Annex A > Chapter 13 - Pre-operative Care > The decision to recommend surgery > Delays in surgery
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Delays in surgery
68 Dr Joffe said: `We were aware that there were constraints at times due to insufficient beds or nurses' [72] in carrying out operations at the BRI. However, he stated that emergency cases were normally dealt with within 24 hours. [73]
`There were certainly continuing and important delays. For example, from about 1990 onwards we were trying to investigate all babies with Down syndrome [sic] and AVSD or large VSD [Ventricular Septal Defect] by three to four months in the expectation that they would then get their surgery within four to six weeks, but they often had to wait that number of months before an operation could actually take place. How much this affected the outcome, is a matter for speculation, but the general view for pulmonary hypertensive patients was that any delay would increase the risks.' [74]
70 Dr Joffe commented on the delays in the urgent group of patients. He told the Inquiry that these were patients:
`... for whom surgery was not so critical as to need an operation within about 24 hours, but who could deteriorate in the course of weeks or months. This group included patients who became increasingly cyanosed; and infants with large communicating defects and left to right shunts, causing high pulmonary blood flows and severe heart failure. Despite intensive treatment with appropriate medication, these babies remained breathless, could not feed adequately, and failed to thrive. They were often hospitalised at BCH for many weeks while awaiting surgery. Also in this group were infants with pulmonary hypertension, as occurs particularly with complete atrio-ventricular septal defects, typically in babies with Down's syndrome.' [75]
`The concern about those who were deeply cyanosed or in persistent heart failure was that they might not be in optimal general condition for surgery. This could lead to difficulties at operation and in the immediate post-operative phase.' [76]
72 Of the urgent patients Mr Wisheart said:
`In many ways these patients offered us the greatest problem because they neither had the emergency status that clearly took priority over everybody else nor could they simply wait. We would normally seek to schedule them in the next gap in our operating programme (we did leave gaps for urgent and emergency cases). Of course the gaps were not usually available at the right time. In that event, either the urgent patient had to wait a little longer or else he had to replace a patient who was expecting surgery with all the disappointment for that family.' [77]
`We did our best within the facilities available to us to ensure that children were operated on at the appropriate time. It should be remembered that for the many patients the "appropriate time" would have spanned quite a long period ... we were not in the position where we had a facility with sufficient spare capacity to be able to deal with every child when he or she presented.' [78]
`It was my practice to give a broad indication when we would like to do the operation so that the parents and families can plan ahead ... We tried to operate at the predicted time, but certainly did not always succeed.` [79]
75 He explained that operations would have to be postponed if there was no ICU bed available, there was a shortage of nurses, and there was an emergency or, rarely, a shortage of blood for transfusion. Every effort would be made by members of the team to overcome these problems. If they could be overcome then the work would be done and the patient would be operated on. If they could not be overcome safely, then it would be dangerous and not in the patient's best interests to proceed. [80]
76 Dr Joffe, commenting on delays in respect of non-urgent cases, said that such cases:
`... would often be delayed beyond the anticipated date for surgery because of competition with the long adult waiting list. On the other hand, the long-term outcome for these patients would usually not be any different, even after delays of several months.' [81]
77 Dr Laband, a junior doctor at the BRHSC from November 1994 to January 1995, stated in a letter to the Inquiry:
`It was a generally held view among the medical staff that these babies were held in the waiting list for far too long and were in a much weaker condition than they need have been.' [82]
`... patients having elective operations sometimes had to wait a considerable time for surgery, perhaps longer than predicted at the outset. For the great majority this was not of critical importance, but for some it may have been of significance.' [83]
79 Mr Dhasmana estimated that elective surgery patients could wait for eight to nine months before surgery and sometimes longer if they were moved in order to accommodate more urgent cases. [84]
80 Mr Dhasmana commented on whether operations were carried out at the appropriate time. He told the Inquiry:
`... every clinician worries about the waiting list and the known fact that a patient may deteriorate over this period. Ideally there should not be a waiting list for any patient, but resources are limited and the clinician has to prioritise amongst his patients on the basis of clinical criterion ... there were targets to be attained for the number of Coronary Arterial Surgery so there was unwritten competition between adults and paediatrics. Some of our colleagues, practising with adults only, used to get unhappy with the prospect of ITU beds getting "clogged" by paediatric patients. Mr Wisheart and myself used to make some adjustments to our operating programme so that not more than three major paediatric operations were carried out in one week ... The availability of beds in ITU also played an important role in the scheduling of both adult and paediatric operations. Similarly, the availability of anaesthetists was a factor in my scheduling of paediatric operations. During the mid to late 80s Dr Masey and Dr Burton were the main anaesthetists dealing with infants and neonates. The situation improved in the 1990s with the appointment of Dr Underwood and Dr Pryn enabling us to operate on infants more frequently. Additionally, the availability of nurses capable of dealing with children was also a known factor ... the situation could get worse if there was leave of absence due to sickness amongst this small core of nurses in the ITU or in the operating theatres.' [85]
81 Mr Dhasmana felt that the operations were at a time `that was not ideal, but most probably appropriate in the circumstances, with limitations in the resources.' [86]
82 Mr Wisheart commented on the waiting lists:
`In the situation in which we found ourselves where most months we would have liked to operate on twice as many patients as we were able to do, it was unfortunately essential to establish priorities amongst patients who were ready for surgery.' [87]
`There were occasions when the intensive care beds were occupied by seriously ill patients and other cases had to be cancelled ... this situation was improved by the expansion of the intensive care beds to eight, and the provision of seven high dependency beds, in 1988. This allowed the less complicated of the adult cases to be "fast tracked" in the high dependency unit, thus leaving the ITU beds available for more seriously ill patients. Occasionally, nursing staff shortages, mainly due to sickness, caused the closure of an ITU bed. There were also occasions when theatre staff sickness caused cases to be cancelled. This also happened when theatre staff had been working during the night on emergency cases, as the first morning case was then postponed. This had a knock-on effect on the theatre list for the rest of the day.' [88]
84 Mrs Herborn explained the organisation and management of theatre lists:
`A monthly meeting would take place between surgeons where the monthly theatre list would be made. This was passed to the theatre sister who would arrange the theatre staff duty roster around the theatre list. However, each list would invariably undergo a multitude of alterations. These may have been due to a shortage of beds in the ITU, a more urgent/emergency case being presented, or the fact that because an operation had overrun the previous day, there was no scrub nurse or anaesthetic assistant available to assist that morning's operation. Daily theatre lists were compiled by the Senior House Officer in cardiac surgery and sent to us the afternoon before. These were more detailed than the monthly lists so that theatre staff were able to prepare the theatres according to the type of operation to be undertaken.' [89]
85 Mr Wisheart also explained that late referral for surgery, whether by a general practitioner, paediatrician or paediatric cardiologist, would be a reason for the operation taking place later than might have been desirable. [90]
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Footnotes
[72] WIT 0097 0302 Dr Joffe
[73] WIT 0097 0301 Dr Joffe
[74] WIT 0099 0042 Dr Jordan
[75] WIT 0097 0300 Dr Joffe
[76] WIT 0097 0302 Dr Joffe
[77] WIT 0120 0137 Mr Wisheart
[78] WIT 0120 0138 Mr Wisheart
[79] WIT 0120 0139 Mr Wisheart
[80] WIT 0120 0140 Mr Wisheart
[81] WIT 0097 0300 Dr Joffe
[82] INQ 0042 0004; letter from Dr Laband
[83] WIT 0120 0142 Mr Wisheart
[84] WIT 0084 0067 Mr Dhasmana
[85] WIT 0084 0067 - 0068 Mr Dhasmana
[86] WIT 0084 0068 Mr Dhasmana
[87] WIT 0120 0137 Mr Wisheart
[88] WIT 0213 0031 Julia Thomas
[89] WIT 0255 0029 - 0030 Mrs Herborn
[90] WIT 0120 0142 Mr Wisheart