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A report's recommending no more operations should be carried out at the Thames Valley's child heart surgery unit unless it can get bigger.
It's after the death of four young patients in three months following or during operations at Oxford's John Radcliffe Hospital. The deaths, between December 2009 and February 2010, prompted an investigation and a temporary closure of the unit.
The investigation's criticised the way the unit was run, saying its surgeons were overstretched.
Chairman of the South Central NHS Strategic Health Authority, Dr Geoffrey Harris, apologised to the families of those babies who died.
"We offer our sincere condolences and we apologise that, in the cases, the standards of care were not what was expected,'' he said.
Surgeon Caner Salih operated on the four babies, shortly after his appointment at the unit, but the report does not criticise his care.
The report included a review of death rates, and found that among 15 patients operated on by the new surgeon, the death rate was 4.8 times higher than would be expected from a national rate. The panel noted though that "all the cases were complex and surgery was high risk."
The report said: "In Mr Salih's four cases, we found no evidence of poor surgical practice, but that he would have benefited from help or mentoring by a more experienced surgeon; and that it was an error of judgment for him to undertake the fourth case."
The report said several problems led to the excess deaths, including the hospital's decision to appoint a new surgeon, planning for his arrival and his induction and mentoring.
It sets out several recommendations, including an overhaul of the system for dealing with serious adverse incidents and better monitoring of death rates.
The panel "also recommends that paediatric cardiac surgery remain suspended in Oxford until or unless the service can safely be expanded."
There needs to be an adequate caseload so surgeons "can maintain their expertise".
"This might require some mix of both expanding the trust's service and forging robust links with another centre," it said.
Criticising the trust's decision to try to take on more patients in an attempt to avoid closure, he said: ``We did find there were serious shortcomings, particularly in the decision to expand.''
Caner Salih was duly recruited, but Dr Kirkup said: "The risks of doing that were insufficiently recognised."
He said the planning process for the arrival of the new surgeon was not adequately carried out.
Dr Kirkup added: "The support arrangements, and the new equipment he would require to use were lacking and there was insufficient agreement about how the two surgeons worked together."
The surgeons did not "work as a team," a factor that "adversely affected the unit," he said.
A separate review is going on to see if it would be better to cut the number of child heart surgery units in England from its current eleven, which could lead to the closure of the John Radcliffe unit.
The next nearest units are in Southampton, Bristol, Birmingham and London. The unit in Oxford currently takes patients from across the Thames Valley.