Review into General Surgery at The Queen Elizabeth Hospital King’s Lynn: What Patients Need to Know

An independent review has raised serious concerns about the quality of care provided within the General Surgery service at The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust.

The review was carried out by the Royal College of Surgeons of England (RCS England), alongside the Association of Surgeons of Great Britain and Ireland and the Royal College of Anaesthetists, following repeated concerns about patient care and service culture.

This article summarises the key findings of the review, outlines the actions that have been recommended, and explains what patients and families should consider if they believe they have been affected.

Why was the review commissioned?

The Trust requested an invited service review after receiving two anonymous letters in September 2023 and August 2024. These letters raised concerns about patient safety, clinical decision-making, and the working culture within the General Surgery department.

Some of the cases referenced had not been fully reviewed through local governance processes, prompting the Trust to seek an external, independent assessment of the service.

A further two whistleblowing letters were received by the Royal College of Surgeons during the review process, raising additional patient safety concerns. These were shared with the Trust, which was asked to provide updates on actions taken.

Key concerns identified by the review

Patient safety and quality of care

Following a review of clinical records and interviews with staff, the review team found:

• Unacceptable standards of care in a number of cases reviewed, including concerns about surgical technique and post-operative management.
• Delays in recognising and treating post-operative complications, which in some cases led to delays in returning patients to theatre.
• Concerns about decision-making, including whether some patients should have undergone surgery earlier than they did.
• Issues relating to locum surgeons, including concerns about competency in at least one case and a lack of effective feedback to locum agencies.

The review concluded that while some care was delivered to an acceptable standard, overall the quality of care was described as “highly variable”, which posed risks to patient safety.

Poor handovers and continuity of care

One of the most significant patient safety risks identified was the lack of effective handover arrangements:

• No consistent or formalised handover process between consultants, particularly over weekends.
• Patients treated by locum consultants were sometimes left without a clearly named consultant responsible for their ongoing care.
• In some cases, substantive consultants were reported to have refused to take over care from locum colleagues.

The review found that these failings created a real risk of patients being overlooked or experiencing delays in treatment.

Culture, communication and leadership concerns

The review highlighted a deeply concerning culture within the General Surgery department:

• Multiple interviewees described a “toxic” working environment and fractured relationships between consultants.
• Previous attempts at mediation had not been sustained or effectively monitored.
• Poor communication and reluctance to seek second opinions were identified as risks to patient safety.
• Leadership within the department was found to lack the authority and support needed to manage ongoing conflict.

The review team warned that unresolved cultural issues could continue to undermine patient care and damage trust in the service.

Failings in clinical governance

The review also raised concerns about how the Trust identified, investigated and learned from patient safety incidents:

• Some serious cases were not discussed at Morbidity and Mortality (M&M) meetings as expected.
• Incident investigations were inconsistent, and learning was not always shared across the department.
• A significant backlog of Structured Judgement Reviews (SJRs) dating back to 2023 was identified.

The review concluded that governance processes were not functioning effectively and were failing to support learning and improvement.

What actions have been recommended?

The review made a series of urgent and longer-term recommendations, including:

• Introducing mandatory, audited handover procedures for all patients, including those treated by locum consultants.
• Ensuring every patient is assigned a named consultant responsible for their care at all times.
• Addressing dysfunctional working relationships, potentially through behavioural agreements and external leadership support.
• Strengthening clinical governance, including better oversight of incident investigations and mandatory attendance at M&M meetings.
• Improving mentoring, supervision and training for consultants, resident doctors and SAS doctors.

The Royal College of Surgeons has stated it will follow up with the Trust to ensure patient safety recommendations are implemented.

What should patients and families do if they are concerned?

Patients who have undergone general surgery at The Queen Elizabeth Hospital King’s Lynn particularly between October 2022 and August 2024 may have questions about the care they received.

Warning signs that may warrant further advice include:

• Unexpected complications following surgery
• Delays in diagnosis or treatment of complications
• A lack of clear communication about who was responsible for your care
• Feeling that concerns were not taken seriously or properly investigated

Seeking legal advice

If you believe that substandard surgical care may have caused you or a loved one harm, it is important to seek specialist legal advice as early as possible.

Medical negligence claims can be complex, particularly where concerns relate to systemic failings rather than a single incident. In these circumstances, group actions could help affected patients pursue answers, accountability and compensation together.

Francesca Paul, Partner in the Medical Negligence team at Fletchers Solicitors, said:

“Reviews like this are deeply troubling because they suggest that patient harm may not have been isolated, but part of wider systemic issues. Where patients have been affected by poor surgical care, they deserve clear answers about what went wrong, why it happened, and what steps are being taken to prevent it from happening again. Seeking early legal advice can help families understand their options and ensure their voices are heard.”

At Fletchers Solicitors, our specialist medical negligence team has extensive experience in complex and high-profile group actions involving NHS trusts. We are committed to supporting patients and families with clarity, sensitivity and determination.

If you have concerns about care received at The Queen Elizabeth Hospital King’s Lynn, our team can offer a confidential, no-obligation discussion to help you understand your next steps.