Final Report > The Adequacy of Care
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The Adequacy of Care
Chapter 19: Observations on the Organisation of the PCS service
1 In the past three chapters, we have examined a number of aspects of the organisation of the paediatric cardiac surgical (PCS) service at Bristol. We now set out our view so far, before proceeding further. The picture we have is of hard-working and dedicated clinicians committed to an area of practice which was demanding, complex and difficult. As Mr Roger Baird, consultant general surgeon and Medical Director, UBHT, 1997-1999, put it: `I think one of the features about cardiac surgery is that the intervention and the outcome are so closely related to each other that they are quite easily linked in people's minds.' [1]
2 To cite one of many examples of hard work and commitment, John Mallone, father of Josie, recalled meeting Mr Wisheart on the ward at 3 a.m., knowing that he would be back at work at 8 a.m. [2] The staff were doing their best as they saw it, within the system at the time. But, in the absence of good, clear, overall organisation and management of the clinical care of the children, it is this dedication which may paradoxically have contributed to the problems of performance. Mr Wisheart, the man at the centre of the PCS service, may simply have been too busy to see the big picture. He concentrated on his surgery rather than on the total range of care, and he lacked sufficient insight into how far he was stretched. The senior consultant surgeons and cardiologists seem to have been unable to find a way out of their difficulties. They simply pressed on, even when things did not improve. There was resistance to the fresh ideas of the new generation of consultants appointed [3] and little interest shown by some, or success by others, in improving the management of the Intensive Care Unit (ICU).
3 In addition, during the period of our Terms of Reference, the approach to caring for children in acute care hospitals made rapid advances. It became increasingly accepted not only that children are not (in the time-worn cliché) little adults, since they have different physiology and need different technical care, but also that they need to be looked after within a paediatric, family-centred environment. Mixing adults and children in the same ICU was coming under criticism, although it was not uncommon in many hospitals, and it was only from the mid 1990s that a major effort was made to provide sufficient paediatric intensive care beds to meet demand. Equally, in the late 1980s and early 1990s there was a rapid development in the concept of intensive care. The idea of the specialist intensivist emerged, usually coming from a background in anaesthesia, with the ability to look across body systems to provide comprehensive care. There were also important developments in the management of ICU, with a consensus developing in favour of the `closed' ICU, in which all the patients are the responsibility of the clinician in charge who can
co-ordinate care, rather than the `open' ICU in which each patient remains the responsibility of the admitting clinician.
4 There is little evidence of Bristol's seeking systematically to embrace these developments, at least at the BRI. Indeed, the evidence is of a conservative, increasingly outdated approach to care, coupled with resistance to those who argued for, or tried to introduce, change. There was little indication of the development of an understanding in all of the professionals, and particularly the surgeons, of belonging to a team in any sense of the term involving shared responsibilities and consultation across specialties. There was a poor understanding of the importance of teamwork, most particularly in the case of collaboration between cardiologists, anaesthetists and surgeons in the management of the ICU: that teams are necessarily multidisciplinary.
5 Nothing effective was done about the difficulties which were identified and recognised. Reference is made now to the unusually complex anatomical difficulties encountered during the surgery, and the less than adequate cardiological support. It could be replied, however, that no attempts by way of practical steps were taken to respond to the problem of lack of cardiological support. Mr Wisheart as Medical Director might, for example, have insisted on mechanisms to improve the cardiological input in the operating theatre and the ICU. Alternatively, he could have said, that without it, the PCS service was not safe. He did neither. Equally, the absence of a sufficient number of nurses trained in paediatric care in the BRI ICU did not cause anyone in a position of responsibility to act.
6 The split site and consequent split service were clearly major factors in affecting the adequacy of care. Unifying the site did not attract sufficient priority in the struggle for resources. The claim of the PCS service was not seen as important enough. But this did not cause the clinicians to cease to offer the service. There seems to have been an overriding sense of pressing on and hoping that one day the service would be moved onto one site, that the new hospital for children would be built, and that the new surgeon would arrive, and then all would be well.
7 The overall problems which we have identified relate to an inadequacy in the system for providing care rather than in any particular individual. The system for delivering PCS services in Bristol was frankly not up to the task. Things were only made worse by the fact that there was insufficient reflection on, and insight into, the overall care experienced by the children concerned.
8 What we observe amounts to a failure of paediatric open-heart surgery to thrive. There is real room for doubt as to whether open-heart PCS on the under-1s should have been designated a supra regional service in Bristol. Once designated, however, it simply never developed sufficiently well. We observe a unit with high aspirations (including at one stage the ambition to become a centre for cardiac transplantation) simply overreaching itself, given its limitations, and failing to keep up with the rapid developments elsewhere in PCS during the late 1980s and early 1990s. In summary, opportunities were not taken. Exhaustion and low morale led to stagnation and an inability to move forward in response to new developments, despite the stimulus provided by the new generation of consultants.
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