Annex A > Chapter 13 - Pre-operative Care > The decision to recommend surgery > The decision on the timing of operations/the operating theatre list
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The decision on the timing of operations/the operating theatre list
54 The Inquiry heard that the joint meetings would discuss the category to which each patient should be assigned: elective, urgent or emergency. [59] The timing of surgery was then dependent on the theatre lists.
55 Dr Jordan felt that the timing of the surgery was in the hands of the surgeons, although:
`The cardiologists did continue to see patients on the surgical waiting list and would remind the surgeons of patients who appeared to be waiting too long.' [60]
56 Dr Jordan told the Inquiry that the timing of operations:
`... was entirely dependent on the waiting lists and the surgeon's assessment of urgency ... in addition, it did also relate to the availability of paediatric trained nurses and the length of stay of children and infants already operated, some of whom stayed for over two weeks in ITU ... certainly some patients, particularly those with AVSD [Atrio-Ventricular Septal Defect] and pulmonary hypertension in whom it was intended that operation should take place within one to two weeks, had to wait that number of months, or even longer.' [61]
57 Dr Jordan stated that the organisation and management of theatre lists was the responsibility of the surgeons at both the BRI and BRHSC. [62]
58 Dr Joffe agreed with Dr Jordan that the organisation and management of theatre lists was entirely in the hands of the surgeons.
59 Dr Joffe told the Inquiry that at the joint meetings:
`The paediatric cardiologists would ... always give their perception of the urgency of the required intervention ... The surgeons made the decisions about the timing of surgery.' [63]
`... the patients are discussed in detail at joint meetings of cardiac surgeons and paediatric cardiologists and others and decisions are jointly come to in the vast majority of cases. Then the patient is either accepted or not, usually accepted, by one or other surgeon and then the patient's name goes on to a surgeon's list, not on the waiting list yet but an acceptance that the surgeon will see the family in outpatients and it is at that time, once the surgeon has had an opportunity to discuss the details of the risks with the families, that they effectively go on to the waiting list.
`So there would be a time period between the joint meeting which itself usually occurred within two to three weeks or so of the cardiac catheter study, if one is done or otherwise on the basis of the echo-cardiographic findings, the paediatric cardiologists would put that patient into the list for discussion, so there is a short period of delay there inevitably in the system and then once the surgeon has accepted the patient after seeing the family, [the patient] goes on to their waiting list.' [64]
61 Mr Wisheart commented on the organisation and management of the theatre lists:
`Mr Dhasmana and I operated on children according to a consistent programme, and on days when cardiac anaesthetists were present ... The operating plan for each month was made in the previous month; some gaps would be left so that emergencies could be accommodated ... in selecting patients from the waiting lists for each month's operating programme I normally reviewed all the children on the waiting list. I would then select six or seven children for the operating programme. The selection would be based on the urgency which had been assigned to the patient and the length of time they had been waiting already. Any other features of note would be taken into account ...' [65]
`If it is either urgent or emergency, then arrangements will be made at that point for the operation to be carried out.' [66]
Timing of emergency operations
63 In relation to emergency cases, Dr Joffe said:
`There were rarely problems with regard to the timing of an operation for patients requiring an emergency procedure ... a theatre slot could always be arranged at the BRI for these patients, even if it meant cancelling a previously booked adult case. Quite often, these operations would be fitted in over the weekends.' [67]
64 Mr Dhasmana confirmed that emergency patients would be operated on:
`Whenever required, out of hours, in the night or over weekends.' [68]
Timing of urgent operations
65 Mr Wisheart provided a `working definition' of the urgent category, namely:
`... that the patient had to be operated on before they left hospital. Occasionally it would have included patients who were well enough to leave hospital, but nevertheless needed to be operated on within the next week or two.' [69]
66 Mr Dhasmana told the Inquiry:
`I would also tell parents, in the group of patients which were categorised as urgent/semi urgent, when to expect surgery. They could ring nearer the time to find out if the operation was on schedule or not. This would also serve as a reminder regarding the state of urgency ... I would also tell parents to take the child to their doctor or referring clinician if there were any changes in the patient's clinical condition. The GP and/or cardiologist would also remind me of the urgency. I used to leave a slot empty each week to accommodate an urgent case or any other patient, I had been informed of deteriorating while waiting for surgery.' [70]
Timing of elective operations
`If the operation is an elective one then a view is needed as to whether the operation should be in one month, three months, six months, one year or whenever. The arrangements will be made to see the family in the outpatients, and if the family accepts the advice which is offered to them, then the patient's name is placed on the surgeon's waiting list. The parents were informed in a broad way of when the operation was expected to take place. In practice, these estimates were not always accurate. The paediatric cardiologist continued to see the patient in his outpatient clinic ... he would keep the surgeon informed of any new development or change in the patient's condition that might influence the timing of surgery. The surgeon, when he made his monthly operating programme, determined the exact date of the proposed operation for each patient.' [71]
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Footnotes
[59] WIT 0120 0134 Mr Wisheart
[60] WIT 0099 0042 Dr Jordan
[61] WIT 0099 0042 Dr Jordan
[62] WIT 0099 0042 Dr Jordan
[63] WIT 0097 0301 Dr Joffe
[65] WIT 0120 0135 Mr Wisheart
[66] WIT 0120 0134 Mr Wisheart
[67] WIT 0097 0299-300 Dr Joffe
[68] WIT 0084 0067 Mr Dhasmana
[69] WIT 0120 0137 Mr Wisheart
[70] WIT 0084 0067 Mr Dhasmana
[71] WIT 0120 0134 Mr Wisheart