Annex A > Chapter 13 - Pre-operative Care > Pre-operative management of care > Further assessment of the clinical condition of children admitted for elective surgery following admission to the BRI
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Further assessment of the clinical condition of children admitted for elective surgery following admission to the BRI
29 In relation to children admitted for elective surgery to the BRI, Mr Wisheart confirmed that these patients would be reassessed following admission:
`... the consultant surgeon had always seen the patients before and their status would be reassessed by the senior house officer, by the registrar and by the consultant. They were reassessed by the consultant paediatric cardiologist when he visited Ward 5. The anaesthetic registrar and the consultant would assess them; this would be for the first time and would not be a reassessment.' [35]
`The pre-operative preparation included a clinical examination of the child as a whole and heart and lungs in particular. Blood tests included haematology, biochemistry, clotting study and for X-matching. The bacteriology tests included swabs taken from nose, throat or any other suspicious areas ... ECG and chest X-rays were taken and patch tests for allergy to tapes and antiseptic solution were performed. A 2-D echo examination was repeated, if indicated. Suitability of the child for surgery was examined by at least three members of the medical team, admitting doctor, myself in all cases and a member of the anaesthetic team, during the pre-operative check-up and also by the nursing staff. Common causes for the postponement of routine operations were evidence of cold and other chest infections. Paediatric Cardiologists also used to see these patients. I would definitely ask for a Cardiologist's opinion if I felt that there was some change in the child's condition that required cardiological reassessment.' [36]
31 However, Dr Jordan and Dr Joffe told the Inquiry of the limitations on the cardiologists' involvement in pre-operative assessment or re-assessment at the BRI. Dr Joffe told the Inquiry:
`Because of their heavy workload with limited junior staff support ... and the difficulties imposed by the split site ... it was not possible for the consultant paediatric cardiologists to play much of a role in the immediate pre-operative assessment and post-operative care in the BRI.' [37]
32 This was confirmed by Dr Jordan who told the Inquiry that reassessment following admission:
`... was not always easy as far as the cardiologists were concerned as the children were admitted direct to Ward 5 at the BRI. Operation lists were produced at the end of the previous month but were subject to change according to the need to deal with emergencies and the availability of post-operative ITU beds in the BRI ward 5. I tried to see admissions of all patients the day before operation, but since there was no formal arrangement for this I often got to Ward 5 to find that the child had been sent off with his parents into town, having had his routine tests done. I was not encouraged to write anything in the notes to say that I had seen the patient. Clearly, if there was anything which I noted which suggested that the decision to operate should be reviewed, I would make every effort to contact the surgeon concerned. In practice this was unusual, but did occur on a few occasions. It should also be noted that the pre-op catheters ... and echo results ... would be at the Children's Hospital. It was possible for me or one of the radiologists (particularly Dr Wilde) to carry out a further echo-cardiogram if this was indicated. This became easier once the Heart Circle had provided money for an echo machine to be kept on the ward.' [38]
`The majority of patients admitted to BRI for non-urgent open-heart surgery (a) would have been assessed fully, with echo-cardiography if necessary, either at BCH outpatients department or at a peripheral clinic, prior to the operation; and/or (b) would not have required further assessment of the cardiac status following comprehensive diagnostic investigations even a year before surgery, if the condition was known not to deteriorate in the medium term ... an exception would be those patients without symptoms but with potentially progressive pulmonary vascular obstructive disease, who comprised a small minority of all open-heart operations. However, repeat clinical, radiological, electro-cardiographic and even echo-cardiographic examination in these cases would have been unlikely to establish whether a patient had changed from an operable to an inoperable state. I believe the only way to confirm the then current haemodynamic situation would have been to repeat the cardiac catheterisation study - or perform a lung biopsy. Even these investigations, of course, as is widely recognised in the field, are by no means infallible.' [39]
34 Dr Jordan told the Inquiry:
`We did set out originally to look at the next weeks' operations in terms of reviewing the catheter and echo data at one of the combined (Monday or Wednesday) meetings with the surgeons, but since they did not manage to get to more than 50% of these at best, and there was often a backlog of recent investigations to discuss with them, this soon fell by the wayside.' [40]
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Footnotes
[35] WIT 0120 0127 Mr Wisheart
[36] WIT 0084 0066 Mr Dhasmana
[37] WIT 0097 0297 Dr Joffe
[38] WIT 0099 0040 - 0041 Dr Jordan
[39] WIT 0097 0297 - 0298 Dr Joffe
[40] WIT 0099 0041 Dr Jordan