St George’s University Hospitals Trust: Cardiac Surgery Mortality Review

Opened the debate

Felicity Buchan secured this debate to address a potential miscarriage of justice involving Professor Marjan Jahangiri, a pre-eminent cardiac surgeon and her constituent. The debate centres on the independent mortality review conducted by NHS Improvement, known as the Lewis review, which found that 67 out of 202 deaths were avoidable at St George's Hospital between 2013 and 2018. Professor Jahangiri’s results have never been subject to an alert or alarm. The review was heavily criticised by the coroner for its flawed methodology and lack of interviews with medical professionals, leading to a public policy issue that has affected the unit's reputation and operations.

Government Response

James Morris responded by outlining the background and history of cardiac services at St George’s, noting growing concerns about cultural issues that may have impacted service safety and quality. He explained that an independent mortality review was commissioned to address these concerns after two mortality alerts from NICOR. The review found shortcomings in 102 out of 202 deaths examined and identified problems contributing to the deaths of 67 heart surgery patients. Morris highlighted that since the mortality review, St George’s has improved its service quality and leadership, with mortality rates returning to normal levels and patient care outcomes improving. He acknowledged ongoing work by NHS England London region to enhance services at the cardiac unit and remove previous restrictions on practice. Morris emphasised that the referral of doctors was not due to the mortality review, which focused on safety issues rather than individual cases, citing legal constraints in commenting further. He concluded with a commitment to reviewing the coroner’s prevention of future deaths report and improving NHS investigations into serious patient safety incidents.