Annex A > Chapter 15 - Post-operative Care > The management of post-operative care
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The management of post-operative care
1 After paediatric cardiac surgery at the BRI, the practice was that the consultant anaesthetist [1] accompanied the child back from theatre to the Intensive Care Unit (ICU, also referred to in evidence as ITU) with the theatre nurse. He or she connected the child to the ventilator and ensured that the necessary drugs were being delivered correctly, and gave instructions to the nurse regarding these matters. The consultant surgeon usually arrived 10-15 minutes later [2] to discuss the way forward with the anaesthetist, and to make any changes to the continuing care if appropriate. [3]
2 The child was received by the senior ward nurse in charge and the ICU nurse who was to look after the patient, who would be given relevant information about the operation performed, any problems encountered, the present condition, and treatment to be given. [4]
`The children always had one nurse per shift, per 24 hours, to care for them. This was always a senior staff nurse or above and NEVER a nurse in training.' [5]
If the patient was very ill, then two nurses per shift were required. This was usually where the child required renal support in addition to ventilation and cardiac support.
4 Mr Roger Baird, consultant general surgeon, described the distance between the cardiac wards and the operating theatre:
`Q. Am I right in thinking that the operating theatre was two floors below the ITU used for cardiac services?
`A. At that time it was. Today they are on the same floor.
`A. Then they were two floors apart.
`Q. And access from one to the other by means of a lift?
`Q. And once one got up to the floor where the Intensive Care Unit was, a distance to be pushed along a corridor before one got to the ICU?
`A. Yes.' [6]
5 Dr Susan Underwood, consultant anaesthetist, spoke of the journey from theatre to ICU. She was asked if this compromised the health or safety of patients:
`A. No, I do not think so specifically. I think because we knew that the journey was long and potentially hazardous, we would not embark on it until the patient was quite stable, so that in moving a sick patient from the operating table to the cot or the bed, there may be some instability in a very sick patient, but then you would not move out of the theatre until you had overcome that period and then you would move to the Intensive Care Unit. There was never any pressure to press on with the next patient if the patient was not fit to make the journey, because everybody understood that you must not set out on the journey unless it was going to be made as safe as possible.
`Q. Did you move directly from theatre to the ITU or was there a room immediately outside theatre where you would stabilise the patient after surgery?
`A. No, you would stabilise in the theatre and then move up to the Intensive Care as one journey.' [7]
6 Dr Sally Masey, consultant anaesthetist, explained the nature of the surgical and anaesthetic presence in the ICU during the period 1984-1995. Her evidence included this exchange:
`A. During that period there was a resident Senior House Officer in surgery and also a more senior surgeon, Registrar or Senior Registrar level, who was not necessarily resident but would sleep in the hospital if there was considered a reason to be so.
`Q. You say "not necessarily resident". You mean not ordinarily resident; not a full-time resident Registrar?
`A. He was not expected to be resident. It was not in the contract to be resident.
`Q. So the usual position would be that the resident Senior House Officer in surgery would be the permanent presence in Intensive Care?
`A. During the whole 24 hours. During the working day there was also an anaesthetist of Registrar or Senior Registrar level who was designated to be on the Intensive Care Unit.
`Q. And at night what was the position for anaesthesia?
`A. At night that Registrar or Senior Registrar was not resident.
`Q. So what was the anaesthetic cover in Intensive Care at night?
`A. The anaesthetic cover was from home both for the trainee anaesthetist and the consultant anaesthetist.
`Q. And so you would have, I imagine, some provision in your contract that you must live within X miles of the hospital, something of that sort?
`A. I believe my contract states a mileage, although I think some contracts now or in certain parts of the country state a time within which one should be able to get into the hospital rather than a mileage.' [8]
7 In their report in 1995 Dr Stewart Hunter and Professor Marc de Leval [9] commented that:
`The overall post-operative management at the Royal Infirmary appears to be less organised with multiple decision making processes between the surgical Senior Registrar and the SHO who do rounds at 8.00 am, the anaesthetists who see the patients at 9.00 am and the intensivists who work three days a week.'
8 Mr Wisheart commented on this criticism. He told the Inquiry:
`I have to say that I was shocked when I read this, and I did not recognise the Intensive Care Unit that I worked in, and have done for many years. I recognise that everybody did not always, at the first word, agree with everybody else, but nearly always, after proper discussion, agreement would be reached. I actually refrained from any comment - well, pretty well any comment - to anybody on this, until very recently, when I read in the transcripts of these proceedings that this remark was based on the evidence of one person only to Mr de Leval and Dr Hunter. That is the evidence of Fiona Thomas. In fact - I am not really wishing to criticise Mr de Leval or Dr Hunter, because they had a very limited time to carry out their inquiry, but they did state quite clearly that they did not take evidence on this point from anybody else. All I knew was that they had not taken evidence from me on this point, but I did not know who else. So I would simply draw your attention to that. I think that, therefore, this conclusion is not based on canvassing a broad spectrum of opinion.' [10]
9 Mr Wisheart confirmed, however, that during the period of the Inquiry's Terms of Reference there was no `common ward round' [11] carried out by the surgeons and the anaesthetists together. He told the Inquiry that the surgical senior registrar and SHO would do their rounds at 8 am, before theatre, in addition to which:
`There would always be a Senior House Officer who was present 24 hours a day, and there would normally be a Surgical Registrar who is not in theatre and who would be available for discussion. And of course, all the consultants are not in theatre at the same time, so some of those would also be available for discussion. I would normally see the case when I came in and that might be 8, 8.30 or 9, depending on whether I had a meeting, so I would normally pick up anything that they had left for me or endorse what they had done or whatever somewhere between 8 and 9 o'clock.' [12]
10 Mr Wisheart confirmed that the anaesthetists would do their ward round at 10.30 or 11, at which time a surgical member of staff:
`... would be present on the ward but he might or might not be physically with the anaesthetist doing their ward round; he might well have other things that he felt he had to do. By the same token, the anaesthetic registrar was present in intensive care at 8 o'clock when the surgical team were doing their ward round and would be available for discussion with the surgeons, so that the opportunity to liaise was certainly present.' [13]
11 Mr Wisheart was asked whether it was easy to co-ordinate the care in the ICU. He explained that there was:
`... a cardiac surgical Senior Registrar, or Registrar, who are available at all times to intensive care. ... the cardiac SHO ... was just the person who was there, and indeed, one of his functions stated explicitly in the "red book" [14] that has been referred to was to ensure that if somebody came at one time and somebody else came at another time, they would be aware of each other's suggestion and advice in the event that it was not written down. So he was very much a co-ordinator, a person who did things that people more experienced than himself advised him to do, or he helped the more experienced person to do it. Then, of course, the consultants involved were actually frequently in intensive care, as operations, outpatients, whatever commitments, permitted. They would be in and out. They were keeping a careful eye and offering their advice, because things change and evolve and it is necessary to do so. So I would regard this as an incomplete picture. I would not claim it was ideal, and the basic reason it was not ideal is that not all of the members of the team were totally committed to either cardiac surgery or paediatric cardiac surgery. Some members of the team had commitments elsewhere, and that was quite a major difficulty, and one of the things we had been seeking to overcome.' [15]
12 Mr Dhasmana was asked to comment on evidence he gave to the General Medical Council (GMC) [16] in which he had said of the paediatric work being done at Bristol that, having worked in Great Ormond Street, and having seen centres like Chicago and Alabama, he felt that Bristol was `at a very low, primitive level ... either because of the facilities, or theatre, or ITU, or availability of beds'.
He told the Inquiry that these comments related to the position in 1984 and 1985 when he was a senior registrar:
`There was only one surgeon doing the paediatric work, Mr Wisheart, and I thought for a centre to work in that type of facility with one surgeon working - and if I remember it correctly, our ITU was not big enough, really, to accommodate more than one patient - I may be wrong - one paediatric patient at that time. You had to juggle with your adult list to fit in the paediatric cases, and I was uncomfortable with some of the waiting list that some of the children were really going through. ... Maybe "primitive" was a little bit too harsh on Bristol, really. ... I would say, if not "primitive", I would say it was at a lower level, really; it was not very high up, even on my scale.' [17]
13 Dr Stephen Pryn, consultant anaesthetist and intensivist, told the Inquiry of his overall impressions of the cardiac surgical unit at the BRI when he was appointed as an intensivist in August 1993:
`It was a unit that was often run minute by minute by relatively inexperienced doctors, with their senior cover not being that available, and it was a unit run by trainees who were not used to general intensive care issues, were quite familiar with managing the cardiovascular system, but were relatively poor at integrating that with the other systems, for instance, the respiratory system. ... Their background was not in general intensive care.'
He told the Inquiry that he felt that there needed to be more input from a general intensive care background, and that senior cover needed to be more available, and agreed that it was an awareness of this that had fuelled the appointment of himself and of Dr Ian Davies. [18]
14 Dr Stephen Bolsin, consultant anaesthetist, was asked whether the situation in ICU ever became so critical that he refused to anaesthetise any more patients because of the problems in ICU. He said:
`I do not think that specific decision was ever made by me, but I think a parallel decision was sometimes made by the surgeons where they would cancel a paediatric case in order to do an adult case because there were already critically ill children on the Intensive Care Unit. Whether that was because there were not enough paediatric nursing staff to go round, or whether it was because they were worried about the human resources and medical resources available, I am not sure.' [19]
15 Mr Wisheart suggested that the problems perceived by the Hunter/de Leval report might have been a result of the team increasing in size over time. He said:
`I believe that historically there was close teamwork, and if we went right back to the beginning of the period of this review, in 1984, there were just two anaesthetists working in paediatric cardiac anaesthesia and they, of course, were unable to have the continual presence that the five or six or whatever number of anaesthetists provided in the 1990s. Interestingly, by their personal commitment and a feeling of being a member of the team, it was actually quite easy to co-operate with them, to get their advice, and there was always a clear knowledge of who to go to. It may be that some of what has been reflected to you is a consequence of the team increasing in numbers and the fact that in some areas of work somebody was responsible on Wednesday, but it was somebody else on Thursday and somebody else again on Friday. It is against that background that the surgeons I think felt not less but more of a pressure to maintain a continual interest, and they had to deal with the differing notions that people might have had on Wednesday, Thursday and Friday, and tried to work that into the system. But I do actually still feel - and I do not want any misunderstanding to come from my remarks - that the commitment of the people who provided that service in the 1990s, I mean, by and large was terrific. I did not, myself, sense that there was any lack of a feeling of being on the same team with them in this area in theatre and so forth.' [20]
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Footnotes
[1] Together with a senior registrar anaesthetist, a Senior House Officer (SHO) surgical team member and a surgical registrar
[2] Unless the child was very ill, in which case they arrived with the child
[3] WIT 0114 0087 Fiona Thomas. Fiona Thomas worked as a nurse on Ward 5 from 1986, became a G grade Sister from 1988, and became Clinical Nurse Manager of Cardiac Surgery from 1992
[4] WIT 0213 0040 Julia Thomas. Julia Thomas was Sister in charge of cardiac surgery, ICU from 1982 to 1988, and Clinical Nurse Manager of the Cardiac Unit from 1988 to 1992. She is now a G grade Sister
[5] WIT 0213 0040 Julia Thomas (witness's emphasis)
[6] T29 p.103 Mr Baird. See Chapter 9 for a diagram showing the departmental relationship at the BRI
[9] PAR1 0008 0118; `Visit of Cardiac Services Directorate of the United Bristol Healthcare NHS Trust 10 February 1995'. The visit and the report are dealt with in detail in Chapter 30
[14] UBHT 0152 0008 - 0098 ; `Bristol Royal Infirmary Cardiac Surgical Unit - A Notebook for Members of the Team.' This was last updated in 1988, and was described by Dr Pryn at WIT 0341 0007 as `... a set of guidelines for the management of patients, both adult and children, undergoing cardiac surgery'
[16] GMC transcript day 42 p. 19