The report cleared consultant Caner Salih of any wrongdoing Child heart surgery should remain suspended at Oxford's John Radcliffe Hospital where four babies died until improvements are made, a report says.
Surgery was suspended when four children died between last December and February, after being operated on by consultant surgeon Caner Salih.The report found the deaths were not due to errors of judgement but Mr Salih was not given appropriate supervision.
Mr Salih was cleared of any wrongdoing by the report.
The independent report, commissioned by the South Central Strategic Health Authority (SHA), found there were problems in Mr Salih's induction and mentoring when he began work at the hospital.
All four deaths occurred shortly after his appointment.
He subsequently decided to stop operating and told the trust of his concerns, including a lack of support.
The SHA's chairman Dr Geoffrey Harris has apologised to the families of the babies who died.
"We offer our sincere condolences and we apologise that, in the cases, the standards of care were not what was expected," he said.
Analysis
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At first glance this report has worrying echoes of the Bristol inquiry a decade ago.
Both dealt with the deaths of babies following heart surgery.
Both listed failings in the management of surgery and the poor culture of reporting concerns.
But the Bristol inquiry was on an altogether bigger scale and dealt with failures stretching over a decade during which time 29 babies died.
Doctors were struck off and a radical overhaul of paediatric heart surgery ordered.
In this case it was the surgeon who performed the operations who raised concerns and there is no suggestion that he performed poorly.
Action was taken within three months of the first death whereas at Bristol the high death rate continued for years.
The report does not criticise his care, saying "all the cases were complex and surgery was high risk".
It found that arrangements for clinical management were "less than adequate".
"In Mr Salih's four cases, we found no evidence of poor surgical practice, but that he would have benefited from help or mentoring by a more experienced surgeon; and that it was an error of judgment for him to undertake the fourth case," the report found.
It recommended an overhaul of the way the hospital deals with serious incidents, better clinical and managerial leadership and to develop ways to identify adverse trends in surgical outcomes earlier.
The hospital's children's heart unit is the smallest in England, carrying out just 120 or so operations a year.
The report also recommended that there needed to be an adequate caseload so surgeons "can maintain their expertise", by a mix of expanding the trust's service and forging links with another centre.
Sir Jonathan Michael, chief executive of the Oxford Radcliffe Hospitals NHS Trust, which runs the hospital, said the hospital had improved its procedures since the deaths.
But he added he did not believe child heart surgery should remain suspended, saying the unit had "a lot to offer the NHS".
In a statement, the trust said it understood the past few months had been "difficult for the families of the children whose deaths resulted in this investigation".
"Children's heart surgery has been carried out at Oxford since 1986, with good outcomes," it said.
It said a review of clinical governance and risk management had begun in April to "streamline our internal systems and reporting lines".
"We recognise that in such a large organisation, processes can become over-complex and we are working to address this issue and ensure that we adopt a more uniform approach across the whole trust in the future.
"We want to be clear that where there are things to learn from the report published today, we will develop plans to tackle those issues as a matter of urgency."
It has until 17 September to report back to the SHA with an action plan.
The Care Quality Commission, which independently regulates health and social care in England, said the hospital was being monitored and its quality and safety standards were to be reviewed.
Meanwhile a helpline has been set up by the hospital trust for patient inquiries: 01865 572900.
BBC
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