At the beginning of this week, an interim update from the external clinical review, chaired by Andrew Kennedy KC, was mistakenly shared on a section of our website.
The update was meant for a private CUH Board meeting but was included in the public board papers that were uploaded to our website.
This update was seen by a BBC journalist and resulted in some of the current summary findings from the review, including the levels of harm identified by the external clinical reviewers so far, being reported in the media before we were able to share them directly with affected patients and families.
We are extremely sorry for this mistake.
CUH Chief Executive, Nicola Ayton, wrote to all patients and families affected by the external clinical review to apologise and share the details that the interim update contained.
Non-urgent advice: You can read the letter here:
Dear
I wanted to write to you to apologise personally for what has happened this week.
An interim update about the external clinical review, chaired by Andrew Kennedy KC, which was meant for our private board meeting was mistakenly uploaded to the section of our Trust website which contains papers for public board meetings. A journalist from the BBC was then able to read the paper by downloading it from the website.
I know that hearing the details about the reviewers’ findings in the media rather than from us directly will have come as a shock. These details included the numbers of patients harmed, many of whom were children, and you had no advance warning that this would happen. I can only imagine how upsetting this must have been at an already difficult period for you and your family.
I want to share with you in this letter exactly what the update contained and our commitment to making sure that when Andrew Kennedy KC’s report is completed later this year, you receive it at least a week before it is shared with the public.
Interim update from external clinical review
The interim update that was mistakenly put onto the CUH website included a summary of the findings of the external clinical review to date. This included the number of cases looked at and the levels of harm identified so far by the team of
independent clinical reviewers. The update did not include any patient identifiable data.
The interim update was summarised as:
- There are 994 patients in scope of the review.
- To date, 924 patients (93%) have had their external review fully completed. Of these, 889 patients have received the results of their review.
- So far, 209 patients (21%) have been found to have experienced harm. Of these patients, the majority (139) received an elective procedure when they were children.
- There is standard guidance for the NHS in England that categorises harm into ‘low’, ‘moderate’, ‘severe’ and fatal which the reviewers used when assessing all cases.
- Of the cases of harm identified by the external clinical reviewers: 53 patients experienced ‘low physical harm’; 108 patients experienced ‘moderate physical harm’; and 47 patients experienced ‘severe physical harm’
- Tragically one child’s harm was fatal
- Of those patients reviewed so far, 31 patients (3%) have needed additional care.
Behind every number is a child, a patient and a family who continue to live with the consequences of these failures. I am so sorry that this has happened and that we have let you down in this way.
We know that our apologies are not enough and we will rightly be judged on the actions we are taking. We are determined that the legacy of this review will be lasting change and improved care, meaning something like this can never happen again.
The clinical review will conclude in the autumn and we expect to receive Andrew Kennedy KC’s report later this year.
Receiving updates from us
You should always hear updates about the review from us first and I am sorry this did not happen due to a basic error that should not have been made in the first place.
Throughout the clinical review, our focus has been on supporting affected patients and families. When I met with families last week, I promised that you would receive Andrew Kennedy KC’s report, which will include the final confirmed levels of harm, from us first. I agreed that you need time to read his findings before it is shared in full with the public. This commitment still stands and once we know when we will receive the final report, we will write to you and let you know.
If you have any questions or concerns about what you have seen in the news, or if you need any support, please contact us. Our Patient and Family Liaison team remains on hand to support you and can be contacted on 07719 407 210 (Monday-Friday, 9am-4pm) or by emailing cuh.familyliaison@nhs.net.
We are here to support you in whatever way we can.
Yours sincerely,
Nicola Ayton
Chief Executive