Annex A > Chapter 13 - Pre-operative Care > The decision to recommend surgery
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The decision to recommend surgery
45 The Inquiry heard that decisions about the type and timing of surgery and which surgeon was to operate were generally made following discussion in the joint cardiology/cardiac surgery meetings which were held twice weekly at the BRHSC catheterisation laboratory (Mondays at 8:00 am and Wednesday lunchtimes).
`These were essentially meetings between the cardiologists, the cardiac surgeons and the cardiac radiologist, but which frequently included the paediatric counsellor together with nurses and radiographers who worked in the catheterisation laboratory. From time to time an anaesthetist attended but this was not common. Where consultants were present, as far as possible, their juniors would attend also ... The paediatric cardiologist responsible for [the] child would indicate to which surgeon the referral was being made. He would then present the case, giving an account of the clinical history, the findings on examination ...' [52]
`In order to reach a decision there would then be a discussion which might primarily be between the referring cardiologist and the surgeon to whom the patient is referred but which would actively include all the others attending the meeting ... the anaesthetists were not usually involved in this initial decision- making process and I think they would generally not regard it as being within their area of specialised expertise.' [53]
48 Mr Wisheart commented that the joint meetings:
`... sought to make plans for the operation and also to foresee any additional features that would need to be taken into account during the procedure. This was recorded in the note of the meeting. If any additional features or developments came to light between the investigation and the operation, then the cardiologist would of course inform the surgeon.
`It was important that the anaesthetists, the nurses and the perfusionists should know what procedure was likely to be undertaken and what special features would be associated with any particular patient. I would expect our colleagues to be familiar with the patient's notes and all the expected details of the operation. If there were any special points affecting anaesthesia, perfusion or scrub nurses, then the surgeon would draw their attention to it prior to the operation. Having said that, it was relatively rare that such a discussion would be needed because all parties were used to working together and were familiar with each others' practice.
`Immediately prior to surgery, the patient was reviewed clinically, from the point of view of their present condition and the possibility of there being any intercurrent illness. The investigations were also reviewed. If such a review led to any new questions or any possible new interpretations of the data, then that would be discussed by the cardiologists, and/or cardiac radiologist and the paediatric cardiac surgeon as appropriate. The management of medication prior to surgery was agreed between us. There was not a meeting in the days or the week prior to surgery when all members of the team met together to discuss the details. However, the surgeon's team of registrar and SHO would discuss the details of all of these patients immediately prior to surgery.' [54]
`... that it was the cardiologist's responsibility to refer their patients for the type of surgery and for the choice of a particular surgeon. However, it could have been influenced at the joint meeting ...' [55]
50 Dr Jordan said that the decision whether or not to operate and when:
`... was the final decision of the surgeon, but it was very unusual for there to be any disagreement on the treatment. More commonly discussions centred on whether other investigations were necessary and the exact timing of the operation. While we could together agree on the optimum timing the surgeon was the only one who controlled the waiting lists.' [56]
51 However, Mr Wisheart's view was that:
`... to assign any "ultimate" responsibility to an individual is not appropriate to this process, which is based on discussion, debate and the agreement of a minimum of two people, before the referral can proceed. The answer to the question who carries ultimate responsibility therefore, cannot be one individual but must be at least two, namely the cardiologist and the surgeon, but it could be argued that it actually lies with the larger team.' [57]
52 If differences of opinion between the clinicians could not be resolved after discussion or it was agreed that further advice was required or that the patient should be referred to another centre, the cardiologist or the cardiac surgeon would make a referral.
53 In the case of urgent patients where decisions could not wait until the next Monday or Wednesday meeting, Mr Wisheart explained:
`The cardiologist will call the surgeon receiving paediatric cardiac emergencies on that day, and they would meet, possibly with the radiologist, see the patient and review the investigations. They would then decide what in their view was the appropriate course of action.' [58]
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Footnotes
[52] WIT 0120 0128 Mr Wisheart. However, of the decision to refer to one surgeon or the other, Dr Jordan said that this `... was largely a function of which surgeon happened to be present, although there were some procedures, particularly the arterial switch, where it had been decided that only one surgeon (i.e. Mr Dhasmana) would carry out all operations.' See WIT 0099 0041 Dr Jordan
[53] WIT 0120 0129 - 0130 Mr Wisheart
[54] WIT 0120 0148 - 0149 Mr Wisheart
[55] WIT 0084 0067 Mr Dhasmana
[56] WIT 0099 0041 Dr Jordan
[57] WIT 0120 0132 - 0133 Mr Wisheart
[58] WIT 0120 0130 - 0131 Mr Wisheart