The family of a man who died needlessly after a 12-hour delay during surgery have called for changes at a troubled NHS trust as regulators expressed alarm over patient safety and waiting times.
The Care Quality Commission (CQC) has upgraded the surgical department at the Royal Sussex County Hospital in Brighton from “inadequate” to “requires improvement” at a time when it is at the center of a police investigation into dozens of patient deaths and allegations of negligence and cover-up.
In Wednesday’s report, the regulator expressed concern about already long and increasing wait times, repeated canceled operations and staff shortages that could compromise safety.
The inspection report comes as The Guardian can reveal that the trust has apologized and reached a settlement with the family of Ralph Sims, who died aged 65 following heart surgery in April 2019 when doctors failed to adequately act in case of a drop in blood pressure.
His family said the apology was hollow after it took months for the trust to admit liability.
Sims, who was an avid runner, suffered a drop in blood pressure and developed an irregular heart rhythm eight hours after surgery to replace an aortic valve in hospital.
An internal investigation into Sims’ treatment acknowledged that hospital staff “failed to recognize the significance of the drop in blood pressure.”
University Hospitals Sussex NHS Foundation Trust, which runs the hospital, accepted that the father-of-three should have returned for surgery to determine the cause of his decline. Instead, medics decided he should be observed overnight.
Due to another emergency, Sims did not have an angiogram performed until just before noon the next day – 12 hours after the pressure drop. The delay caused irreversible – and avoidable – damage to the heart muscle, leading to his death five weeks later.
A statement from the family said: “The best thing the trust can do now is to ensure guidelines and protocols are followed. The staff did not contact the surgeon who completed the operation, did not send Ralph for an angiogram in time and did not seek advice from the consultant on duty, who was not even on site but was 14 miles away in Worthing. The outcome could have been very different if these things had been done as they should have been done.”
It added: “Although the trust has apologized to our family, it feels hollow. Ralph’s death was completely unnecessary, and despite the problems under his care, it took several years for the trust to apologise.
Thomas Riis-Bristow, a specialist medical negligence lawyer at Irwin Mitchell who acted for the family, said: “The trust has admitted worrying failings. In cardiac surgery, every minute counts and the longer the reduced blood flow goes untreated, the more damage is done to the heart muscle over time. Tragically, in Ralph’s case, had he received adequate care, his death would have been completely avoidable.”
It is not known whether Sim’s death is one of more than forty hospital deaths being investigated by Sussex Police as part of Operation Bramber.
Neil Cox, CQC’s deputy director of operations in the south, warned the trust that enforcement action would be taken if the situation did not improve quickly.
He said: “While we found improvements in some areas, other issues remained. Leaders must address these issues at a much more urgent pace.”
“We noticed a major gap in the relationship between staff and senior leaders and the way they worked together. These issues clearly had a knock-on effect on the quality of care provided to people using services.
“There were still reports of bullying and low staff morale as a result of not being listened to, although the trust took steps to support staff in speaking out.”
Last week, the trust’s bosses were criticized by the Royal College of Surgeons for ‘bullying’ and promoting a ‘culture of fear’ among staff.
George Findlay, chief executive of the University Hospitals Sussex Trust, said the CQC had found signs of “fundamental strengths”.
He said: “But the CQC has also found too many things we need to do better – from more consistent record keeping to training, managing pressure on overstretched staff, improving our culture and, in some of our hospitals, making colleagues feel more confident to speak out. We accept these challenges and are working hard to correct them.”
The trust has not yet commented on the Sims settlement.