Coroner rejects ‘faulty’ report that blamed surgeons for deaths

A CORONER has criticised “extraordinary” shortcomings in an NHS report that wrongly blamed a team of awardwinning surgeons for the deaths of dozens of patients.

The report by NHS Improvement found that cardiac surgeons at St George’s Hospital in south London had caused the deaths of 67 patients, leaving their reputations in tatters.

St George’s NHS Trust suspended two surgeons and paid out hundreds of thousands of pounds in legal fees over claims of clinical malpractice.

But in the latest of a series of inquests, Prof Fiona Wilcox, the senior coroner for inner west London, has criticised the findings of NHS Improvement’s review and said that no blame should have been attached to St George’s medical staff and the two surgeons, Prof Marjan Jahangiri and Dr Justin Nowell.

Over the course of two inquests in the last fortnight, Prof Wilcox has delivered a series of criticisms of the Independent Mortality Review, ruling that the “entire process” was “faulty”, that its conclusions contained “material errors of fact”, and led to grieving families getting a “confusing and distressing” picture of the care their loved ones received. The latest inquest, held on Thursday, heard the NHSI report had made a series of inaccurate claims when it blamed surgeons for the death of Reginald Bowler, a 76-year-old retired postman with severe heart disease.

Prof Wilcox said she would “entirely reject the findings” of the report and ruled that there was “nothing to criticise in the care received by Mr Bowler”.

‘Mr Donald received all appropriate and reasonable expert care from his point of admission until his death’

Olinga Tahzib, representing Mr Bowler’s family, told the inquest that the hearing had been “difficult” for his widow and family.

Another inquest presided over by Prof Wilcox heard that the NHSI review had said that failures in care “definitely” contributed to the death of Graham Donald, a 70-year-old former chief executive from Tadworth, Surrey.

However, the coroner “wholly rejected” that finding, ruling instead that the evidence from NHSI was “lacking”, “based only on a reading of the notes” and “put forward expert opinion for which there was no expert to support that opinion”.

She said that the NHSI review had criticised the use of the perfusion, but had not allowed “any feedback from an expert perfusionist”. Prof Wilcox said: “I find that frankly extraordinary.”

Concluding, Prof Wilcox said: “I have found no failures in the care of Mr Donald, and, in fact, I have found the opposite. In my view, Mr Donald received all appropriate and reasonable expert care in his management, from his point of admission until his death. But sadly, despite all of this care, his heart was in too poor a state and he died.”

Prof Jahangiri and Dr Nowell were reinstated and received apologies and compensation after a High Court judge ruled in August 2019 that no blame should be attached to them.

NHSI said its review was not undertaken to determine cause of death or attribute blame to individual clinicians, but to examine historic care failings in the cardiac surgery unit at St George’s between 2013 and 2018.

A St George’s spokesman said: “We will continue to give every assistance to the coroner and our continuing focus is ensuring our patients receive the best possible care when undergoing heart surgery.”