Annex A > Chapter 14 - Care in the Operating Theatre and the `Learning Curve' > The `learning curve' > Mr Dhasmana's visits to Mr Brawn in Birmingham
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Mr Dhasmana's visits to Mr Brawn in Birmingham
114 Mr Dhasmana stated that he halted the programme and sought help from outside Bristol:
`As I could not get any advice locally, I talked to my fellow surgical and cardiological colleagues during a BPCA [British Paediatric Cardiac Association] meeting held at Birmingham in November 1992. A cardiologist from the GOS Hospital, London, told me of problems Mr de Leval had experienced with neonatal switches on his most recent 7 or 8 patients, and that Mr Brawn had helped him to rectify the problem. I was therefore advised to seek Mr Brawn's help in this matter. I met Mr Brawn, at the same meeting, and he was very receptive, advising me to visit him in Birmingham when he was operating on the next neonatal switch. I did invite him to Bristol and help me with the operation, to which he politely declined.' [132]
115 Asked why he chose Mr Brawn, Mr Dhasmana told the Inquiry:
`It was not Birmingham I went to initially, it was the BPCA meeting at Birmingham in November 1992, which I was attending as a member. There I met a lot of my other colleagues, both cardiologists and paediatric surgeons and I discussed my problem with them, and one of the paediatric cardiologists from the Great Ormond Street Hospital then told me that they had a similar problem at Great Ormond Street Hospital and Mr Brawn was able to help really and "It would be a good thing if you talked to Mr Brawn". It so happened Mr Brawn was also attending the meeting, so I talked to Mr Brawn and also Mr Sethia. So it was following that meeting that I decided to go to Birmingham.' [133]
116 Dr Masey, who accompanied Mr Dhasmana, said that the reason for the visit was that:
`A programme to perform neonatal Switch procedures had started in 1992 and the results had been uniformly poor, so it was felt that some form of retraining was required in order to see whether we could proceed with this particular procedure.' [134]
117 Mr Dhasmana and Dr Masey visited Birmingham in December 1992 in order to observe Mr Brawn at work. The operation was recorded on video and Mr Dhasmana kept a copy. Mr Dhasmana stated:
`I was particularly impressed with the organisation. As a result of this I arranged for theatre nurses and other perfusionists to visit and learn the workings of the Birmingham set-up ... I believe that the whole team received further training as a result of these visits.' [135]
118 Dr Masey described Mr Dhasmana:
`He came back on the train and he was extremely enthusiastic about what he had seen and what he had been able to talk through with Mr Brawn, and felt very encouraged by what he had seen in relation to how he felt he would go forward with the neonatal Switches that he was going to be operating on.' [136]
119 On his return, Mr Dhasmana stated that he:
`... discussed proposed changes in the technique, set-up, pre- and post-operative management, with anaesthetists, cardiologists and nurses. They agreed to make the changes and to re-start the neonatal Switch programme ... On the table I made various changes in technique, for example reductions in cross clamp and by pass time, as observed during Mr Brawn's neonatal operation, and from studying the video recording ... Nurses were involved with operations. These changes resulted in an observable improvement, with the next two patients surviving the operation. Although the third patient died the fourth survived resulting in optimism in the Unit.' [137]
120 The neonatal programme was recommenced. Six operations were carried out. Patients one, two and four survived. After the death of the sixth patient, Mr Dhasmana halted the programme and again visited Mr Brawn in Birmingham.
121 Mr Dhasmana told the Inquiry:
`I lost two patients in succession and both of these patients had normal coronary arteries, so in a way, that raised doubt again in my mind that here I was, I did two successful operations, the third did not make it, but it was a highly abnormal coronary artery and probably could be explained in any centre. But the next one survived so I am still happy, I have got, you know, out of four, three survivals. And the next two did not, although of course, with one of them we did have evidence of myocardial infarction, but nevertheless, these two did not and they had a normal coronary artery.
`... during this period, between 1992 and this time, July 1993, I had operated on about 7 or 8 older Switches and they all survived. So that is why, really, I was very concerned that something is probably a little different in neonates which I have not still been able to transfer. That is what was quite worrying me.
`I told Dr Joffe that, "I am very sorry, it appears that I will not do any more neonatal switches" ... He said, "Well, it so happens that I was going to get in touch with you". I said "What for?" He said "I have got another patient admitted with a similar problem".
`Then I narrated again what happened during the day in theatre and he I think tried to probably comfort me, saying "Let us just wait for the post mortem examination and then we can really ...". I said, "Well, I am not taking that next case on ...".
`... He said "Well, what should we do?" I said "I tell you. We talk to Birmingham". He said "Well, why do you not do that?" So the next day, I ring Birmingham, I ask for Mr Brawn. It so happened he was nearby ... he said "No problem, you know, bring the patient and I will operate here, and I tell you, I have got another patient here, so you will see two patients operated on the same day".' [138]
`I re-visited Birmingham in July 1993 accompanied by Dr Underwood and a patient from Bristol that Mr Brawn had agreed to operate on. We had further discussion on the problem being experienced in the Unit. We returned to Bristol, re-assured and prepared to re-start the programme. The next neonatal patient survived followed by a further fatality and the programme was ended.' [139]
123 Dr Underwood accompanied Mr Dhasmana to Birmingham. Dr Masey on her return from Birmingham in 1992, had instituted changes in practice. Dr Underwood told the Inquiry:
`... when I went in the middle of 1993, it was to observe them doing the same thing which Dr Masey had described to me, and I do not remember adding anything different or extra after that particular visit.' [140]
124 When asked by Counsel to the Inquiry what he expected to discover from a second visit to Birmingham, Mr Dhasmana replied:
`What I noticed over these cases is that somehow, from outside and even when I have gone back in, the coronary artery looked in the right place. There was no obvious kink from outside. So I started asking myself whether what I called at that time the "lie", the way they are lying over the heart, have I got the angulation right, and maybe, technically anastomosis fine, and when you are looking at the post mortem, it looks fine, no problem, but the heart did not work. One of the things with anastomosis I think is the coronary artery, which I think is very important.' [141]
125 Professor de Leval commented as to whether Mr Dhasmana's visits to Birmingham constituted retraining:
`Whether this is what Mr Dhasmana was looking for, I am not sure. I think that the word "retraining" here might not be appropriate because he had never achieved good results in the Switches, so it was a question of training rather than retraining, which is slightly different, I believe.' [142]
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Footnotes
[132] WIT 0084 0112 Mr Dhasmana
[135] WIT 0084 0112 - 0113 Mr Dhasmana
[137] WIT 0084 0113 Mr Dhasmana
[139] WIT 0084 0113 Mr Dhasmana