Heart surgery services at a major hospital were dysfunctional, grossly understaffed and pervaded by bullying, which put the care of patients at risk, according to a scathing review obtained by the Herald.
The Waikato District Health Board commissioned an external review of cardiac surgery services in 2018. A team of Australian experts conducted the inquiry and found a "broken system" with a raft of problems that contributed to "concerning outcomes for patients", their report said.
The review led to an overhaul of cardiac surgery services which finished last year and has not been revealed until now.
"The staff are struggling to survive in the current environment and are calling out for resources, an effective leadership and interdepartmental collegiality," the review panel found.
In one of the most alarming findings, the panel said the intensive care unit was "grossly understaffed" in terms of senior specialists capable of handling cardiac surgery cases. This was an "immediate" and "critical" risk to patient safety, the experts said.
The DHB fought to keep the review report secret, denying a request by the Herald to release it under the Official Information Act. After a complaint to the Ombudsman, it eventually provided a copy to the Herald but redacted all but some introductory comments, citing "protection of privacy".
However the Herald obtained an unredacted copy of the report — and it raises serious questions about patient safety. Among the problems identified by the review panel were:
• Staff reported a "culture of blame" with little accountability and "lack of insight into personal contribution to the poor culture".
• Bullying and oppressive behaviour were "prevalent at all levels of the organisation".
• A "silo" mentality meant different specialities involved in cardiac surgery didn't work well together, and "tightly held data at the expense of other departments", including important metrics such as waitlist deaths.
• The structure for referring patients to cardiac surgery was "monopolised and exclusive". "This must change as a matter of priority as it is adversely affecting patient safety and maintaining inter-departmental conflicts," the reviewers said.
• The majority of intensivists - doctors who specialise in caring for critically ill patients - did not have the skills required to manage complex cardiac surgery patients.
• Handling of operating lists in cardiothoracic surgery was "grossly dysfunctional", and the department was too dependent on the then clinical director, "to the point that it is dysfunctional and affecting patient care".
• Staff told the panel of "a real inertia to change" and that "patients' needs were of a lower priority than those of some staff".
The reviewers said the service had strayed from the values it claimed to uphold and urged the DHB to make staff sign new contracts that held them to "expected behaviours and commitment to education, teaching and teamwork".
They recommended "strong consideration" be given to limiting Waikato Hospital to doing only low-risk cardiac surgeries until "at least 1000 cases [were] done with a mortality rate of less than 1.5 per cent".
Waikato's cardiac surgery service is the country's second-biggest. The review was ordered after data indicated there may have been an increase in patient deaths.
The Herald first learned about the existence of the report in December 2019 and requested a copy. The DHB refused to release it, saying publication would impede the ability of staff to have "free and frank" discussions. The Herald challenged this, and in February the document was released, after the involvement of the Ombudsman.
However, the DHB provided only a heavily redacted copy, arguing "a number of new employees would be impugned by a report that held criticisms to which these individuals were not connected".
When the Herald obtained the full, unredacted report, the DHB provided a new response, which claimed the Australian reviewers had included "speculation" in the report and breached the terms of reference by identifying individuals. It said the review contained "procedural deficiencies" and had sparked complaints from the doctors' union.
"Unfortunately the report included claims about the service and service outcomes which were based on comments from interviews and were not supported by data," the DHB said in a statement.
No patients were harmed as a "direct consequence" of the problems raised in the 2018 report, the DHB said. It had nevertheless accepted most of the review's 30 recommendations and conducted a "service improvement" programme in 2019 and 2020.
Immediately after the review, some high-risk patients were sent to Auckland for treatment, while new staff were recruited, including surgeons, cardiologists and specialist nurses. Since then, cardiac surgery has developed robust governance procedures, improved surgical facilities, and brought a new focus to teamwork, the DHB said.
There is a "zero tolerance" to bullying, the DHB added, and staff are encouraged to speak up about any safety concerns.
Waikato DHB said further analysis of the patient data that triggered the review found there had not been an increase in mortality.
In 2020, its cardiac surgery survival rate was in line with "clinical modelling" and similar to that of other hospitals in Australasia, it said, with "strong surgery success rates, with extremely low complications and faster recovery times".
Dr Shane Reti, the National Party's deputy leader and health spokesman, told the Herald he was alarmed by the findings of the 2018 review and that the DHB had sought to keep them from the public. He called for more information about what led to the review and what action was taken.
• We want to hear from patients and families affected by the cardiac surgery problems. Contact email@example.com
Timeline - the Herald's fight to make the report public
• November 2018: An independent review into cardiac surgery is delivered to the DHB's chief operating officer.
• December 3 2019: Under the Official Information Act the Herald requests a copy of the report.
• January 20 2020: Waikato DHB refuses to release the report, citing parts of the OIA that allow information to be withheld, "to maintain confidentiality and the effective conduct of public affairs through free and frank expression of opinion". The Herald complains to the Ombudsman.
• February 24 2020: The Herald reports on the decision to keep the review secret, and delays for heart scans and procedures including putting in pacemakers at Waikato DHB. A health union says cardiac services have been under stress for some time, with too few staff risking fatigue and burnout.
• April 2020: Waikato DHB advises it can't respond to the Ombudsman complaint because of the Covid-19 pandemic. The complaint is paused, and restarts on May 19.
• February 26 2021: Waikato DHB releases the report but redacts all but some introductory comments, citing different grounds under the OIA; "to protect the privacy of individuals". The Herald lodges a new complaint with the Ombudsman, but, in the meantime, obtains a copy.
What was withheld
Waikato DHB redacted most of the 2018 review report. Instead, it released a statement it said summarised the findings. Below are examples of how that compared with what was in the actual report, which was obtained by the Herald.
DHB statement: "Increase specialists staff in the intensive care unit, particularly more specialist senior staff."
Unredacted report: "The intensive care unit is grossly understaffed from a staff specialist perspective. This needs to be addressed urgently as an immediate patient safety issue ... the panel feel that the intensive care unit staffing is a critical risk in the provision of sustainable and safe patient care."
DHB statement: "Reduce the silos between individual departments to improve the patient journey, and change the current structure for referring patients for cardiac surgery to use standardised documentation and better communication and transparency in the theatre booking list process."
Unredacted report: "The current structure for referring patients for cardiac surgery is monopolised and exclusive. This must change as a matter of priority as it is adversely affecting patient safety and maintaining interdepartmental conflicts ... the current referral process of cardiology patients to CTS [cardiothoracic surgery] and the management and planning of operating lists was grossly dysfunctional."