal surgery by Mr Williamson, have called for a full recall of all patients on whom the surgeon operated. Read full story Source: BBC News, 24 April 2025
  8. Event
    until
    Surgical teams are under growing pressure, from rising case complexity and elective backlogs to increasing care demands and system fragmentation. But is it possible to redesign surgical pathways to improve both outcomes and efficiency? And what does good clinical pathway management really look like? On Wednesday 16 April 2025, Surgery International will host a free online webinar exploring the future of clinical pathway management through the lens of perioperative medicine. The session will bring together leading voices in surgery and digital health to explore how we can build safer, smarter and more connected surgical pathways, without losing sight of individual patient needs. Register
  9. News Article
    The care of hundreds of NHS patients — many of them children — is being urgently reviewed because concerns about a surgeon at one of England’s leading hospitals. She is Kuldeep Stohr, a specialist paediatric orthopaedic consultant at Cambridge University Hospitals Trust. Stohr, who spoke of seeing 200 patients a month at Addenbrooke’s Hospital during a 2022 webinar, has been suspended by the trust after an initial review in January identified nine children who had suffered care “below the standard” the trust would expect. This review was conducted by James Hunter, a surgeon and the national clinical leader for paediatric trauma and orthopaedics at NHS England, who found that the quality of some children’s lives had been affected. Now the trust has worked with Hunter to identify 800 of Stohr’s patients to be assessed by a team of experts in a new review. Of these, about 560 are children and 140 are adults. Another 100 adults and children who were treated as emergencies at the Cambridge hospital will have their care reviewed. Many of the cases involving Stohr are linked to osteotomies — a surgical procedure where a bone is cut to reshape or realign bones such as those in the legs. Some families fear the operations were not performed correctly, with some children having to have multiple operations over several years. There are concerns about poor post-surgery follow-up and alleged delays in complications being recognised and treated. Read full story (paywalled) Source: The Times, 5 April 2025
  10. News Article
    A study has demonstrated that AI can create more accurate operative reports than surgeons. Published in the Journal of the American College of Surgeons, it is the first report on fully automated, video-based AI surgical documentation. The research highlights the potential of AI-driven solutions to reduce administrative burdens and improve surgical documentation. Surgeons frequently regard the creation of operative reports as essential yet time-consuming. These reports are inevitably subjective and may contain inaccuracies or incomplete information. The administrative task of documentation has also been recognised as a potential factor in physician burnout. Recent advancements in AI, especially in computer vision, have allowed automated systems to accurately detect surgical steps from video footage. Researchers aimed to create a platform that automates the generation of video-based AI surgical operative reports for robotic-assisted radical prostatectomy (RARP). Using an AI-powered algorithm, surgical steps were automatically identified in video recordings and mapped to pre-specified text to generate narrative AI operative reports. The accuracy of these AI-generated reports was then compared to traditional surgeon-written reports using an expert review of raw surgical video footage as the gold standard. The findings suggest that AI-driven operative reporting can enhance accuracy, reduce the documentation burden, and improve transparency in surgical procedures. Read full story Source: Surgery News, 24 March 2025
  11. News Article
    A large teaching trust has launched reviews of surgery on nearly 800 patients operated on by a children’s orthopaedic surgeon – and whether concerns raised 10 years ago could have prevented harm. Cambridge University Hospitals Foundation Trust said concerns were first raised about the surgeon’s work in 2015 and an external clinical review was carried out. A new review by Verita will look at whether the 2015 recommendations “was acted upon appropriately and, if not, why”. The surgeon, who has not been named, had their work restricted last year while a smaller external review was carried out into new concerns. They were suspended when this identified outcomes below expected standards in nine cases. The BBC has reported that these involved complex hip surgery cases and found some of the children’s quality of life had been affected, including their mobility. The trust announced that, following further findings, it has asked barrister Andrew Kennedy to chair a panel of expert clinicians reviewing the care of almost 700 patients who had planned surgery. It will also review an initial 100 adult and paediatric orthopaedic trauma cases. Read full story (paywalled) Source: HSJ, 24 March 2025
  12. News Article
    Children who underwent operations with a now-suspended surgeon at a Cambridge hospital are being let down again by a lack of information and transparency from the hospital's trust, according to a lawyer representing one of the families. Last month, Addenbrooke's Hospital announced it had contacted the families of nine children whose complex hip surgeries "fell below" the expected standard, following an external review. The orthopaedic surgeon, who has not been named, has since been suspended while a second external review is carried out. But families are said to be "frustrated" by a lack of communication from Addenbrooke's, which is yet to release the findings of the first review. A lawyer instructed by one of the families has accused Cambridge University Hospitals NHS Foundation Trust of failing to follow official guidance in their handling of the patients and their families. Catherine Slattery, associate solicitor at Irwin Mitchell, told Sky News: "Families should feel they are being supported through this process, and that their child is the centre of this investigation. The National Patient Recall Framework - for patients "recalled" by a healthcare provider after a problem has been identified - states that the patient's needs should "always be placed at the centre" of the process. The guidance adds: "There should be appropriate and compassionate engagement with patients to ensure that the process remains patient focused." Read full story Source: Sky News, 19 March 2025
  13. Content Article
    The Royal College of Surgeons of Edinburgh’s Patient Safety Group is dedicated to upholding patient safety and ensuring that the highest standards of care remain central to the College’s mission. These core values are at the heart of everything the College does. Learn more in the attached e-flyer, including some resources available on page 2.
  14. News Article
    An orthopaedic surgeon with “almost complete clinical freedom” is likely to have harmed nearly 100 patients, a long-running investigation has found. The review examined 382 elective complex upper limb procedures at Walsall Healthcare Trust in the West Midlands. It found treatment was “sufficiently sub-optimal to have caused moderate or serious harm” in 24% of cases. As well as the surgeon who carried out the procedures being “apparently not fully competent to perform” them, there was a lack of robust oversight and poor coding, and notes which made it difficult to establish what had happened. The cases studied involved “procedures of concern”, meaning the rate of harm among other all patients operated on by the surgeon is likely to be lower. Surgeon Mian Munawar Shah was stopped from carrying out some operations after concerns were raised about his work in 2020 and was later suspended from patient-facing work. He also worked at a nearby private hospital, Spire Little Aston, but work there is not covered by the reviews published today. After two external reviews, the trust decided to notify and recall patients who had undergone complex upper limb surgery done by him. Some hand and wrist surgery was also examined and found to involve poor or very poor care, including cases where the wrong bone was removed. The final reviews were completed in September, and findings have been published by the Trust. Read full story (paywalled) Source: HSJ, 11 March 2025
  15. Content Article
    Following concerns raised in early 2020 about surgical outcomes of an individual orthopaedic Surgeon, Mr Mian Munawar Shah, his employer, Walsall Healthcare NHS Trust (the Trust) sought external review of a small number (17) of complex upper limb surgery cases by a specialist team from the Royal College of Surgeons (the RCS) through the invited review mechanism. This reported in November 2020 and identified some concerns regarding practice within the trauma and orthopaedic department. The Trust subsequently requested a further RCS review specifically of Mr Shah’s practise, to more fully assess possible concerns regarding outcome after his surgery. Through this the total number of cases reviewed by the RCS was extended to 99. The results of this review were released in April 2022, and following evaluation of both reviews, the Trust decided to undertake a patient notification exercise (PNE) and recall of patients who had undergone complex upper limb surgery by Mr Shah. The recall was initiated in September 2022, the final patient case reviews being completed in September 2024. This report describes the process, oversight, scrutiny and findings of that recall.
  16. News Article
    The number of patient deaths being investigated as possible manslaughter at a troubled NHS hospital has more than doubled to 90, the Guardian can reveal. The growing number of allegedly suspicious deaths, up from an initial total of 40, has forced Sussex police to ask the Home Office for extra resources in dealing with its expanding inquiry into University Hospitals Sussex (UHS), known as Operation Bramber. It is examining allegations of medical negligence and cover-up in the general surgery and neurosurgery departments of Brighton’s Royal Sussex County hospital, part of UHS, between 2015 and 2021. There are also growing internal concerns within the trust about surgeons who continue to operate at the hospital, despite their alleged negligence being reviewed by police. Earlier this month, a group of anaesthetists asked the trust’s medical director for guidance on what to tell patients who inquire about the safety of surgeons about to operate on them. A source at the trust said: “It’s a very valid question. The anaesthetists are in an awkward position of having to anaesthetise the patients before surgery with consultants under suspicion.” There have been calls to suspend some surgeons while police investigate. The source added: “I think the reason they have been allowed to continue, is that the trust does not want to show they have made any mistakes.” Read full story Source: The Guardian, 25 February 2025
  17. News Article
    A 74-year-old surgeon accused of abusing 299 people, most of them children, while they were anaesthetised or recovering from operations has told a French court he did “hideous things” and is prepared to take responsibility for them. Joël Le Scouarnec is accused of raping or sexually abusing the victims, whose average age was 11, during a 30-year career, and detailing the abuse in notebooks. “I’ve done hideous things,” the 74-year-old told a court in Vannes on Monday, the opening day of his trial. He said he was “perfectly aware that these wounds cannot be erased or healed” and he was ready to “take responsibility” for his actions. Almost all the children were unaware of the alleged abuse until police knocked at their doors having discovered their names in the handwritten “black books” found at Le Scouarnec’s home. The abuse is alleged to have taken place between 1989 and 2014, when Le Scouarnec worked at more than a dozen private and public hospitals in Brittany and other parts of western France. Read full story Source: The Guardian, 24 February 2025
  18. News Article
    Surgeons at a top NHS trust were embroiled in allegations of racism, sexism, homophobia and bullying that created a “toxic” culture and harmed patient care, according to a secret report. Consultants responsible for treating thousands of facial trauma patients at Barts Health NHS Trust in London have accused each other of poor surgery, causing avoidable complications and negligence. They say three patients went blind and others needed repair surgery. The surgeons’ relationships have deteriorated since 2017 amid “a constant fight for power and control of the unit”. At least seven patients, who had been waiting for operations for between three and five years, had their procedures cancelled after two doctors refused to work together. The trust admitted that no action had been taken against any of the surgeons and it only informed the Care Quality Commission about the report and its findings on Friday morning, after The Sunday Times made inquiries. The trust said it had found no evidence of patient harm and believed the service was safe. Read full story (paywalled) Source: The Times, 3 February 2025
  19. News Article
    A coroner wants to reopen an inquest into the death of a teenager who died during an operation by a disgraced NHS surgeon. The Sunday Times exposed a report in 2022 that said the once-renowned spinal surgeon John Bradley Williamson’s “unacceptable and unjustifiable” actions contributed to the death of 17-year-old Catherine O’Connor at Salford Royal Hospital in February 2007. Greater Manchester police has concluded an investigation and passed its findings to the Bolton coroner, Timothy Brennand, who will seek permission to reopen the inquest. The teenager’s family believe they have evidence showing Williamson misled the initial inquest. The prime minister intervened last week to promise a meeting with ministers after MPs raised dozens of other cases of patient harm linked to the surgeon, which they say need investigating. More than a dozen staff at Salford Royal, once hailed as the safest hospital in England, have spoken out about what they described as Williamson’s bullying, toxic behaviour and the unsafe surgery that left many of his patients with severe complications. A review of 130 patients treated by Williamson between 2009 and 2014 found 23 had screws misplaced in their spines; five lost excessive blood during surgery; more than 40 had problems with consent; and in 35 cases there was poor surgical practice. Read full story (paywalled) Source: The Times, 25 January 2025
  20. News Article
    Families of children operated on by a disgraced surgeon have labelled independent reports into their care as a "whitewash" and a "final insult". Yaser Jabbar, a former surgeon at London's Great Ormond Street Hospital (GOSH), carried out procedures including leg lengthening and straightening. He also operated on children with complicated disorders. But some cases linked to him resulted in harm, including life-long injuries and amputation. Mr Jabbar left the hospital in 2023 after a report by the Royal College of Surgeons (RCS) found some of the surgery had been "inappropriate" and "incorrect". Following the RCS report, GOSH said each of Mr Jabbar's 723 patients would receive an independent report to conclude what level of harm they had suffered. The reviews, which are being carried out by specialist surgeons who did not work at GOSH, are based on patient notes provided by the hospital. Families have started receiving reports about the care their children received. BBC News has now spoken to four families - and had indirect contact with 12 more - who say the reports do not reflect their children's experiences and often raise more questions than they answer. Many of the reports were concluded without any interviews or interaction with the family or patient, they say. Parents describe the reports as part of a "culture of cover-up", telling the BBC that GOSH has "failed their children", leaving them physically and mentally damaged. Read full story Source: BBC News, 6 December 2024
  21. Community Post
    Subject: Looking for Clinical Champions (Patient Safety Managers, Risk Managers, Nurses, Frontline clinical staff) to join AI startup Hello colleagues, I am Yesh. I am the founder and CEO of Scalpel. <www.scalpel.ai> We are on a mission to make surgery safer and more efficient with ZERO preventable incidents across the globe. We are building an AI (artificially intelligent) assistant for surgical teams so that they can perform safer and more efficient operations. (I know AI is vaguely used everywhere these days, to be very specific, we use a sensor fusion approach and deploy Computer Vision, Natural Language Processing and Data Analytics in the operating room to address preventable patient safety incidents in surgery.) We have been working for multiple NHS trusts including Leeds, Birmingham and Glasgow for the past two years. For a successful adoption of our technology into the wider healthcare ecosystem, we are looking for champion clinicians who have a deeper understanding of the pitfalls in the current surgical safety protocols, innovation process in healthcare and would like to make a true difference with cutting edge technology. You will be part of a collaborative and growing team of engineers and data scientists based in our central London office. This role is an opportunity for you to collaborate in making a difference in billions of lives that lack access to safe surgery. Please contact me for further details. Thank you Yesh [email protected]
  22. News Article
    The jailed breast surgeon Ian Paterson has said he did not tell women if he was going to perform an unauthorised cleavage-sparing mastectomy on them because “it was frightening and they didn’t need to or want to know”. Giving evidence for the first time at an inquest into the deaths of 62 of his former patients, Paterson said he considered a cleavage-sparing mastectomy to be an “adaptation of a standard operation” that did not require separate consent. After previously refusing to give evidence in the hearings, Paterson spoke on Thursday at the inquest of Elaine Turbill, who died, aged 63, in 2017 when her cancer returned after undergoing a mastectomy carried out by Paterson in 2005. The inquest heard that at a recall clinic in 2010, it was recorded that 20% of her breast tissue had been left behind after the operation. Speaking via video link from prison, where he is serving a 20-year sentence for multiple counts of wounding linked to unnecessary operations he carried out on patients, Paterson said he did not explain the procedure in detail to his patients. “Most ladies know what a mastectomy is. I never went into great detail, it scares them and I don’t think they hear it, they just hear the word cancer,” he said. “This lady [Turbill] would have been taken into a separate room with a breast care nurse and would have discussed things in more detail.” He later said: “It was frightening and [patients] didn’t need to or want to know.” Read full story Source: The Guardian, 31 October 2024
  23. Content Article
    Infection Prevention and Control (IPC) is considered to be a practical, evidence-based approach to prevent avoidable infections in healthcare settings, including those caused by antimicrobial resistant germs. In this blog, Claire Kilpatrick highlights a review article published in 2020. It outlines the approaches to prevention of surgical site infections (SSI) and adds new information on the world of global IPC, including recently launched initiatives that might impact on and support the surgical community. It also summarises some of the resources to implement the World Health Organization’s (WHO) SSI prevention guidelines. The founding member of WSIS, Joseph Solomkin, was chair of and played a key influencing role in this guideline evidence.
  24. News Article
    An orthopaedic surgeon who specialises in treating children has been suspended from a hospital in Cambridge after nine surgeries were found to fall "below expected standards". A review was commissioned in October after colleagues raised concerns about the doctor. The review, completed in January, looked at a number of complex paediatric hip surgery cases performed at the unit over two and a half years. It found the outcomes of treatment provided to nine children were "below the standard we would expect", Cambridge University Hospitals chief executive Roland Sinker said. The impacted families were approached by the hospital. A helpline has now been launched for any parents concerned their children may have been impacted. The surgeries did not involve loss of life or limb but in some cases impacted the children's quality of life, the Trust said. Now the Trust is undertaking a retrospective review into all of the planned surgical operations carried out by the individual during their employment. This will review the quality of care received by those patients and schedule any further clinic assessments. Read full story Source: Sky News, 14 February 2025
  25. Event
    This event gives trainees at all levels the opportunity to attend, present and gain feedback on their Audit and QI work. Further lectures will include the McKeown Medal Lecture, a keynote on patient safety and discussion from a Trainee Committee member. Trainees are invited to submit their abstracts for consideration for presentation at this event. Topics for submission: General Surgery, Trauma & Orthopaedic Surgery, Specialties & Common Interest and Patient Safety. Register

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