All Children’s CEO: Not telling parents about needle left behind was “complete failure”

The hospital told the <i>Times</i> editorial board that it’s looking to rebuild the Heart Institute after stopping most surgeries late last year.
Johns Hopkins All Children's Hospital. [JIM DAMASKE |Times]
Johns Hopkins All Children's Hospital. [JIM DAMASKE |Times]
Published May 22, 2018|Updated May 23, 2018

Johns Hopkins All Children’s Hospital halted most pediatric heart surgeries last year, the hospital’s top administrator said Tuesday, providing new details about its response to problems within its Heart Institute.

The only operations currently being performed in the Heart Institute are “low complexity ones,” Dr. Jonathan Ellen told the Tampa Bay Times editorial board. They are all being led by a surgeon who is flying in from Johns Hopkins Medicine in Baltimore.

“We’ve shut our program down as low as we can go,” Ellen said.

Ellen also addressed a state review that found the hospital failed to properly report two cases in which surgical needles were left behind in patients. In one case, the report said, the hospital did not tell the child’s parents.

Related: Read: All Children's never told state about needle left in baby

Ellen said the hospital addressed the incidents internally but wrongly believed it did not have to report them to the state.

The fact that the family was not told, he said, was “a complete failure.”

“I can’t sit here and defend it in any way, shape or form. … That broke my heart. That’s the reality,” Ellen said.

The problems at the Heart Institute were first made public in a Times report in April.

The report focused on a heart-surgery patient who had been discharged from All Children’s in 2016 with a needle in her chest. Her parents told the newspaper they didn’t know until a physician flagged the needle at follow-up visit, and that even then, their surgeon at All Children’s said it didn’t exist.

The needle was later removed at St. Joseph’s Children’s Hospital.

Related: Read the story: A baby left All Children's with a needle in her heart

In an April interview, Ellen acknowledged that the heart surgery program had experienced broader “challenges,” including an increase in the mortality rate. In response, he said, the hospital had “gone so far as to reduce the number of complex cases we do and slow down the amount of care we do.”

He also said one of the program’s three surgeons, Dr. Tom Karl, was no longer operating. Medical records indicate Karl was involved in the 2016 needle incident. Karl declined to comment through a hospital spokeswoman on Tuesday and did not reply to an email from the Times.

Ellen provided additional details about the Heart Institute’s response on Tuesday.

The CEO said the program stopped taking neonatal cases — generally considered the most complex — in early 2017. But by the fall, Ellen remained dissatisfied with the outcomes and cut the volumes even further, he said.

Ellen said the Heart Institute is now doing about six surgeries each month.

“It is very clear that our program is really at this point a very small program doing very limited work,” he said.

Ellen said he is working to hire a new chief surgeon and expects the program to eventually return to its former volumes of about 350 surgeries annually.

Ellen has declined to release the program’s 2017 mortality figures. On Tuesday, he said publishing one year of data would be out of line with industry standards. Most hospitals, including All Children’s, report four-year averages.

Ellen called the hospital’s failure to file reports about the needle case and a second similar incident “an honest mistake.” Not informing the patient’s parents, he said, was the hospital’s “biggest failure.”

“Our policy has always been to disclose immediately,” he said. “In this case it didn’t happen.”

All Children’s has since “reeducated” its medical staff on the policy, Ellen said.