Raymond Griffiths
9 May 2022 · Coroner Dr Fiona Wilcox · Inner West London
The coroner's concerns
1. restrictions in cardiac surgical capacity
“That restrictions in cardiac surgical capacity at SGH is causing patients to be diverted to other overstretched units, increasing their risk of death”
2. emergency patients being diverted away from SGH
“That emergency patients being diverted away from SGH has resulted in unnecessary deaths”
3. public confidence being dented
“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. evidentially inadequate and critical SJR process
“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. SJR process undermining the department
“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. unnecessary restrictions on operating rights of cardiac surgeons
“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”