“That restrictions in cardiac surgical capacity at SGH is causing patients to be diverted…”

The coroner’s concerns

1. That restrictions in cardiac surgical capacity at SGH is causing patients to be diverted to other overstretched units, increasing their risk of death. 2. That emergency patients being diverted away from SGH has resulted in unnecessary deaths. 3. That public confidence has been so dented that patients requiring care have been discouraged from presenting to SGH thus increasing their risk of death. 4. That the evidentially inadequate and critical SJR process has failed to identify factors from which lessons could have been learnt and thus patient safety improved, and future deaths prevented. 5. That this SJR process has undermined the department unnecessarily, impacting on morale and the mental health and confidence of the cardiac surgeons and other clinicians and non-clinicians within SGH which may translate into a lower quality of care for patients. 6. That the apparently unnecessary restrictions on operating rights of the cardiac surgeons is reducing the overall capacity for cardiac surgery and thus may increase the risk of death for patients awaiting such surgery, as they die on waiting lists. 7. That the apparently unfounded damage to the reputation of the cardiac surgery department will take years to repair, increasing the risks of future deaths by damaging public confidence in SGH and the NHS. 8. That restrictions on training, collapse of research and staff leaving, further damages not only the cardiac surgery at SGH but also the wider cardiac surgery field, increasing the risk of death to patients by reducing their access to high quality care. 9. The restrictions at SGH may make surgeons more risk adverse and thus deny care to the most complex patients and so increase the risk of future deaths. 10. That the SJR process as deployed in SGH is not fit for purpose, further undermining the public confidence in the NHS, which the public may perceive as the NHS being unable to appropriately audit its own work.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2022-0135

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0