Christine Smith KC said that O’Brien was a skilled surgeon “who did not set out to cause harm”, but the trust “failed to recognise that he was a doctor in difficulty and failed to manage him appropriately”.<\/p>\n
The report said concerns about O’Brien’s practice were known for many years before 2016, including triage delays, record-keeping failures, storage of patients notes at home, delayed dictation, non-standard prescribing and other clinical and administrative concerns.<\/p>\n
It said medical and operational management did not consistently recognise that issues labelled as ‘administrative’ could amount to significant patient safety risks.<\/p>\n
It added that the prolonged failure to triage referrals properly created a clear risk that urgent cases, including cancer cases, would not be identified or escalated in time.<\/p>\n
The inquiry also found that the trust ought to have recognised that O’Brien was at points a doctor in difficulty and managed him as such, with a formal support and improvement plan, rather than repeated tolerance of unsolved risk.<\/p>\n
Key findings include:<\/p>\n
Patients suffered serious harm, including failures in diagnosis, treatment and follow up<\/p>\n
Repeated missed opportunities to act on a doctor in difficulty, with risks not addressed<\/p>\n
Weak systems failed to identify and act on risk early<\/p>\n
Systemic failures in governance, oversight, leadership, culture and Board accountability<\/p>\n
Three core recommendations: <\/p>\n
Smith said the report is about patients who were “badly let down”.<\/p>\n
“They faced delays in diagnosis and treatment including cancer care, poor communication and too often they were left without the clear high-quality, timely intervention they should have expected.<\/p>\n
“The inquiry makes clear that the deeper causes were systemic. <\/p>\n
“Weak governance, poor oversight, ineffective escalation, and underdeveloped leadership created the conditions in which patients were seriously harmed,” the chair added.<\/p>\n
The inquiry did not determine criminal or civil liability or make findings on fitness to practice.<\/p>\n
It examined how that harm occurred, why it was not fully recognised, and what changes are required to ensure safer care in the future.<\/p>\n
It finished gathering evidence two years ago after hearing from 75 witnesses and receiving 650,000 pages of written evidence.<\/p>\n
Aidan O’Brien was referred by the GMC for a hearing at the Medical Practitioners Tribunal Service (MPTS), for a tribunal to hear all the evidence, and make an independent decision about the doctor’s fitness to practise. <\/p>\n
This process is still ongoing. <\/p>\n
The inquiry recognised that improvements have been made since these issues came to light, including changes within the trust and wider work led by the Department of Health.<\/p>\n
But it said it is clear that further, sustained and transformational change is required.<\/p>\n","protected":false},"excerpt":{"rendered":"Christine Smith KC said that O’Brien was a skilled surgeon “who did not set out to cause harm”,…\n","protected":false},"author":2,"featured_media":655935,"comment_status":"","ping_status":"","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[43],"tags":[102,2960,56,54,55],"class_list":["post-655934","post","type-post","status-publish","format-standard","has-post-thumbnail","category-healthcare","tag-health","tag-healthcare","tag-uk","tag-united-kingdom","tag-unitedkingdom"],"_links":{"self":[{"href":"https:\/\/www.newsbeep.com\/uk\/wp-json\/wp\/v2\/posts\/655934","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.newsbeep.com\/uk\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.newsbeep.com\/uk\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/uk\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/uk\/wp-json\/wp\/v2\/comments?post=655934"}],"version-history":[{"count":0,"href":"https:\/\/www.newsbeep.com\/uk\/wp-json\/wp\/v2\/posts\/655934\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/uk\/wp-json\/wp\/v2\/media\/655935"}],"wp:attachment":[{"href":"https:\/\/www.newsbeep.com\/uk\/wp-json\/wp\/v2\/media?parent=655934"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.newsbeep.com\/uk\/wp-json\/wp\/v2\/categories?post=655934"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.newsbeep.com\/uk\/wp-json\/wp\/v2\/tags?post=655934"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}