Final Report > Concerns
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Concerns
Chapter 11: The Expression of Concerns by Individuals and Reaction to Those Concerns
1 Here we set out in outline the evidence on concerns raised, identifying by whom and to whom, and in what way (for example, by letter or conversation) they were raised. [1] We also set out any response to the concern raised, where this, in effect, involved passing on (and thereby raising) the concern to another, or not doing so. This section is descriptive. Differences of view are noted when they occur. The evidence is set out in chronological form. What is recounted may from time to time appear confusing or disorganised. We could, of course, impose some order on the events we describe. But that would be to impose order which did not exist at the time. There was confusion.
2 In 1984, as regards the inclusion of the UBH's paediatric cardiac surgical (PCS) service in the supra regional service (SRS), Bristol `did not actually shine as a star' and performance was not on a par with other units in terms of numbers of operations performed, [2] according to Dr Norman Halliday, Medical Secretary to the Supra Regional Services Advisory Group (SRSAG).
3 In 1986-1987, concerns were raised in Wales, where the development of a more comprehensive cardiac service in Cardiff was under discussion.
4 In October 1986, Professor Andrew Henderson, then Professor Emeritus, University of Wales, distributed a letter at a meeting of the South Glamorgan Health Authority (SGHA) stating `it is no secret that their [UBH's paediatric cardiac] surgical service is regarded as being at the bottom of the UK league for quality'. [3]
5 Professor Gareth Crompton, Chief Medical Officer (CMO) Wales, in the light of Professor Henderson's letter, raised the matter with Professor (later Sir) Donald Acheson, CMO, England. Professor Acheson referred him to Dr Halliday, with whom he had a meeting. Professor Crompton felt that, at the meeting, the issue of quality was not addressed. [4] Dr Halliday described how he saw the meeting as dealing with questions of volume of cases rather than quality of outcome. Dr Halliday told the Inquiry that he could not take Professor Henderson's points further as no supporting evidence was attached. Further, he said that he was cautious in view of the Welsh ambitions to develop their own centre for cardiac services in Cardiff. [5] He also stated that monitoring performance was not part of the SRSAG's role. [6]
6 In autumn 1986 Dr Jennifer Lloyd, Senior Medical Officer (SMO), Welsh Office, reported on behalf of the group from the Welsh Office that had visited [7] the UBH to follow up the concerns expressed by Professor Henderson. Dr Lloyd stated in her report that the standard of the equipment for paediatric radiology was `impressive' [8] and in the paediatric Intensive Care Unit `high'. Dr Stephen Jordan, consultant cardiologist, however, speaking of the `facilities generally for cardiac surgery [adult and paediatric]' told the Inquiry: `... ever since I was appointed in Bristol, [they] lagged far behind centres elsewhere'. [9]
7 In 1987 the Children's Heart Circle in Wales published `Meanwhile our Children are Dying' by Neil Hall, referring to long waiting times before receiving care in Bristol. [10] Mr Peter Gregory, Welsh Office, advised his Ministers that the report was inaccurate. [11]
8 In June 1987, BBC Wales broadcast the programme `Heart Surgery - The Second Class Service'. [12]
9 The surgeons Mr Wisheart and Mr Dhasmana and the paediatric cardiologists Dr Joffe and Dr Jordan wrote to the editor at the BBC who was responsible for the programme, refuting the criticisms. They described the outcomes for paediatric cardiac surgery at Bristol for 1984-1986 as: `equivalent to the UK national results for 1984 ... and better for certain conditions'. [13]
10 In August 1987 Mr Wisheart, Mr Dhasmana, Dr Joffe and Dr Jordan also wrote to the Chair of the Cardiology Committee of the Royal College of Physicians (RCP), who had been asked to report on the development of services in Wales. They spoke of `a campaign of vilification' and described the results in Bristol as: `at least equal to those achieved by other paediatric units'. [14] In evidence to the Inquiry, Dr Joffe said that `that was a partial overstatement'. [15]
11 In 1987 Miss Catherine Hawkins, Regional General Manager (RGM) for the South Western Regional Health Authority (SWRHA), reported informal expressions of concern from various district general managers (DGMs) about waiting times and outcomes in the cardiac surgical service, but not specifically the paediatric service. She approached Dr John Roylance, DGM of the Bristol and Weston District Health Authority (B&WDHA) 1985-1991, and was reassured. She told us that Dr Roylance attributed the problem to an individual who shortly afterwards retired. [16] Dr Roylance stated in his evidence that this was not the explanation he would have given. [17]
12 In 1988 concerns began to be raised within the UBH. Dr Stephen Bolsin, consultant anaesthetist, told the Inquiry that following his appointment in September 1988 as a consultant anaesthetist at the BRI, he was concerned at an early stage about the conduct of open-heart surgery. He was particularly concerned about the duration of operations, and the length of time children were on bypass, in comparison with what he had observed at the Brompton Hospital, [18] and the consequent effect on outcomes.
13 In 1988 the Paediatric Cardiology and Cardiac Surgery Annual Report of the Bristol Unit for 1987 gave little indication of cause for concern. The 30-day mortality rate for open-heart surgery for children over 1 was within a percentage point of the UK Cardiac Surgical Register (UKCSR) rate for 1984-1986. For children under 1, it was 26.5%, close to the UK figure of 21.8%. There was also an increased volume of work.
14 The Annual Report for 1988 gave a mortality rate for PCS in the under-1s in Bristol for 1988 of 37.9%, and 27% for the period 1984-1987. The most recent UKCSR figure covering 1984-1987 was 22%. [19] In the autumn of 1989, after completing a report on his first year of work at the BRI, Dr Bolsin approached Professor Cedric Prys-Roberts, Professor of Anaesthesia in Bristol, about his concerns. He was advised to keep a record. [20]
15 In 1989 Dr (later Professor) Peter (Jem) Berry, consultant paediatric pathologist at the UBH/T, published a paper with a colleague at Bristol in which he described post-mortem examinations performed on 76 children who had undergone surgery for congenital heart disease. He found that `despite intensive investigation during life, there was a high rate of unsuspected abnormalities at necropsy (80 per cent): 29 cases had undiagnosed additional cardiac anomalies or surgical flaws, which contributed to death in 13 cases.' [21]
16 The Annual Report of the Unit for 1989/90 gave a mortality rate of 37.5% for PCS on children under 1. The UK figure was 18.8%. [22] The disparity, according to Mr Wisheart, lay in a small number of complex procedures. [23] The clinicians in Bristol were also aware that the figures in each Annual Report might not be noteworthy on their own, because of the small numbers involved. We received evidence that for that reason they aggregated data over a number of years. By 1989 these data showed a consistent pattern of poor outcome when compared with the reported national average performance.
17 The Annual Reports were circulated within the BRI. There was no obligation on anyone to respond to or act on them. [24]
18 In 1989 the Society of Cardiothoracic Surgeons was asked by the Department of Health (DoH) to report on units carrying out neonatal and infant cardiac surgery (NICS). In September 1989 the report to Dr Halliday showed that two units, one of which was Bristol, had a higher mortality rate than the others. [25] Sir Terence English, a cardiac surgeon and, from 1989 to 1992, President of the Royal College of Surgeons of England (RCSE), acknowledged that, as a member of the SRSAG, he should probably have taken more account of these data. [26] Dr Halliday visited the BRI in 1990. At the July meeting of the SRS, Sir Terence is recorded in the minutes as saying: `... this unit should retain designation but [the Royal College of Surgeons of England] recommended they should be pressed to increase the workload'. [27]
19 In the summer of 1990 Dr Bolsin spoke of his concerns to Dr Brian Williams, Chair of the Division of Anaesthesia at the BRI. Dr Williams stated that Dr Bolsin had no data at the time. [28]
20 On 7 August 1990 Dr Bolsin wrote to Dr Roylance about what he considered to be a misleading statement in the appendix to the application for Trust status submitted by the UBH. In his letter, he also referred to mortality for open-heart surgery for under-1s as: `one of the highest in the country, and the problem should be addressed'. [29] He told the Inquiry that he expected this letter to be treated as raising a concern and that he expected a response. [30]
21 Dr Trevor Thomas, Chair of the Medical Audit Committee at UBH, had advised Dr Bolsin on the drafting of this letter. He advised that a copy should be sent to Mr Geoffrey Mortimer, then Chair of the Health Authority. A copy was also sent to Mr Christopher Dean Hart as Chair of the Hospital Medical Committee (HMC) at the BRI. Mr Dean Hart stated that he saw the letter as concerned with the application for Trust status. [31] Dr Roylance also told the Inquiry that he saw the letter as being about Trust status, and that he telephoned Dr Bolsin to respond on that issue. Dr Roylance said that he did not see the letter as requiring an investigation of open-heart PCS on the under-1s. [32]
22 Dr Bolsin stated that he was called to Mr Wisheart's office and rebuked for taking information about PCS to `outsiders'. According to Dr Bolsin, Mr Wisheart included Dr Roylance in that category. [33]
23 Mr Wisheart told us that he was not told about the letter from Dr Bolsin to Dr Roylance and that the meeting referred to by Dr Bolsin between himself and Dr Bolsin did not take place. [34]
24 A copy of Dr Bolsin's letter was also sent to Dr Brian Williams who stated: `... when I met with Mr Wisheart he expressed annoyance at the content, style and distribution of Dr Bolsin's letter'. [35] Dr Williams stated that: `No one supported the way in which Steve Bolsin had raised the issue but all were fully supportive of his efforts to obtain appropriate data to assess the problem more accurately in an endeavour to improve results'. [36]
25 Mr Wisheart told the Inquiry that he did not recollect any conversation with Dr Williams taking place. [37]
26 In January 1991 Dr Elliot Shinebourne, paediatric cardiologist, visiting the UBH on behalf of the Joint Consultants' Specialist Advisory Committee (JCSAC) of the Royal College of Physicians, recommended that the BRHSC should not be accredited for a training post in paediatric cardiology, essentially because of the split site. [38]
27 Also in 1991 there was a meeting between the cardiac anaesthetists at UBHT, the Clinical Director of the Directorate of Anaesthesia, Dr Christopher Monk, and Dr Peter Baskett, then President of the Association of Anaesthetists of Great Britain and Ireland (from 1990 to 1992) and a consultant anaesthetist at the UBHT, at which Dr Bolsin's concerns were discussed. Dr Bolsin told the Inquiry that at this meeting Dr Baskett said that Dr Bolsin should not be the vehicle for criticism of the PCS service, and should `keep his head down'. [39] Dr Monk told the Inquiry that he and Dr Williams were asked at the meeting to speak to Mr Wisheart and Mr Dhasmana. [40]
28 On 28 July 1991 an audit meeting was held jointly between the cardiologists, cardiac surgeons and anaesthetists. Dr Bolsin drafted minutes, referring to a problem with mortality which he expressed as having been `thought to be reaching crisis proportions', based on the differences between the figures in the Annual Reports and the national figures, but which had been averted. Dr Bolsin said: `I thought I was reflecting what the unit told me, but I was subsequently told after producing these minutes that they were not representative and I was not to produce them ever again.' [41] Dr Bolsin also said: `I was told "these minutes will not be circulated, this is not how we do things, I do not want you keeping minutes again." '
29 Dr Bolsin was asked by Leading Counsel to the Inquiry: `We have been told by Dr Masey [42] that it was she who said that to you, and we have been told by Mr Wisheart ... that he did not say that to you. Are they right or are they wrong?' He replied: `I think Dr Masey is right, she did say it. Mr Wisheart may be wrong. I believe he also said that to me as well.' [43]
30 A table prepared within the UBH/T by the cardiac surgeons, available in mid-1991, indicated a mortality rate in Bristol between 1984 and 1989 of 32.2% for open-heart surgery on under-1s, compared with the rate according to the UKCSR for the same period of 21.2%. The table then gave the rate for 1990 in Bristol as 12.8%. [44]
31 In October 1991 Dr Bolsin again met Professor Prys-Roberts and showed him data on mortality. Professor Prys-Roberts advised him to continue to keep accurate records. [45] By this time Dr Bolsin had been elected the first National Audit Co-ordinator for the Association of Cardiothoracic Anaesthetists of Great Britain, responsible for the collation of data on outcomes in cardiac surgery on adults.
32 In October 1991 Professor John Norman of the Department of Anaesthesia, University of Southampton, wrote to Professor Prys-Roberts saying that he had been approached by young anaesthetists from the BRI with their concerns, and offering help through his colleague Dr Thomas Abbott. [46] Professor Prys-Roberts discussed this with Dr Baskett, as a senior cardiac anaesthetist, and thought that Dr Baskett had followed up this offer. Professor Prys-Roberts told the Inquiry that all the cardiac anaesthetists had expressed concerns about PCS at some stage. [47]
33 Dr Andrew Black, Senior Lecturer in Anaesthesia, University of Bristol, was by this time helping Dr Bolsin in the analysis of data. He stated that he discussed the desirability of informing Mr Wisheart and Mr Dhasmana of the intention to collect and analyse data. Dr Bolsin argued, according to Dr Black, that this would impede their task. [48]
34 In the autumn of 1991 Dr Bolsin spoke to Dr John Zorab, Director of Anaesthesia and Medical Director of the Frenchay Hospital, Bristol, about his anxieties. Dr Zorab told Dr Bolsin that he would informally appraise Sir Terence English and did so by letter in July 1992. [49]
35 Having spoken to DGMs about their concerns relating to the process of contracting with the UBHT, on 20 November 1991 Miss Hawkins wrote to Dr Roylance about: `... how poorly Bristol Trust is now performing on Cardiac Surgery contracting ... I am sure Mr Wisheart would like to be made aware of the gross dissatisfaction Region-wide'. [50] These concerns related largely to the treatment of adults and did not relate to NICS since NICS was contracted for through the SRSAG. Miss Hawkins' concerns do, however, identify the tension between engaging in NICS and treating adults who were sometimes kept waiting for treatment.
36 The reply from Dr Roylance, drafted by Mr Wisheart, addressed only the issues of contracting and ignored what, according to Miss Hawkins, she considered `the real issue': that there was a general dissatisfaction in a major part of the Region with the cardiac unit, which the Medical Director was disregarding. [51] Miss Hawkins visited the BRI and spoke to Mr Wisheart and was reassured that the problems would be addressed. [52]
37 In October 1991 Dr Bolsin saw Professor Prys-Roberts again about the PCS results. Professor Prys-Roberts agreed to speak informally to Dr Roylance. Professor
Prys-Roberts having seen preliminary data, spoke to Dr Roylance. Professor
Prys-Roberts told us: `I was seeing soft evidence that gave me concern'. [53]
38 A table prepared in the UBHT and supplied to the Inquiry disclosed a mortality rate in 1991 of 30% for open-heart surgery on under-1s. The UKCSR figure for 1990 was 15.8%. [54]
39 On 3 January 1992 Mr Martin Elliott, consultant cardiothoracic surgeon, Great Ormond Street Hospital, wrote to Mr Wisheart saying that he had decided not to apply for the Chair in Cardiac Surgery at Bristol because: `I have lingering doubts about the security of the paediatric volume [and] a worry about the separation of cardiology from cardiac surgery...'. [55] He had also met Mr Peter Durie, Chairman of the UBHT 1991-1994, and expressed his concerns about the split site. In a separate paper written at Mr Wisheart's request, he stated that:
`The separation of open and closed paediatric cardiac surgery must be inefficient, and is potentially dangerous.' [56]
40 Following a site visit by the SRSAG in February 1992, data on Bristol's death rates in PCS on the under-1s were passed by Mr Steven Owen, Administrative Secretary to the SRSAG, to Dr Halliday. [57] Dr Halliday told the Inquiry that he often received data, but that they were difficult to interpret in isolation. [58] He said:
`The difficulty is, as I have said, having figures in isolation without the machinery to analyse it, is of no particular value. ... I was not given any figures with the suggestion that there was a problem here. I was given figures as I was on many visits. ... If, however, we were given the data and told that there was a problem with that data, that would be a different matter.' [59]
This contrasts with the previously mentioned response by Dr Halliday to Professor Henderson's points: that he could not take Professor Henderson's expression of concern further because he had no supporting evidence.
41 Professor Prys-Roberts stated that in `early February or March 1992', [60] he met Dr Roylance and told him that Dr Bolsin had data that he would show Dr Roylance. Professor Prys-Roberts stated that Dr Roylance said that he would deal with it. [61] Dr Roylance does not recall this, but recalls discussing with Professor Prys-Roberts the need to appoint a cardiac surgeon. [62]
42 In the spring of 1992 Dr Bolsin went to see Mrs Kathleen Orchard, General Manager, Directorate of Surgery, UBHT 1991-1993. She recalled that he expressed a `worry' rather than a serious concern about PCS. [63]
43 In 1992 `Private Eye' published six articles (14 February, 27 March, 8 May, 3 July, 9 October and 20 November) criticising the PCS services at the BRI.
44 Mr Durie told the Inquiry that the articles in `Private Eye' were raised informally at a meeting of the Trust Board, but the minutes do not record this. [64]
45 On 22 June 1992 Dr Roylance received a letter from Ms J Binding, an official in the Corporate Affairs Department of the NHS Management Executive, about concerns raised by a parent who had read articles in `Private Eye' and whose child was about to have surgery at the BRI. [65] Mr Wisheart drafted the reply which indicated that results at Bristol were good. [66]
46 In April 1992 Dr Bolsin met Dr Phil Hammond and showed him `very provisional' logbook data. [67] Dr Bolsin told the Inquiry that he regarded Dr Hammond as a concerned trainee GP. Dr Hammond told the Inquiry that he was also the author of the articles in `Private Eye'. [68] Dr Bolsin said that he did not know in 1992 that Dr Hammond wrote the articles [69] and may not have known until 1995. [70]
47 In mid-1992 after being unsuccessful in an application for a post in Oxford, Dr Bolsin again spoke to Professor Prys-Roberts about collecting data. Professor Prys-Roberts had had no further discussion of the matter with Dr Roylance. [71]
48 In June 1992 the Report of the Working Party of the Royal College of Surgeons, commissioned by the SRSAG, was delivered to Sir Terence English as President of the RCSE. It recommended the designation of nine centres including Bristol. [72] Sir Terence thanked the Chair, Professor David Hamilton, by letter on 2 July, describing the Report as `balanced and authoritative'. [73]
49 On 15 July Dr Zorab wrote to Sir Terence at the RCSE about `great anxieties' being expressed by colleagues at the BRI, brought to a head by the articles in`Private Eye'. [74] Sir Terence had been succeeded as President of the RCSE on 8 July by Sir Norman Browse, who forwarded the letter to Sir Terence. Sir Terence described how the letter acted as a stimulus to him to revisit the figures on mortality in Table 1 of the Working Party's report. [75] These figures showed the results in Bristol as being worse than those at any other centre.
50 Sir Terence asked for the report of the RCSE's Working Party to be withdrawn for amendment. Professor Hamilton initially agreed but then withdrew this agreement. Sir Terence then spoke to Dr Halliday and asked for his reservations about Bristol to be conveyed to the next SRSAG meeting, which he would be unable to attend. Sir Terence told the Inquiry that he specifically raised the mortality figures with Dr Halliday. [76] It is Dr Halliday's recollection that he understood Sir Terence's reservations about Bristol to be the long-standing concerns about the volume of work being carried out. [77] At the meeting of July 1992 the SRSAG decided to de-designate the entire PCS service. [78]
51 Sir Michael Carlisle, Chairman of the SRSAG 1989-1994, and the other members of the SRSAG were not shown, nor told of, Dr Zorab's letter to Sir Terence English, [79] nor were they told by anyone of the nature of Sir Terence English's reservations.
52 In July 1992 Dr Bolsin and Dr Black began to tabulate the data on 233 children who had undergone open-heart surgery at the BRI in 1991 and 1992. They became concerned about high mortality in patients with Ventricular Septal Defect (VSD), Tetralogy of Fallot, and Atrio-Ventricular Septal Defect (AVSD). [80] Dr Bolsin and Dr Black showed their data to Professor Gianni Angelini, Professor of Cardiac Surgery, University of Bristol, and Professor Prys-Roberts. [81]
53 Ms Mona Herborn and Mrs Kay Armstrong, Sisters in the operating theatres at the BRI, stated in their evidence to the Inquiry that by 1992 they were concerned about mortality rates in PCS and discussed the matter with Dr Bolsin. [82]
54 No annual reports from the Unit were produced after the 1989/90 report as Dr Joffe, on his appointment as Clinical Director of the Children's Services, told us that he did not have the time to devote to continuing them, which he `very much regretted'. [83]
55 Because, as Mr Dhasmana put it, `the neonatal switch programme ended in failure' involving the deaths of five babies, it was halted in September 1992. [84] Mr Dhasmana sought the advice of Mr William Brawn, consultant paediatric cardiac surgeon at Birmingham Children's Hospital. [85] On 1 December 1992 he visited Mr Brawn at the Children's Hospital, Birmingham together with Dr Masey. He talked about the procedure with Mr Brawn, observed an operation and took away the video of the operation for further reference. [86]
56 Also in December 1992 the minutes of the Trust Board record that Dr Roylance advised that dissatisfaction had been expressed about the quality and cost of cardiac services for adults and children over 1 in Bristol, and that Dr Roylance would discuss this with Mr Wisheart. [87]
57 Early in 1993 Dr Bolsin saw Professor John Farndon, Director of the Division of Surgery at the University of Bristol since 1988, about his concerns. Professor Farndon advised him to validate and then share the data with those providing the service. [88] Professor Farndon recalls being approached by Mr Alan Bryan, consultant cardiac surgeon, Dr Monk, Professor Prys-Roberts and Dr Sheila Willatts, consultant in anaesthesia and intensive care, about their concerns about open-heart PCS. [89]
58 Dr Masey was shown their data by Dr Black and discussed the data with Dr Bolsin. She advised Dr Bolsin to share the data with the surgeons. Dr Bolsin's reply was that he thought this might limit his access to data. [90] In 1993-1994, Dr Willatts recalls prolonged discussions among the anaesthetists of the results of PCS. She stated that she had hoped that they could be examined by a joint meeting of surgeons and anaesthetists which Professor Farndon volunteered to chair. [91]
59 In July 1993 Mr Dhasmana again went to Birmingham for training. He remained `... very concerned that something is probably a little different in neonates which I have not still been able to transfer' [92] and decided to stop carrying out the neonatal Switch procedure.
60 In the autumn of 1993 Dr Bolsin presented statistics on outcomes in open-heart PCS for specific diagnoses to Mr Bryan who said he found them disturbing. Mr Bryan, senior lecturer in Cardiac Surgery, University of Bristol, and consultant cardiothoracic surgeon, UBHT, was also aware of concern being expressed by senior colleagues: Professor Angelini, Professor Prys-Roberts, Professor Farndon and Dr Monk. [93]
61 Dr Monk stated that he was shown data. He stated further that he did not take the data to Mr Wisheart or Mr Dhasmana because the data were not verified. [94] He said that he spoke to them both about his concerns. [95]
62 In November 1993 Professor Angelini talked to Mr Jaroslav Stark, consultant cardiothoracic surgeon at Great Ormond Street Hospital, about Dr Bolsin's data. Mr Stark advised Professor Angelini to go to see Professor Farndon.
63 Also in November 1993 Dr Bolsin saw Professor John Vann Jones, first Clinical Director of the newly created Directorate of Cardiac Services, with data on four specific conditions. [96] Professor Vann Jones questioned the data on VSDs, asked Dr Bolsin to check his figures and expected him to return. [97] (These figures were later found to contain an error and ultimately Dr Bolsin apologised to Dr Roylance.) [98]
64 Dr Bolsin does not recall expecting to return to see Professor Vann Jones. He told the Inquiry that he believed that he had explained his view that there was a need for a full investigation. [99]
65 Mr Wisheart visited Professor Vann Jones a day or two later to present his own figures after learning that Dr Bolsin had spoken to Professor Vann Jones and Professor Paul Dieppe, Dean of the Faculty of Medicine, University of Bristol. [100]
66 In December 1993 Dr Bolsin spoke to Dr Jane Ashwell, SMO at the DoH, about outcomes in PCS. She then spoke and wrote to Professor Farndon, as Director of the Division of Surgery at the BRI. [101]
67 On 23 December 1993 Professor Angelini and Professor Farndon went to see Mr Wisheart about their concerns about PCS and the need to appoint a consultant paediatric cardiac surgeon. [102] Data were placed on the table.
68 Mr Wisheart recalls the discussion of the need for the appointment, but not of concerns nor of data. [103]
69 Late in 1993 Professor Peter Keen, Dean of the Faculty of Medicine, University of Bristol, agreed that Professor Angelini should take matters forward concerning the PCS service. [104]
70 On 20 January 1994 a special meeting of cardiologists, surgeons and anaesthetists involved in paediatric care was called. Mr Dhasmana was absent. Dr Bolsin did not present any data. There was no Chair, nor an agenda. (Mr Dhasmana described it as a meeting of the `paediatric cardiac club'. [105]) Dr Stephen Pryn, consultant in anaesthesia and intensive care, presented some data and Mr Wisheart presented the surgeons' data, which was unchallenged. Dr Pryn recalls:
`Whilst Mr Wisheart was presenting his data, I was looking down through my very rough workings and was trying to count in my mind.
`I particularly chose the AV canals, because I think Mr Wisheart had said, "Here are the realities for the AV canals; they are not good but they are tolerable", and I wanted to cross-check that with my data. So I was counting the AV canals and I got a little confused between children who were aged over 1 and under 1, and at the end I made some comment about, I do not know, mortality in children with AV canal over 1, and both Mr Wisheart and Alison Hayes, the cardiologist, actually said to me, "Your data must be rubbish because we do not do AV canals in the over 1s". So that was it. So I sat down again; basically, I had not prepared for a presentation.' [106]
71 In March 1994 Dr Peter Wilde, the senior radiographer at the UBHT, distributed a discussion document on `Echocardiology on the Cardiac Unit'. In a covering letter he said: `The system is certainly unsatisfactory at present and could potentially be very much better if we had an organised strategy. I feel sure that a high quality supporting echo service would undoubtedly lead to improvements in cardiac outcomes.' [107]
72 Early in 1994 Dr Bolsin wrote to Dr Ashwell at the DoH thanking her for her support and advising her that: `There is now in place a programme for the appointment of a new paediatric cardiac surgeon and a commitment from the highest levels of the Trust to improve and maintain performance. There would seem to be little benefit from any further investigation from your end at this stage although this should not be ruled out if words are not converted speedily into actions.' [108]
73 In March 1994 Professor Angelini again met Dr Roylance, having previously seen him in December 1993 with Professor Farndon. On this occasion Dr Monk went with him to discuss their concerns over the mortality data for PCS. No written materials were presented nor discussed at the meeting. [109]
74 At the instigation of Dr Monk and with the aim of discussing concerns, he and Mr Wisheart took Dr Bolsin and Professor Angelini to a private dinner on 5 April 1994 at a restaurant in Bristol (Bistro 21). Dr Monk asked whether there were any concerns regarding PCS. Neither Dr Bolsin nor Professor Angelini replied. [110] No discussion of the matter took place. Three days later Mr Wisheart reported to the Trust Board that the Unit was obtaining excellent results with children. [111]
75 On 18 April 1994 Dr Bolsin went to see Mrs Janet Maher, General Manager of the Directorate of Surgery 1993-1998, about his concerns. She advised him to talk to Dr Monk and the surgeons.
76 Mrs Maher spoke to Dr Monk, Dr Roylance and Mr Wisheart, and formed the view that Mr Wisheart found Dr Bolsin's comments about data confusing, as these comments did not tie in with his own data. [112]
77 In April 1994 Professor Vann Jones was asked by Ms Lesley Salmon, Associate General Manager, then General Manager 1991-1994, to convene a meeting for non-medical staff to inform and reassure them about the PCS service, in view of the rumours which were circulating. [113]
78 In May 1994 Professor Angelini was visited by Mr Peter Durie, Chairman, UBHT, and Mrs Margaret Maisey to talk about the quality of PCS. Professor Angelini suggested as a solution the appointment of a new paediatric cardiac surgeon. [114] Mr Durie asked Professor Angelini to write him a letter dealing with the point and also suggested that Professor Angelini see Professor Vann Jones. This he did and he and Professor Vann Jones then wrote to Mr Durie.
79 Mr Durie went on leave at this time and does not recollect seeing the letter. He presumed that it would have been `given to the Chief Executive [Dr Roylance] to work on' [115]. Mr Durie stood down as Chairman of the Trust Board on 30 May. The new Chairman, Mr Robert McKinlay, took up office on 1 July 1994. Dr Roylance told us that he, Dr Roylance, did not see the letter. [116]
80 On 12 May 1994 a draft report was circulated for consideration by the UBHT's Cardiac Expansion Working Party. The draft report referred to the `perception that the quality of paediatric cardiac services in the UBHT does not match the standards of the Trust's major competitors ...'. [117]
81 Towards the summer of 1994 Professor Angelini and Mrs Maher had a conversation about the move of the children's service to the BRHSC. Their respective recollections of this conversation differed. Professor Angelini explained that he was `trying to understand ... the reticence of the management to have the paediatric service moved to the Children's Hospital', [118] whilst Ms Maher recalled that the move to the BRHSC was taking place and that it was happening `despite [Professor Angelini], and not because of him', as he seemed to her to be taking credit for something he had not been involved in. [119]
82 In early June 1994 the six paediatric anaesthetists met to review the results of the Arterial Switch operations. On 21 June they drafted a letter expressing concern about PCS. According to Dr Bolsin and Dr Masey, the first draft was intended for Dr Roylance. Dr Monk was to be a co-signatory. However, subsequent drafts or versions seen by the Inquiry were addressed to Dr Monk. This alternative version was taken by Dr Monk to Dr Roylance. It referred to `unacceptably high mortality' in the neonatal Arterial Switch operation and requested a review. Dr Davies, Dr Baskett, Dr Pryn, Dr Bolsin, Dr Masey and Dr Underwood each signed a draft, although all six of them did not all sign any one draft.
83 In July 1994 Dr Monk saw Dr Roylance twice on the matter. He told us that Dr Roylance told him that the issue was clinical and therefore for clinicians to resolve. [120] Dr Roylance does not recall the discussion nor the letter, [121] which he told us he did not see until he had retired. [122] However, he did tell us that if he had been shown the letter: `I would have acted very quickly and very strongly.' [123]
84 In July 1994 the anaesthetists' concerns were brought to Mr Dhasmana's attention when they asked him to notify and consult them before arranging any further Switch procedures [124] (he had already stopped the neonatal Switch operation). [125]
85 On 19 July 1994 Dr Peter Doyle, SMO, DoH, attended an audit meeting at the BRI. On his way back to the railway station in a taxi, he was given an envelope which Dr Bolsin told him contained data about PCS. Dr Doyle told the Inquiry that he did not look at the data. He filed the document. He wrote to Professor Angelini indicating that concerns had been expressed to him over mortality rates in children undergoing PCS and seeking to be reassured that steps were being taken to remedy the problem. [126]
86 In August 1994 Professor Angelini replied, referring in his letter to the plan to appoint a new paediatric cardiac surgeon, and eventually to move open-heart surgery to the BRHSC. [127] Dr Roylance wrote to Dr Doyle in September confirming these two steps had been decided on by the Trust Board. [128] Dr Roylance was advised by Mr Wisheart to indicate in his letter to Dr Doyle that the problem was limited to one procedure. [129] No minutes informing the UBHT's Board of the decisions referred to by Dr Roylance in his letter to Dr Doyle have been found. The letter also confirmed the Trust Board's `awareness of this problem'. [130] In fact, the Board was not aware, and had never been told, of the problem.
87 In September 1994 Mr Ashwinikumar Pawade was appointed as consultant paediatric cardiac surgeon, with effect from May 1995. Professor Farndon, Mr McKinlay and Professor Angelini met to discuss this appointment. Professor Angelini and Mr McKinlay recall a discussion of poor results in PCS at the meeting. [131]
88 In November 1994 at a meeting of consultants, Professor Angelini suggested to Mr Dhasmana that the PCS `should be rationalised' [132] prior to Mr Pawade's arrival.
89 On 17 November 1994 Professor Farndon discussed the concerns about PCS with Mr Wisheart, and kept a note of the meeting. [133] The note recorded an agreement to tabulate results and hold an open discussion to discuss the data relating to operations on both adults and children. Professor Farndon described himself as ready to act as an honest broker. He was not asked to do so by anyone.
90 On 8 December 1994 there was a meeting of the `paediatric cardiac club' at Dr Joffe's house. The non-neonatal Switch operation was discussed. It was agreed that Mr Dhasmana should continue to carry out this procedure. Dr Bolsin was not present. [134]
91 Mr McKinlay stated that by Christmas he told Dr Roylance that he wanted an independent external inquiry into the unit as a whole and he agreed. Dr Roylance, however, denied that before Christmas he had agreed to an Inquiry. [135] On balance we prefer Mr McKinlay's account. [136]
92 In late December 1994 18-month-old Joshua Loveday (who had been seen in the Joint Cardiology Clinic by Dr Martin on 21 November 1994) was scheduled to be admitted for a Switch operation to be performed by Mr Dhasmana. On 6 January Professor Angelini saw Mr Wisheart to seek to persuade him that it would be unwise to proceed. This was the first occasion on which Mr Wisheart recalls an open expression of concern about PCS. [137] Professor Angelini put his views in writing to Mr Wisheart on 10 January, [138] after speaking to Dr Roylance, Dr Doyle, Dr Willatts and Professor Farndon.
93 On 11 January Dr Bolsin contacted Dr Doyle to inform him that a Switch operation was listed for the next day. [139]
94 A clinical meeting was held on 11 January at which Dr Joffe, Dr Hayes, Dr Martin, Mr Dhasmana, Mr Wisheart, Dr Masey, Dr Monk, Dr Bolsin and Dr Pryn were present. The purpose of the meeting was to discuss whether to proceed with the operation on Joshua Loveday. It was decided that only clinical factors should be considered. Dr Martin advised that the case was urgent. All those present agreed that there were no clinical reasons for not proceeding with the operation, as Mr Dhasmana's non-neonatal Switch results were within the acceptable range. [140] While not objecting on clinical grounds, Dr Bolsin dissented on the basis of what Mr Wisheart remembered as `institutional reasons' with `political consequences'. [141] Mr Wisheart was aware that Dr Roylance was minded to call for an independent review of PCS but Mr Wisheart did not reveal this to others. Mr Wisheart told the Inquiry that he felt it might have added to the pressures on Mr Dhasmana. [142] There was also a joint discussion in a side meeting, involving Mr Wisheart, Mr Dhasmana and Dr Martin, as to whether it was clinically appropriate to proceed with Joshua's operation. [143]
95 On 12 January, Mr Wisheart informed Dr Doyle of the death of Joshua Loveday following surgery. Dr Doyle wrote to Dr Roylance stating that `it would be extremely inadvisable to undertake any further neonatal or infant cardiac surgery' (Joshua was in fact 18 months old and his operation did not fall into the category of NICS). He also urged Dr Roylance to expedite the proposed independent inquiry. [144]
96 Dr Roylance replied expressing concern about the way in which Dr Doyle had been informed. [145]
97 Later in January 1995, Mr Wisheart was asked as Medical Director by Dr Roylance to set up the independent external inquiry previously discussed. Professor Marc de Leval, Professor of Cardiothoracic Surgery, Great Ormond Street Hospital, and Dr Stewart Hunter, consultant in paediatric cardiology, Freeman Hospital, Newcastle upon Tyne, were invited to undertake it. [146]
98 Dr Hunter recorded in his notes at the time that Dr Roylance offered them a free hand, and expressed his concerns about the PCS service [147] and the existence of conflict between professional groups. When he met Dr Hunter and Professor de Leval, Dr Roylance identified three questions which he wished to have answered: whether the appointment of a new paediatric cardiac surgeon was a proper solution to the problem; whether moving to the BRHSC was proper; and what the service should do between the time of reporting and the arrival of Mr Pawade? [148]
99 On 10 February 1995, Professor de Leval and Dr Hunter visited Bristol. Mr Wisheart told the Inquiry that it was at the open meeting at the end of the day that he heard for the first time about the existence of audit data collected by Dr Bolsin. [149]
100 The Hunter/de Leval Report described a degree of confusion in the organisation of the Intensive Care Unit, and identified the need for better communication and trust and a monthly morbidity and mortality conference with open discussion. The report stated that the critical factor in solving the overall problem was the appointment of the new surgeon with a proven track record in a major centre. [150] Professor de Leval told the Inquiry [151] that although the data available to them were weak, there was a problem with the outcomes in PCS, and that the surgeons had been reticent in recognising and confronting this in the past. The first draft of the report, prepared in confidence for Dr Roylance, described one of the surgeons (Mr Wisheart) as being among the higher- risk surgeons, but the other (Mr Dhasmana) as comparing favourably with the best in other UK units. The report was discussed with all consultants at two meetings in March and modified in a second draft when it became clear that it would have a wider readership than originally anticipated by its authors.
101 In Dr Roylance's absence, Mr Graham Nix, as acting Chief Executive, consulted Mr McKinlay concerning a response to the report. After discussion with Dr Gabriel Laszlo, Chairman of the HMC, Dr Joffe, Dr Monk and Dr Vann Jones an agreed report and response was issued which accepted the recommendations. A protocol was agreed whereby complex PCS would either await the arrival of Mr Pawade or, if urgent, be referred elsewhere. Mr Wisheart was to cease PCS, except in cases where he had treated a child previously and the parents asked him to continue caring for the child.
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Footnotes
[1] A fuller chronology can be found in Annex A Chapter 31
[3] WO 0001 0006; letter from Professor Henderson and others to the SGHA
[4] WIT 0070 0003 Professor Crompton
[5] T89 p.125 and 130-1 Dr Halliday
[6] See Chapter 14
[7] The precise date of the visit is unclear
[8] WO 0001 0265; Welsh Office Report, 10 December 1986
[10] WO 0001 0361 `Meanwhile our Children are Dying', Neil Hall
[11] WO 0001 0315; minute dated 18 August 1987
[12] Broadcast 16 June 1987
[13] UBHT 0194 0022; see letter apparently dated 25 June 1987
[14] UBHT 0133 0029 - 0031; letter dated 3 August 1987. Mr Peter Gregory was, from 1986 to 1990, Head of Health Services Planning Division in the NHS Directorate in Wales. From 1994 to 1999 he was Director of the NHS in Wales
[17] T88 p.56 Dr Roylance. It should be noted that the contemporaneous correspondence is somewhat equivocal
[18] WIT 0080 0107 Dr Bolsin
[19] UBHT 0055 0039 - 0040
[20] T94 p.5 Professor Prys-Roberts
[21] Russell GA and Berry PJ. `Postmortem audit in a paediatric cardiology unit'. `J. Clin. Pathol'. 1989; 42:912-18
[22] UBHT 0133 0085 - 0086 `Annual Report on Paediatric Cardiology and Paediatric Cardiac Surgery at Bristol Royal Hospital for Sick Children and Bristol Royal Infirmary, 1989/1990'. For a fuller discussion of these data and the implications which can be drawn from them see Chapter 19
[23] JDW 0003 0081 - 0082
[24] UBHT 0055 0008. It is not clear to whom the Annual Reports were circulated. Dr Joffe claimed that they (or at least that for 1987) were also sent to district health authorities (the local DHA and those at peripheral centres). T90 p.16
[25] DOH 0002 0233; Figure 3, Interim Working Party report, July 1989
[26] T17 p.123 Sir Terence English
[27] DOH 0002 0196; minutes of meeting on 26 July 1990
[28] WIT 0352 0026 Dr Williams
[29] UBHT 0052 0290; letter dated 7 August 1990
[33] WIT 0080 0109 Dr Bolsin
[35] WIT 0352 0027 Dr Williams
[36] WIT 0352 0037 Dr Williams
[42] Dr Sally Masey, consultant anaesthetist, UBH/T
[44] UBHT 0055 0082
[45] WIT 0382 0002 Professor Prys-Roberts
[46] WIT 0382 0006; letter dated 11 October 1991
[47] T94 p.30 Professor Prys-Roberts
[48] WIT 0326 0013 Dr Black
[49] WIT 0296 0002 - 0003 Dr Zorab
[50] UBHT 0038 0430; letter dated 20 November 1991
[53] T94 p.21 Professor Prys-Roberts
[54] UBHT 0055 0144
[55] JDW 0003 0102; letter dated 3 January 1992
[56] WIT 0467 0013; Mr Elliott's paper `The Chair of Cardiac Surgery in Bristol'
[60] T94 p.12 Professor Prys-Roberts
[61] T94 p.33 Professor Prys-Roberts
[63] WIT 0170 0044 - 0045 Mrs Orchard
[65] JDW 0003 0134; letter dated 22 June 1991
[66] JDW 0003 0157; letter dated 23 July 1992
[67] WIT 0080 0111 Dr Bolsin
[68] WIT 0283 0001 Dr Hammond
[69] WIT 0080 0111 Dr Bolsin
[71] T94 p.49 Professor Prys-Roberts
[72] RCSE 0002 0167; Working Party Report
[73] RCSE 0002 0179; letter dated 2 July 1992
[74] RCSE 0002 0188; letter dated 15 July 1992
[75] T17 p.124 and T18 p.150 Sir Terence English
[76] T18 p.184 Sir Terence English
[77] T89 p.157 and T89 P. 157 Dr Halliday
[78] DOH 0002 0099; minutes of meeting on 28 July 1992
[79] T15 p.74-5 Sir Michael Carlisle
[80] See Annex A, Chapter 3, for an explanation of these clinical terms
[81] WIT 0326 0015 Dr Black
[82] WIT 0255 0014 Ms Herborn; WIT 0132 0055 Mrs Armstrong
[84] WIT 0084 0112 Mr Dhasmana
[85] WIT 0084 0110 Mr Dhasmana
[86] WIT 0084 0113 Mr Dhasmana
[87] UBHT 0005 0226; minutes of meeting on 7 December 1992
[88] T69 p.89-90 Professor Farndon
[89] WIT 0087 0007 Professor Farndon
[90] WIT 0270 0014 Dr Masey
[91] WIT 0343 0002 Dr Willatts
[93] WIT 0081 0023 Mr Bryan
[94] WIT 0105 0025 Dr Monk
[96] In evidence, Professor Vann Jones referred to these conditions as Tetralogy of Fallot, VSD, AV Canal, and single ventricle. T59 p.104
[97] WIT 0115 0019 Professor Vann Jones
[98] UBHT 0061 0053; letter from Dr Bolsin to Dr Roylance (undated)
[99] WIT 0115 0025 Professor Vann Jones
[100] WIT 0115 0207 Mr Wisheart
[101] WIT 0338 0005 Dr Ashwell
[102] T61 p.85 Professor Angelini
[103] WIT 0073 0104 Mr Wisheart
[104] WIT 0413 0001 Professor Keen
[107] UBHT 0146 0050; letter dated 3 March 1994
[108] UBHT 0061 0270; letter dated 10 February 1994
[109] T61 p.108 Professor Angelini
[110] WIT 0105 0023 Dr Monk
[111] UBHT 0020 0015; minutes of meeting on 8 April 1994
[112] WIT 0153 0023 - 0025 Mrs Maher
[113] T59 p.155 Professor Vann Jones
[114] T61 p.127 Professor Angelini
[117] UBHT 0275 0139; draft report `Options for Development of Adult and Paediatric Cardiac Services in UBHT', May 1994
[118] WIT 0153 0028 Professor Angelini
[119] WIT 0153 0061 Ms Maher
[121] WIT 0108 0128 Dr Roylance
[126] UBHT 0052 0287 - 0288; letter dated 21 July 1994
[127] DOH 0001 0012; letter dated 19 August 1994
[128] UBHT 0061 0278; letter dated 12 September 1994
[129] UBHT 0061 0276; letter dated 4 September 1994
[130] UBHT 0061 0278
[131] WIT 0073 0016 Professor Angelini; WIT 0073 0055 Mr McKinlay
[132] T61 p.176 Professor Angelini
[133] T69 p.170 Professor Farndon
[134] WIT 0120 0455 Mr Wisheart
[136] WIT 0102 0028 - 0029 Mr McKinlay
[137] WIT 0120 0455 Mr Wisheart
[138] WIT 0120 0455 Mr Wisheart
[139] DOH 0001 0009; memorandum dated 16 January 1995
[140] WIT 0120 0456 Mr Wisheart
[141] WIT 0120 0456 - 0457 Mr Wisheart
[143] UBHT 0340 0350; Dr Martin's minute of the meeting
[144] UBHT 0061 0282 - 0283; letter dated 25 January 1995
[145] PAR2 0001 0027; letter dated 26 January 1995
[146] UBHT 0061 0337; letter dated 25 January 1995
[147] WIT 0319 0013; Dr Hunter's notes
[150] WIT 0322 0007 Dr Hunter