Recurring concern

Insufficient capacity for time-critical cardiac interventions

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First reported 5 Sep 2016•Latest report 9 May 2022

Definition

What this concern includes

Includes deficiencies in the availability, staffing, beds, facilities or service capacity specifically needed to provide time-critical cardiac interventions, including rescue PCI and urgent cardiac surgery, where the deficiency can delay treatment or cause unsafe diversion.

Not included

  • Excludes elective or non-time-critical cardiac procedures where urgency is not a material part of the reported concern.
  • Excludes generic hospital, critical-care or bed-capacity shortages unless they directly restrict capacity for a time-critical cardiac intervention.
  • Excludes delays caused solely by referral, communication, transfer or clinical decision-making failures when cardiac intervention capacity is not itself deficient.
  • Excludes non-cardiac services and cardiac diagnostic testing unless the report explicitly identifies its capacity as limiting a time-critical cardiac intervention.
Reports
2

Distinct published reports

Individual concerns
3

A report can raise multiple concerns

Date range
2016–2022

First to latest report issue date

Stated actions
6

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Cardiff & Vale University LHB1
Cwm Taf Morgannwg University Local Health Board1
Next of kin1
NHS England1
St George's Hospital1
Swansea Bay University Local Health Board1
Welsh Government1
Welsh Health Specialised Services Committee1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Inner West London

    AI-generated summary

    Raymond Griffiths · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Raymond Griffiths was admitted to St George’s Hospital for coronary artery bypass grafting on 21 May 2013, underwent surgery the following day, developed acute on chronic liver failure post-operatively, and died in intensive care three days later. The inquest concluded that his care was beyond reproach and that his liver failure could not reasonably have been predicted or prevented. The report raised concerns about restrictions on cardiac surgical capacity, diversion of emergency and other patients, damage to public confidence, and the adequacy of the SJR process, which were considered capable of increasing risks to future patients.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Restrictions in cardiac surgical capacity causing diversion to overstretched units

    Wider context from the report

    “1. That restrictions in cardiac surgical capacity at SGH is causing patients to be diverted to other overstretched units, increasing their risk of death. ”

    Source location

    Raymond Griffiths · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Introduce and implement transitional arrangements, including dual-consultant operating, to support the safe return to full cardiac surgery activity.

    Verbatim wording from the response

    “At a meeting of the Single Item Quality Surveillance Group, convened by NHSI/E London Region on 7 April 2021, it was confirmed that the restrictions on planned surgery could be lifted. This represented a collective agreement by the key stakeholders who have been involved in overseeing the quality of the Trust’s Cardiac Surgery service (as stated above). A set of transitional arrangements were agreed with the Single Item Quality Surveillance Group to support the unit, and the consultants within it, as it resumed full functioning, which included dual consultant operating on cases that would have been subject to restrictions in place previously. Initially, some of the surgeons were reluctant to accept the transitional arrangements given the possibility, which remained at that stage, that they may be investigated by the General Medical Council.”

    Source location

    Response from St George's University Hospital NHS Foundation Trust
    Page 6 · response
    Published 10 May 2022

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Appoint an external cardiac surgery lead to provide experienced clinical leadership and operate on restricted-risk planned cases.

    Verbatim wording from the response

    “The proportion of patients whose planned care fell under the restrictions that were in place between 3 September 2018 and 7 April 2021 was not high – it was only 8% of the total number of planned operations at the time of the lifting of restrictions in April 2021, and around 20% of planned operations during the six months of transition requirements between November 2021 and May 2022 (see below for further details of these transitional arrangements). Furthermore, the appointment of an external lead for cardiac surgery, who started in December 2018, meant that the team included a highly experienced cardiac surgeon who was not subject to these restrictions. This lead cardiac surgeon was able to operate on the majority of those planned cases at the Trust that fell under the restrictions without them having to be treated elsewhere.”

    Source location

    Response from St George's University Hospital NHS Foundation Trust
    Page 5 · response
    Published 10 May 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Appoint locally employed specialty doctors to maintain uninterrupted clinical service during trainee removal.

    Verbatim wording from the response

    “The potential for the removal of trainees to have a negative impact on the delivery of the cardiac surgery service at the Trust was mitigated by the appointment of locally employed specialty doctors and these appointments ensured that the provision of clinical services to patients was not interrupted or reduced.”

    Source location

    Response from St George's University Hospital NHS Foundation Trust
    Page 16 · response
    Published 10 May 2022

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Increase substantive cardiac surgery consultants and strengthen cardiac anaesthesia capacity through substantive appointments, including conversion of a locum post.

    Verbatim wording from the response

    “• The total number of substantive consultants in cardiac surgery has risen from six in 2017 to seven now: the six consultants who were in post in 2017 are still in post now, and the seventh, the lead for the service, joined in December 2018.”

    Source location

    Response from St George's University Hospital NHS Foundation Trust
    Page 17 · response
    Published 10 May 2022

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Continue supporting the Trust as the South London Cardiac Surgery Network evolves, including its collaborative approach to capacity and patient safety.

    Verbatim wording from the response

    “Cardiac surgery has significantly evolved since the restrictions were put in place in August 2018. Indeed, as with most elective surgical specialties, the temporary pause during the initial impact of the Covid pandemic, provided an opportunity to reset and refocus surgical practice and procedures. We believe the support provided by the stakeholders to the Trust over the past few years has resulted in a more collaborative approach to cardiac surgery in South London. KCH, GSTT and the Trust meet regularly and are committed to work closer as part of the South London Cardiac Surgery Network benefiting patients, promoting patient choice and patient safety. This same network has also continued to regularly consider”

    Source location

    Response from NHS England
    Page 2 · response
    Published 10 May 2022

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    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    South London cardiac surgery units were not overstretched, and restrictions did not increase patients’ risk of death.

    Verbatim wording from the response

    “• Cardiac surgery units in south London were not overstretched during the time that restrictions were in place at the Trust;”

    Source location

    Response from St George's University Hospital NHS Foundation Trust
    Page 8 · response
    Published 10 May 2022

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    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Restrictions did not reduce capacity or increase the risk of death for patients awaiting cardiac surgery.

    Verbatim wording from the response

    “• The restrictions on cardiac surgery did not create a reduction in capacity that increased the risk of death of patients on waiting lists, and”

    Source location

    Response from St George's University Hospital NHS Foundation Trust
    Page 14 · response
    Published 10 May 2022

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    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The cardiac surgery restrictions were necessary and proportionate responses to serious concerns, rather than apparently unnecessary measures increasing mortality risk.

    Verbatim wording from the response

    “We have been unable to identify the evidence base for this concern. For the reasons outlined in significant detail in the Trust’s response, it was clear that the restrictions put in place were necessary and proportionate in response to serious concerns raised and investigated, prior to the commissioning of the Review referenced in the PFD report. These concerns arose from multiple different sources prior to the Review, and we believe that as a matter of public confidence, both commissioners and providers must respond to concerns and protect and promote patient safety.”

    Source location

    Response from NHS England
    Page 9 · response
    Published 10 May 2022

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    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    There is no evidence that the Review or resulting actions caused patient harm, increased mortality, or lower-quality care.

    Verbatim wording from the response

    “In terms of impact, we are not aware of any evidence to suggest that the Review, or any action taken in response to it, has resulted in any patient coming to harm, or indeed death (as stated in your paragraph 5 – see further below). The PFD response from the Trust provides further detail regarding the absence of any connection between the Review and additional safety issues flowing from actions taken by the Trust in response to the Review.”

    Source location

    Response from NHS England
    Page 6 · response
    Published 10 May 2022

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    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The regional cardiac surgery network and alternative capable centres provide appropriate access when patients are diverted or complex care is unavailable locally.

    Verbatim wording from the response

    “We defer to the Trust’s detailed response regarding the paucity of incidents arising from the diversion of patients linked to restriction of cardiac surgery capacity. As commissioners, we are unaware of any specific deaths arising from the clinical pathways arrangements for patients during the restrictions outlined earlier in this response. The Trust has described a single emergency care incident in which the restrictions were found to have been one of a number of factors that may have delayed care. We would welcome established facts and corresponding data and evidence from you, if this is the case, so that we or the Trust may investigate further.”

    Source location

    Response from NHS England
    Page 8 · response
    Published 10 May 2022

    Open published response
  2. South Wales Central

    AI-generated summary

    Dr Imad Hassan · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    On 17 April 2016, Dr Imad Hassan suffered an out-of-hospital heart attack and cardiac arrest, was resuscitated, and taken to Prince Charles Hospital. He suffered a further cardiac arrest and died at 04:35 on 18 April 2016. The report raised concerns about the lack of a formal backup and transfer pathway for patients requiring PCI when capacity was unavailable at the relevant hospitals, including for unconscious STEMI patients.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Insufficient capacity for admission to designated hospitals for PCI

    Wider context from the report

    “2) In such circumstances, a patient meeting the criteria for PCI is unable to undergo that procedure, increasing the risk of his/her death, until there is such capacity for that patient to be admitted to UHW or Morriston Hospitals for PCI. ”

    Source location

    Dr Imad Hassan · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of capacity for rescue PCI at designated hospitals

    Wider context from the report

    “5) In similar circumstances as pertained on the evening prior to / the morning of Dr Hassan's death such a patient (as described in 4)) may be deprived the opportunity of undergoing rescue PCI due to lack of capacity at either UHW in Cardiff or Morriston in Swansea. ”

    Source location

    Dr Imad Hassan · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Develop an all-Wales longer-term strategy for patients not admitted to a hospital offering primary percutaneous coronary intervention.

    Verbatim wording from the response

    “We have confirmed with the United Hospitals University Bristol Trust that they will take patients in the event there is insufficient critical care capacity in South Wales. The transfer of care will be facilitated by the usual regional PPCI centre both for patients in the South West and the South East of Wales. In addition as we outlined in our original response there is work underway on an all Wales basis to agree a longer term strategy for these patients.”

    Source location

    Imad-Hassan-Response-2
    Page 1 · response
    Published 5 September 2016

    Open published response
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Data last updated 7 September 2026