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NHS patients who suffered complications during eye surgery outsourced to a private company felt the procedures were rushed and complained that they endured pain during the operations and were shouted at by medical staff, a confidential report obtained by the Guardian has revealed.
Eye operations carried out by a private company on behalf of an NHS hospital appeared “rushed” and surgeons were allowed to press on even after patients reported serious complications, a confidential report obtained by the Guardian has revealed.
The report, which health bosses are refusing to publish, says the private company agreed to perform 20 cataract operations a day – at least six more than the hospital’s own surgeons would usually undertake.
The report, which NHS health bosses still refuse to publish, says some patients who underwent what should have been routine cataract operations suffered burns and loss of iris pigment. Others were left with microscopic metallic fragments in the eye and some had to have further surgery because cataract fragments remained.
In addition, the report suggests that the combination of staff, equipment and facilities had not been tried before. It says training was still going on when the first patients arrived at the mobile operating theatre at Musgrove Park hospital in Somerset.
Of the 62 patients treated by private provider Vanguard Healthcare Solutions for Musgrove Park Hospital in Somerset, only 25 had “normal” recoveries. Some patients said they felt the procedures were hurried, complained of pain during the procedures and claimed they were shouted at by medical staff. The complications reported were ten times the number that might have been expected.
Concerns are also raised that the operations were not halted as quickly as they could have been when it became clear that patients were suffering complications. Rather than stopping procedures and finding out what had gone wrong, they pressed on.
Marked “strictly confidential”, the report reveals that Vanguard agreed to perform 20 cataract operations a day, at least six more than the hospital’s own surgeons would usually undertake. It suggests the combination of staff, equipment and facilities had not been tried before and says that training was still going on when the first patients arrived at the mobile operating theatre. Concerns are also raised that the operations were not halted as quickly as they could have been when it became clear that patients were suffering complications.
By the time the operations at the Taunton hospital were stopped, 62 patients had undergone surgery. Of them, only 25 had a “normal recovery”.
The report gives a rare insight into how contracts between NHS hospitals and private operators work. Musgrove Park drew up a contract with Gloucestershire-based Vanguard, which subcontracted the provision of surgeons and equipment to another company, The Practice, in Buckinghamshire. It in turn subcontracted the supply of some equipment to a third company, Dorset company Kestrel Ophthalmics.
The report says the complications reported were 10 times the number that might have been expected. Among the complications were burns caused by the machine used to break up cataract, and loss of iris pigment. Some were left with microscopic metallic fragments in the eye, and others had to have further surgery because cataract fragments were left in their eyes.
The case has raised concerns about how private healthcare providers and an NHS trust work together while the refusal to publish the report seems to fly in the face of the government’s commitment to openness about mistakes following the Mid Staffs hospital scandal.
The report, marked “strictly confidential: not to be disclosed to any other party”, also gives a rare insight into how contracts between NHS hospitals and private operators work. Musgrove Park drew up a contract with the global health giant Vanguard Healthcare Solutions. It in turn sub-contracted the provision of surgeons and equipment to another private company, which in turn sub-contracted the provision of some equipment to a third company.
Musgrove claimed it wanted to publish the report but was advised not to do so for fear that it would defame individuals or parties involved and open the hospital up to legal action.
It raises worrying questions about how a private healthcare company and an NHS trust work together. The decision not to publish the report seems to fly in the face of the government’s commitment to openness about mistakes following the Mid Staffs hospital scandal. Musgrove claimed it wanted to publish the report but was advised not to do so for fear that it would be defamatory and expose the hospital to possible legal action.
Mike Rigby, an independent Somerset county councillor, claimed many unanswered questions remained. He said: “I have long been concerned that this sort of problem could occur following the fracturing of comprehensive patient care caused by the government’s reorganisation of the NHS and the huge involvement of private health firms.”
Mike Rigby, an independent Somerset county councillor who has been trying get answers about what went wrong since the problems happened in May, said many unanswered questions remained. He said: “I have long been concerned that this sort of problem could occur following the fracturing of comprehensive patient care caused by the government’s reorganisation of the NHS and the huge involvement of private health firms that it invited.”
Clara Eaglen, eye health campaigns manager at the Royal National Institute of Blind People, said it was “unacceptable” that an operation with such low risk of serious complications had left patients with a reduced quality of life. She said: “Our key concern is that outsourcing does not compromise patient safety and reduce the quality of care.”
The report says that in spring 2014 Taunton and Somerset NHS foundation trust needed a “decisive” solution to a backlog of cataract cases to meet government waiting list rules. The trust drew up a contract with Vanguard to treat 400 patients during May 2014. The final contract was agreed on 1 May and operations began next day. Operations were carried out on 2, 3 and 4 May.
Laurence Vick, a medical negligence lawyer representing some of the victims, described the contracting and subcontracting agreement as “bewildering” and said questions remained over how Musgrove “vetted” the various companies.
But on 6 and 7 May, according to the report, concerns were raised by Musgrove consultants regarding three patients who had attended the eye casualty department with problems following surgery at the Vanguard facility.
The refusal to publish the report has caused wide concern within the NHS.
No issues or concerns had been raised by Vanguard. Following discussions between the trust and the private companies involved, it was decided that products – drugs and chemicals – used during the operations were likely to be the problem, rather than surgical problems. It was decided to change the products and carry on with surgery as planned on 9 May.
Prof Azeem Majeed, head of the department of primary care and public health at Imperial College London, tweeted: “Very surprising that this report has not been published. The NHS has a duty to report & learn from system failures.”
Concerns were still being expressed by hospital staff but operations began again at 9.48am on 9 May. By 11am it was clear that other patients were reporting complications and operations were stopped. The contract was suspended and cancelled on 12 May.
Musgrove turned to Vanguard in May to help clear a backlog of cataract cases to meet government waiting list rules. The trust drew up a contract with Vanguard to treat 400 patients. But, within days, patients began to report complications.
The report found that the two surgeons had “significant relevant experience” and both were working in NHS consultant posts. But the combination of staff, equipment and facilities had not been brought together before.
Following discussions between the trust and the private companies, it was decided that products – drugs and chemicals – used during the operations rather than surgical problems were likely to be the cause. It was decided to change the products and carry on with surgery. Only when more complications surfaced was the surgery suspended and the contract terminated.
Investigators looked at whether poor surgical technique was to blame. But the report says this “cannot be the whole explanation” or such problems would have been picked up by the surgeons’ own hospitals or while working in private practice. Patients were affected following operations by both surgeons.
The report says the “pressure of operating on 20 patients each day may have contributed to the possible deterioration of surgical quality and reduction in patient experience”. It suggests that “clearer escalation processes” could have led to an earlier decision to halt operations but it concludes that “no single cause was identified”.
But the report says the “pressure of operating on 20 patients each day may have contributed to the possible deterioration of surgical quality and reduction in patient experience.”
Vanguard has said there are lessons to be learned “by all parties”. The Practice said the two surgeons involved were experienced NHS consultant ophthalmologists with nearly 8,000 procedures between them.
It says some patients reported the procedure felt “rushed”. Several reported experiencing pain during the procedure and being “shouted at” for moving.
Kestrel simply confirmed it was commissioned by The Practice to supply equipment and materials.
The report concludes that “no single cause was identified … the trust has not been able to identify any clear cause that explains all the complications.”
It says: “From the first session on the first day of operating, the number of cases was fixed at 20 per day. This did not allow for significant on-site training time … Patients were arriving at the Vanguard facility while training was going on, creating pressure to start the lists promptly and shorten training.”
The report sais that in retrospect the products identified as the possible reason for complications are unlikely to have been the cause for complications. It suggests that “clearer escalation processes” could have led to an earlier decision to halt operations.
The report says that by the time it was written, of the 37 patients who did not have a “normal recovery”, 32 had been discharged and five were still receiving follow-up treatment.
In a statement released before the report was obtained, Musgrove said: “We have now concluded a thorough investigation. The purpose of this was to try and establish what happened to cause the complications that the patients operated on in the Vanguard mobile theatre experienced, and how we could learn from these events to minimise the risk of recurrence in the future.
“As with similar ophthalmic incident clusters there is no clear single cause for the range of problems our patients appear to have experienced. Instead we have identified a number of factors which may have led to the unusually high level of complications seen. The detail of the investigation has been shared with patients.”
Ian Gillespie, Vanguard’s chief executive, said: “Our focus remains first and foremost on the patients and their care, and I’d like to personally convey my sympathy for any patients who have experienced discomfort or distress.
“This was a collaborative contract, and we have been working closely with the trust throughout this investigation. The investigation does not identify any one cause, but instead points to a number of different factors which may have led to the complications experienced by patients. No issues have been identified with the Vanguard mobile theatre facility itself; however, there are clearly lessons to be learned by all parties. We are working with the trust to ensure that measures are put in place to prevent this happening again.”
