Leeds children’s heart surgery services review

During 2013 concerns were raised in relation to the quality of care offered to patients undergoing surgery for congenital cardiac conditions at Leeds Teaching Hospitals NHS Trust’s (LTHT).This led to a temporary cessation of surgery on 28 March 2013, pending an investigation.


A Quality Surveillance Group (QSG) was convened by NHS England and chaired on 2 April 2013 to oversee the investigation process.

A  subsequent Risk Summit was held on 4 April 2013 where it was agreed by NHS England, Care Quality Commission, the NHS Trust Development Authority (NTDA) and LTHT that a two-phase review would be carried out.

Phase One

Following the first phase, a rapid review, no significant or immediate safety concerns were found. Surgery re-commenced on 10 April 2013, whilst the second phase of the review took place.

Phase Two

The second phase of the review comprised three strands:

  • A case note review of the child deaths that had occurred in the period from 2009 to 2012 which was the time period used in the collection of NICOR data (Mortality Case Review).
  • An investigation of the experiences, views and concerns of parents and families (The Family Experience Review).
  • An investigation of concerns being raised by other clinicians in relation to inter-unit transfers and patient pathways.

NHS England has published the findings of the Mortality Review and the Family Experience Review.