One of the country's leading children's hospitals has been issued with a safety warning by one of its own trust executives after an internal review into its operating theatres.

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Above: preview clip of tonight's Channel 4 News report on trouble at Alder Hey.

Channel 4 News has seen a leaked copy of the review at Alder Hey Children's NHS Foundation Trust, which says in the starkest possible terms that "the level of risk is such that urgent action needs to be implemented to avoid an adverse outcome or serious incident".

The review was ordered following ongoing concerns over the operating theatres departments, which are in effect the core of the paediatric surgery unit and are responsible for some of the sickest children requiring some of the most complex treatments.

Safety concerns

The internal review of the department was prepared by the director of nursing Gill Core and presented to the trust board in December.

It paints a picture of a unit in trouble.

Under the heading "safety concerns", it says that safety shortcuts "have created high risk activity" and there is a limited reporting of incidents - that is, near-misses and mistakes.

The report goes on: "Some individuals have reported that the 'working environment is hostile' and 'there are numerous examples of staff feeling pressurised to undertake activities that they do not believe are safe.'"

There are complaints that the working environment is 'not welcoming or child friendly'. This, in a children's hospital.

And there are complaints that the working environment is "not welcoming or child friendly". This in a children's hospital.

"There is a total absence of toys," the report says.

Even the scrubs suits used in the operating theatres are described as "shabby and mismatched".

Good intentions

Ms Core's report does acknowledge the massive effort staff make. She said: "It is immediately apparent that responses from theatre staff have centred on a desire to deliver the best possible service and the highest standard of care to patients."

But the report also says: "Staff have adopted some high risk practices in order to avoid cancellations; whilst safe outcomes have been maintained, the level of risk is such that urgent action needs to be implemented to avoid an adverse outcome or serious incident."

It adds that there is a "limited reporting of incidents", which means near-misses or mistakes are not always being recorded.

'Feeling of hoplessness'

Now Channel 4 News has also learned that the Care Quality Commission made an unannounced inspection in December after being directly approached by theatre staff. Ms Core expressed regret in her report that the staff felt this was the necessary course of action.

Yet the reasons for this are reflected further in the review.

Not only is there the claim that staff believe that management know about the problems but, the report states, the "perception of mistrust of management and the board is such that there is a widespread feeling of hopelessness that change will ever be achieved".

Leaked copy of report suggests high risk activity at Alder Hey (screen grab)

Last October, Channel 4 News highlighted the case of a whistle-blower at Alder Hey who, with a colleague, had raised safety issues and made bullying claims. Neither of the surgeons now works at the trust.

The claims were first made in 2009 and in 2010 an internal psychological review of the department revealed high stress levels among staff, including concerns of self-harm and suicide. Managers were described as "bullying...intimidating...coercive...aggressive...hostile...vindictive".

Theatre staff were said to be exhausted from long hours, or physically and mentally unable to perform their duties confidently or competently: "Several incidences were recounted where staff had fainted or had been otherwise incapacitated whilst in theatres".

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In 2011, the trust called in the Royal College of Surgeons and the subsequent report found paediatric surgery was no longer world class although they broadly concluded it was safe. It was later discovered that the college had not been given the internal psychological review to consider.

New protocols

We did ask the trust Chairman, Sir David Henshaw, the trust chief executive, Louise Shepherd, the medical director, or anyone else in a position of authority for an interview but we were refused.

Read more on the NHS from Channel 4 News Correspondent Victoria Macdonald here

Instead, in a statement, they said: "We acknowledge that there have been difficulties within the theatre team at Alder Hey for some time. Over the past year we have undertaken a range of measures to address these and make changes within the department.

Nobody should be under any illusion that the problems at this trust are an isolated matter Peter Walsh, Action Against Medical Accidents

"We recognise that changes to the culture of the department may take time and therefore we have made a long term commitment to supporting the team."

Action taken following the director of nursing's report includes providing new toys and new scrub suits. The statement says that there are new protocols around staffing, equipment checklists have been strengthened, and there has been more training on the incident reporting system.

Peter Walsh, chief executive of the medical negligence charity, Action Against Medical Accidents, said that they were aware of concerns with the hospital.

Mr Walsh said that they had hoped some of the problems had been addressed:

"These revelations are doubly concerning because we have had experience in the past of there being a problem at this trust with staff being able to raise concerns and getting them acted on," he said.

"There are some positives to be taken, arguably, from this incident. This is a remarkably refreshing, frank report to the board meeting of the trust. But nobody should be under any illusion that the problems at this trust are an isolated matter.

"It is a symptom of an NHS working under increasing pressure and staff feeling unable to raise concerns and compromises to patient safety being allowed to continue."

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