Annex A > Chapter 15 - Post-operative Care > Involvement of clinical staff > Communication between the specialties
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Communication between the specialties
121 Mr Dhasmana was asked what, if any, measures he took to make sure that each part of the team responsible for the patient was performing adequately. He said:
`I thought I was trying to get the communication right but it appears it was not very good, communication amongst the staff. As a result I used to put in a lot of presence there just to make sure that what we talked about in the morning was being carried out during the day. What we are talking about in the evening would be carried out in the night; what we left in the night was carried out for the remaining part of the night because the rest of the staff were moving or changing. So the communication was not very good and I used to find that sometimes that could create confusion specially amongst nurses really because it is possible a different set of doctors may have advised differently on the same line because, as you know, for any management there could be more than one way of dealing with the problem.' [152]
122 Mr Wisheart commented on the Hunter/de Leval criticism that:
`The overall post-operative management at the Royal Infirmary appears to be highly disorganised with conflicting decisions between surgical senior registrar and the SHO who do the rounds at 8.00 am, the anaesthetists who see the patients at 9.00 am, and the intensivists who work three days a week.' [153]
`I thought that there was not a particular difficulty. The people involved in the intensive care of children following surgery came from a number of disciplines, and of course, in order to provide that care, they had to work together. Sometimes their views would coincide and at other times their initial views would be different ... so frequently there were discussions, and some of those would have been quite vigorous discussions ... usually an agreed way forward would emerge from that discussion.'
However, Mr Wisheart conceded that:
`Occasionally, however, a difficulty might arise if one party instituted a course of action, for whatever reason, without discussing it with the other party and the second party then comes along and may not agree with what has been done. ... but it was usually resolved if the two people simply talked to each other ... Whether there were issues that [when] ... the anaesthetists did their ward round at 10.30 or 11 ... when we were mainly in the operating theatre, but whether there were issues that emerged then that the nurses on the ground were more conscious of than I was when I came back at midday or lunchtime or whatever to see how things had progressed, I cannot say, but I was quite surprised when I saw this description.' [154]
123 Asked whether there was any formal mechanism for briefing and handover, Mr Wisheart told the Inquiry:
`The formal mechanism was that there was a surgical SHO and registrar and there was an anaesthetic registrar who at any time was either on call or present and available and I would have expected them to discuss any issues that would appear to occur between them ... it must be correct to say that there were occasions when it did not happen, but it had been my understanding that they were relatively rare.' [155]
124 Mr Wisheart was asked by the Chairman of the Inquiry about the difficulties of having ward rounds at different times and the possibility of advice being given at 8 o'clock that might be changed at 9 o'clock, or countermanded by someone of a different specialty:
`Q. (The Chairman) Of course, if that has then to be communicated to a nurse who then has to speak to a parent who may have been up all night, that X is going to take place soon, that is the advice given at 8 o'clock, but then at 9 o'clock that decision is changed, you can see that the, as it were, rollercoaster of emotion which is already there in a parent might be even more exacerbated, if you can exacerbate a rollercoaster. Is that not a problem in a very real and personal sense, as well as the organisational sense of managing the care of the child?
`A. ... I think that, taking the point of the consultant coming in at 9 o'clock, the junior having seen the patient at 8 o'clock or 8.30, or whatever ... The junior surgeons and the junior anaesthetists were both present at 8 o'clock, so there is absolutely no reason why their views should not have been co-ordinated, or if they were not unanimous, some way found to resolve it. I think the question of coming in at 9 o'clock and changing the orders is one that has received some prominence in evidence, and of course I can only speak from my own perspective; I cannot speak for the other four cardiac surgeons, because I think that comment actually picked up adult and paediatric cardiac surgery. I would say that occasionally that happened, but the notion that it was the general rule I think lacks perspective. Of the occasions when it happened, it would only rarely, I think, have had consequences of the type that you have described. Usually it would be some adjustment of what was happening, which would not necessarily impinge in any dramatic way upon the parents. Of course, it would have to be communicated and discussed with the nurse, naturally, and if it were important, it would need to be discussed with whoever else had been involved in the earlier decision, so that everybody was working to the same plan. So I think that occasionally it may have happened the way you mentioned, but I think quite rarely. I think there is a perspective which needs to be applied to that.' [156]
125 Dr Bolsin was asked what steps were taken to address the difficulty of there being blurred responsibilities between anaesthetists and surgeons and the difficulty of the one group, because of timing, talking to the other. He said:
`One of the big advances was bringing in an anaesthetic registrar into the Intensive Care Unit who became the communication point for the consultant anaesthetists with the surgical side. So that whenever the surgeons did a ward round there was always an anaesthetic presence. If we as anaesthetists had done our ward round earlier he would be able to pass on our view of what was happening to the patient. ... I think the fact that things improved over time indicates that people were aware of the problems and were trying to address them as best they could.' [157]
126 John Mallone, father of Josie, told the Inquiry of her care at the BRHSC:
`About three weeks into her stay in ICU I think, a doctor who we had never seen before, a middle-aged man, came and introduced himself, I cannot remember his name, and said he was a consultant and went straight over to Josie's ventilator and said "That looks a bit low" and turned it up, almost doubled the pressure and increased the frequency by 50 per cent I think as well. The following morning she had a punctured lung. That was the thing that staggered me most. He just seemed to walk straight into the ward without consulting any notes or talking to anybody whatsoever, I still have no idea who he was, and just interfere with the treatment of a child who had been on quite a continuous routine for something like three weeks post-operatively at that stage, I think.
`Q. Who had been looking after the child, who had been in charge as you saw it in a practical sense until then?
`A. In the practical sense Dr Martin, he was the one who we saw most often and he would tell us that he had consulted Mr Wisheart about certain things and we also saw Mr Wisheart from time to time, but on a daily basis it was Dr Martin who was saying what treatment would be followed for that day. I am sure you are aware there are big wall charts that operate for 24 hours and when they would come round in the morning they would look at what had happened in the previous 24 hours and it would be Dr Martin who would say "Okay, I think we ought to do this for the next 12 hours", until the next ward round and so on.
`Q. This other doctor was interfering in Dr Martin's arrangements?
`A. So far as I know he acted entirely on his own initiative. I think they were shocked when she developed this pneumothorax I think they called it, punctured lung anyway.
`Q. What sense did you have of the treatment strategy being co-ordinated and organised, in a coherent sense?
`A. Apart from that one incident it seemed to be very methodical, that the doctors would meet with the nurses and the nurses would say what had happened to Josie since they had last seen them and they would look at the charts and they would look at the notes hanging on the end of her cot and then they would talk about it for a bit and then they would say "I think we ought to do this", it seemed to have a method to it, it seemed to be well organised.
`Q. Did you have different doctors coming round at different times; you have mentioned two ward rounds?
`A. I do not know, I cannot remember what their particular working hours might have been, but the person who seemed to be in overall charge was Dr Martin.' [158]
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