Royal College of Surgeons Recommendations

Statement regarding Royal College of Surgeons review of Upper GI cancer surgical care
Maidstone and Tunbridge Wells NHS Trust proactively requested an independent review, by the Royal College of Surgeons, into upper gastro intestinal (GI) cancer surgery to help look at some unexpected deaths following this type of procedure in 2012/13.
Paul Sigston, Medical Director at Maidstone and Tunbridge Wells NHS Trust, said: “We have now spoken with families of patients who died following complications after their upper gastro-intestinal (GI) cancer surgery during 2012 and 2013, and have apologised for the failings in care that occurred.
“As promised, we are now making the recommendations of the Royal College of Surgeons review publicly available.
“The Trust is working with St Thomas’ Hospital in London to provide upper gastro intestinal (GI) cancer surgery.  This partnership arrangement will continue while the Trust implements improvements to its own upper GI cancer surgery service.
“We are sorry that some patients did not receive the level of care and treatment that they should have due to potentially avoidable surgical complications.
“Our first priority is to our patients and the actions we have taken will ensure the quality of care they receive is of the highest possible standard.”
Royal College of Surgeons Recommendations:
Prioritised patient safety actions for the Trust:
1.     The oesophageal and gastric resection service should be suspended until the other recommendations made below have been addressed, and significant improvements have been demonstrated  to the working practices, team working and insight of the three upper gastro-intestinal surgeons who have been working as a distinct unit.
2.       Oesophageal and gastric cancer resections performed using laparoscopic techniques should be suspended indefinitely, as the upper gastro-intestinal surgeons in post have not been able to demonstrate sufficient attention to the detail of surgical outcomes or clinical decision-making to provide a safe service to patients.
Consideration should be given to the implications of these recommendations for upper gastro-intestinal surgery for benign conditions and particularly using laparoscopic surgical techniques.
3.      The structure of MDM printed outcome forms should be reviewed to make clear the patient’s pre-treatment stage, management plan, key worker and the clinician in charge.
4.      Improved surgical attendance at MDMs should be mandated. The gastro-intestinal surgeons should be present for at least 75% of MDM meetings, as per peer review requirements, and when they attend they should be there for the whole meeting.
5.      The clinical decision-making of the upper gastro-intestinal surgeons must be improved, with particular attention given to the appropriate pathway for patients with pre-treatment staging of advanced disease and with significant co-morbidities, and to the appropriate treatment response to post-operative complications.
6.     The management of post-operative upper gastro-intestinal complications requires attention. In particular: a) The upper gastro-intestinal surgeons should make contemporaneous entries into a patient’s records documenting any discussions about complications and their management; b) It should be clear to all staff within the multi-disciplinary team which surgeon has responsibility for a patient and is overseeing their ongoing care; c) The three upper gastro-intestinal surgeons who have operated as a distinct unit need to individually increase their presence on the intensive care unit and on the wards; and d) The job plans of the upper gastro-intestinal surgeons should be organised in such a way that other staff within the multi-disciplinary team know where the surgeons are should they need their advice about the management of post-operative complications.
7.     Monitoring of post-operative complications must be strengthened and systematised. Complications associated with the upper gastro-intestinal surgeons should be recorded and collated by an independent person suitably experienced in this type of surgery and monitored in real-time, with external scrutiny by a consultant from another trust who is completely impartial. The impact on patients on any post-operative complications should be discussed as part of a more patient-centred approach to upper gastro-intestinal surgery, and this may be a role for the clinical nurse specialists to lead.
8.     Arrangements for consenting patients must be reviewed. All patients must be provided with adequate written and verbal information and consent obtained by the consultant intending to operate, well in advance of the proposed date of surgery. This should be documented clearly in the patient’s records.
9.     The working practices of the consultant surgeons should be re-organised to provide for continuity of patient care in a consultant-delivered service. Annual appraisal should include discussion about how the surgeons demonstrate their commitment to patients.
10.   Live links of upper gastro-intestinal surgery should not be conducted outside of standard operating times.
11.   Consultant surgeons should attend fixed sessions in person and not delegate these responsibilities to others.
12.   Chairing of the upper gastro-intestinal multi-disciplinary meeting should be given to the consultant oncologists. A review of the case load discussed at these meetings should be undertaken with a view to making the meetings shorter and more tightly focused. The upper gastro-intestinal surgeons should be freed of other commitments (with the exceptions of on-call) and held to account for their attendance for the duration of the meeting.
13.   There should be a separate MDM for HPB cancer patients. This is a requirement if the hospital is to run Oesophago-gastrectomy Cancer Centre. If, however, this ambition is not realised then a generic upper gastro-intestinal MDM is acceptable.
Notes to editors:
The review of upper GI cancer surgery did not identify wider issues pre 2012-13 and mortality rates for this service were within national levels.
Patients (and their relatives) who have undergone upper GI cancer surgery can talk to their clinical nurse specialist at any time if they have any general or specific questions about their care.
We always urge people to talk to us so that we can help them and can continue to improve our services.
The three gastro-intestinal surgeons mentioned in the Royal College of Surgeons’ recommendations continue to work for the Trust.  They no longer carry out complex cancer resection surgery.
The release of the recommendations follows a meeting held by the Clinical Advisory Group on Wednesday evening (16 April 2014).