Annex A > Chapter 22 - Concerns 1987 > Concerns
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Concerns
Concerns expressed in Wales
1 In the late 1980s the Children's Heart Circle in Wales (CHCW) had taken a lead in advocating to the Welsh Office the development of a comprehensive paediatric cardiac service in Wales.
2 Mr Peter Gregory, of the Welsh Office, wrote a minute for Ministers in which he described the Heart Circle as:
`... the Welsh arm of a national organisation representing the interests of parents of children with heart complaints and the patients themselves. It is well known for its charitable works and, through the Trust for Sick Children in Wales, is much involved in fund raising for the parents' accommodation to be built in association with the paediatric cardiac unit in Cardiff. The CHCW is not very cohesive, lacking a strong central focus, and its members are highly motivated people (most of them have children with heart problems). Accordingly, the CHCW is a volatile and outspoken Group and one heavily influenced to their way of thinking by clinicians in the cardiac unit in Cardiff.' [1]
3 Mr Gregory added that the CHCW had been:
`... alleging that Welsh Office Ministers are dragging their feet about the provision of the paediatric cardiac unit and that, in an attempt to cut its cost, the highly specialised cardiac surgery for the newly born and children under 1 year has been dropped'. [2]
4 In May 1987 Mr Neil Hall wrote a report for the CHCW entitled `Meanwhile our Children are Dying'. [3] The report supported the creation of a paediatric cardiac surgery unit in Cardiff. The report also included remarks about the paediatric cardiac service in Bristol:
`... a degree of concern has been expressed by independent, well-informed sources about the standard of operations carried out at the receiving centre at Bristol. It has been suggested that this concern is widely held. If we consider the referral practices of doctors in Wales now and in the past, it is apparent, at least, that doctors without a vested interest in any particular receiving centre (they used to work there, for example) are less inclined to refer to Bristol than might be expected, given that it is much nearer than any of the other centres. Some parents have actually asked that their children not be referred to Bristol for surgery, preferring to travel to London. It has also been suggested that, in other areas, cases that might have been appropriately referred to Bristol have been referred elsewhere. In the absence of other explanations, these observations seem to confirm the suggestions that concern is widely held. It cannot be stressed too strongly, however, that such information in no way represents "hard evidence" and the author does not suggest that it does. Nevertheless, in view of the critical nature of its subject matter, and the increasing likelihood that cases from Wales will be referred to Bristol ... sufficient concern has been expressed for questions to be asked.' [4]
5 Mr Gregory described the report in his minute for Ministers as: `a highly partial, very emotive, frequently inaccurate and barely concealed piece of journalistic propaganda'. [5]
6 Dr Hyam Joffe told the Inquiry that Mr Hall's report contained `extraordinary and outrageous statements' about Bristol. [6]
`... the Heart Circle itself decided to reject the document as coming from them as a Group, and that it was Neil Hall's own specific view.' [7]
8 On 16 June 1987 BBC Wales broadcast a television programme entitled `Heart Surgery - the Second Class Service'. In the course of the programme's support for a paediatric cardiac surgery unit in Wales, criticisms were made about Bristol. In particular, Mr Hall said in interview:
`We have heard - always off the record - from a number of informed sources that questions ought to be asked about the standard of care that Bristol could provide ... observation of the referral practices of doctors in South Wales and in Bristol's own area would seem to confirm that there are reservations within the specialist field of paediatric cardiology about using Bristol in the future as a regional centre for South Wales.' [8]
9 In the course of interviewing Mr John Gray, then Administrator, Legal Services, Bristol & Weston District Health Authority (B&WDHA), the interviewer suggested that the Bristol Royal Infirmary (BRI) was not receiving patients from Wales because of doubts regarding the service.
`Different consultants decide to refer patients to different parts of the country for various reasons and because a consultant in this region decides to send a patient elsewhere does not mean that he is criticising our Unit, it may be that the patient has had previous investigations or that that consultant or general practitioner has personal links with another centre and wants to send the patient there.' [9]
11 To the observation that `Consultants have told us they wouldn't send their own children there', Mr Gray replied:
`Well that's not the view of independent assessors. Independent assessors have looked at the results of this Unit and found that each year is average and above average in many respects. Its mortality is very low and it has been considered by the supra regional committee to be a very good unit to develop for a supra regional purpose.' [10]
12 The Inquiry asked Mr Gray to comment on this interview and received the following response from the solicitors to the United Bristol Healthcare NHS Trust (UBHT):
`I refer to your letter of 6 May 1999 concerning Mr Gray's interview for BBC Wales in 1987. Mr Gray's comments are as follows. First, as you know, he no longer works in the capacity of the Trust's Public Relations Officer and ceased exercising those functions approximately five years ago.
`At the time, in 1987, Mr Gray states that he would have been supplied with a brief by the then Chief Executive Dr John Roylance. He then acted in the capacity of spokesman for the Health Authority, working from the brief he had been given. In essence, he said what he had been told to say. Therefore, his quoted comments do not reflect either independent knowledge or his personal views. Mr Gray has no absolute knowledge of this interview after all these years.' [11]
13 In response to the programme, Mr Wisheart, Mr Dhasmana, Dr Jordan and Dr Joffe wrote a joint (undated) letter to `the Editor', which took issue with the programme's comments about Bristol:
`Sir - In a BBC Wales television programme screened on 16th June 1987 on the subject of cardiac facilities in Wales, certain allegations were made about the standard of paediatric cardiac surgery in Bristol.
`These allegations are totally unfounded. In fact, the outcome for operations in children performed in this unit during the period 1984-1986 is equivalent to the UK national results for 1984 (latest available data), and better for certain conditions. This is true for both open- and closed-heart surgery, and for critically ill new-borns and infants as well as for older children. We wish to set the record straight and, particularly, to allay the anxieties of families whose children are currently being treated in Bristol, or may receive attention there in the future.' [12]
14 On 3 August 1987 the four clinicians also wrote a letter to Dr D Chamberlain, Chairman of the Cardiology Committee of the Royal College of Physicians. The Cardiology Group of the Royal College of Physicians had been asked by the Welsh Office to report on the development of cardiological services in Wales. The Bristol clinicians were of the opinion `it is inevitable that the work of our unit will be considered in the Inquiry'. [13] The clinicians wrote:
`... Firstly, it should be recognised that children with heart defects have been referred to Bristol from various parts of South Wales, especially from neighbouring Gwent, from as long ago as the late 1960s and early 1970s. There has been a steady increase in referrals since then, with a rapid rise in the number of neonates and infants needing acute attention since the designation of Bristol as a supraregional centre in 1984. Since the unfortunate death of Dr LG Davies last year, the Bristol paediatric cardiologists have been invited to run joint clinics locally and these are now held in Abergavenny, Newport, Haverfordwest and about to be in Swansea and Carmarthen. It is emphasised that these invitations were totally unsolicited; the initiatives have all come from the paediatricians in Wales and must reflect satisfaction with the service offered to the acutely ill patients, mainly infants, in the past.
`Secondly, it was the Welsh Office which made an approach to ourselves and the Bristol and Weston Health Authority to explore the financial and other implications of the provision of a supraregional service for neonates and infants. The medical and managerial staff of the Bristol and Weston Health Authority have expressed their readiness to respond positively to the Welsh Office recommendation, in the hope that a joint Bristol/Cardiff service could be developed appropriate to the population of the South Western Region and South Wales. Of course, final decisions about the provision of services for children in Wales must rest with the Welsh authorities and medical advisors, and we would agree that individual doctors should retain the right to make referrals to a unit of their choice, but we would expect any policy decisions to be made on the basis of fact and not misinformation ...
`Thirdly, and apparently related to the above recommendation, the Bristol Paediatric Unit has been subjected to a campaign of vilification, and the word is chosen advisedly, which we find quite extraordinary and very sad. To illustrate this, and without wishing to elaborate at this stage, the following is quoted from a document written under the auspices of the Welsh Heart Circle in Cardiff, who have no direct contact with Bristol, and circulated to the other local committees in Wales, which do include many families whose children have been treated in Bristol. Many of these comments were repeated verbatim in a television programme entitled "Heart Surgery - the second class service", screened on 16th June 1987 in the BBC Wales series "Week in, week out":
`"However, a degree of concern has been expressed by independent, well-informed sources about the standard of operations carried out at the receiving centre at Bristol. It has been suggested that this concern is widely held. If we consider the referral practices of doctors in Wales now and in the past, it is apparent, at least, that doctors without a vested interest in any particular receiving centre (they used to work there, for example) are less inclined to refer to Bristol than might be expected, given that it is much nearer than any of the other centres. Some parents have actually asked that their children not be referred to Bristol for surgery, preferring to travel to London. It has also been suggested that, in other areas, cases that might have been appropriately referred to Bristol have been referred elsewhere. In the absence of other explanations, these observations seem to confirm the suggestions that concern is widely held. It cannot be stressed too strongly, however, that such information in no way represents `hard evidence' and the author does not suggest that it does. Nevertheless, in view of the critical nature of its subject matter, and the increasing likelihood that cases from Wales will be referred to Bristol, sufficient concern has been expressed for questions to be asked."
`And later in the document, "Given the questions raised about surgery in Bristol, this" (the recommendation to use Bristol as a receiving centre) "is a very distressing development. The notion that any deficiency that might exist in Bristol would be attended to by practising on Welsh cases is not only ethically chilling but untenable." (The full document is available for perusal if required.)
`It is stressed that these sections form part of a long and highly emotive plea for improved paediatric cardiac services in Wales, which aim we would fully support, but it is nonetheless damning of Bristol for all that. The undermining effect on the trust and confidence which should exist between doctors and the parents of children who are or have been patients in Bristol can be imagined. In an attempt to counter the effect of the television programme, several aggrieved parents spontaneously wrote letters to the Welsh Press in support of Bristol. We, too, felt obliged to seek publication of a letter in the Welsh press, indicating that the allegations made against Bristol regarding surgical results are totally false. `A summary of the results in Bristol in the period 1984-1986 compared with national figures for 1984 (the latest available) is enclosed for your information.
`However, the most distressing aspect of this affair is the fact that much of the information in this document, including the allegations about the service in Bristol, emanates from "three consultant cardiologists of such qualification, experience and present position to be well placed to make such judgements". This was suggested in the document, but stated categorically by its author in a subsequent letter in reply to a parent. It seems, therefore, that this view is widespread and, we believe, based on ignorance of the facts, since there has been no recent inquiry into the actual status of the facilities (better than most, in our view) or the surgical results (which are at least equal to those achieved by other paediatric units). We can think of no motive, other than one of medical political gain, to account for this deliberate and calculated campaign to denigrate a supraregional unit which is showing sustained growth in the number of patients treated, a steady improvement in the results achieved, and which is highly respected in paediatric and other circles throughout the South West Region, and indeed, in most parts of South Wales ...
`Despite our sense of outrage, it was our wish that this issue should have been contained, but it must now be brought to your attention since you and your committee are bound to be given various opinions regarding the Bristol service during your forthcoming investigations in Wales. There is also the risk that the adverse publicity already given to the Bristol service will be spread further and it is, naturally, our wish that this should be avoided and that any potential conflict between medical colleagues should be settled within the profession, if at all possible. We believe that the issue should be resolved on the basis of facts, and hope that you and your committee will use your good offices to this effect. From our part we are keen to provide you with all the detail you require, and would be happy for you to send a copy of this letter to Professor A Henderson if you wish.
`We should like to invite you or your representatives to visit Bristol to see what the facilities are like and to establish the facts. We look forward to hearing from you and hope that your intervention will facilitate a satisfactory resolution of this problem.' [14]
15 Dr Joffe was asked about the joint letter of 3 August 1987 and told the Inquiry:
`Yes, I wrote this letter ...'. [15]
16 He went on, in the following exchange:
`Q. Did you think that somebody in the Bristol Unit was possibly passing information to others?
`A. No, I do not believe this was based on Bristol information.
`Q. This was somebody within the medical world?
`A. Yes. ... I cannot point a finger, I have some ideas, but I am unable to point to an individual or several individuals.' [16]
17 Dr Joffe was asked by Counsel to the Inquiry about some of the claims made for Bristol in the letter of 3 August 1987. In particular, he was asked about the claim that Bristol's surgical results were `at least equal to those achieved by other paediatric units'.
`I believe, to be honest, that that was a partial overstatement on my own part because of my passion at the time. But I believed that they were in fact roughly equal to those of other units using the relatively imprecise data that we had at our disposal at that time, and that was the belief in the Unit, I believe, that we were doing pretty well the average of what others were doing but there were a couple of conditions, two or three maybe, where we were not doing as well as we felt we ought to.' [17]
19 Dr Joffe also told the Inquiry that:
`It was at that time, 1987, that Mr Wisheart talked to me on one occasion, as I think I put it in my statement, on the way back from a joint clinic in one of the centres, probably Exeter, that we had got to the point where we needed to move up a gear in order to improve the service and that the means of doing so was to appoint a full-time paediatric cardiac surgeon and that the opportunity might become available through funding from the British Heart Foundation of a Chair in Bristol which he at no time thought otherwise than that it would be allocated to a children's paediatric cardiac surgeon.' [18]
20 Mr Dhasmana told the Inquiry that in his view the criticisms of Bristol from those in Wales were made as part of a determined campaign to establish a paediatric cardiac centre in Cardiff. He told the Inquiry:
`... the problem in a way was that there were too many cardiologists coming from different parts of the country running their clinic in Wales, and I felt they came out a bit more aggressive in 1986 in order to establish their unit. That is my personal feeling: to attack the nearest and closest to get their own service, really. And I feel that that was probably the emotive part behind all these things. We in Bristol always supported a move to Cardiff - to facilitate their development of paediatric cardiac surgery, but at the same time, were anxious that we are so close by, there are not so many cases, we would have to support each other.' [19]
21 Dr John Roylance, District General Manager of the B&WDHA at the time, told the Inquiry that he had no memory of the letter of 3 August 1987 nor the events to which it related: [20]
`... I think if this had been brought to my attention at that time I would remember it now and I have no memory of it at all.' [21]
22 Mr Wisheart wrote to Mr Gray on 22nd December 1987, sending copies to Dr Jordan, Dr Joffe and Mr Dhasmana. He referred to a letter from a solicitor, Mr Robert Johnson, to Mrs Bennett of the CHCW of 16th June 1987. [22] Mr Wisheart's letter stated:
`The tenor of that [Mr Johnson's] letter is that while proceedings against the Heart Circle are possible it is not our wish, and in order to enable us not to take proceedings against them we require the following:-
`(i) that the paper is amended;
`(ii) that we are told to whom the paper was circulated, and perhaps most importantly an expression of our concern that the parents of children in Wales due to be operated in Bristol will have their confidence in the service undermined. One must add to that that Mr Hall, either in his personal capacity or on behalf of the Children's Heart Circle in Wales, used some of that defamatory material in the BBC programme screened on 16th June 1987. Bearing in mind these basic considerations, the letter [in reply] dated 13th November seems to be severely deficient, in effect it is saying that the references to Bristol have been omitted and that it was not publicly distributed. I believe therefore that they need to be reminded that what we are still trying to do is to avoid taking legal proceedings against them and that in order to do so they need to be much more frank about the distribution of the paper. It is certainly our understanding that unless the committee includes a very large number of members of the Heart Circle its circulation was not restricted to the committee and we need them to provide us with names and addresses. I believe they should also be challenged with the fact that this material was used on the BBC programme, and that whether Mr Hall was acting personally or on behalf of the committee, he was using material which the committee had asked him to compile. Finally, they have made no suggestions as to how to counteract any undermining of confidence which might have taken place in the minds of parents in Wales. In all I think that further pressure should be brought on them to take this a good deal more seriously than they have done to date.' [23]
23 Dr Roylance told the Inquiry that he was not aware at the time that legal advice was being sought in relation to a possible action for defamation. He said:
`I am quite calm in not knowing about it. Saying whether I expected to know about it, no, I think the legal department worked closely with doctors on professional matters and I would only be invited to involve myself if it became a managerial issue.' [24]
24 Dr Roylance went on to say that if it came to the point at which there was a need to commit resources (for example, money to fund a legal action) then:
`... I think I would have been told ...'. [25]
`... I do not think this in fact is a letter about the hospital taking umbrage but about clinicians taking umbrage about what is said about them. I certainly was not advised to address the view that the hospital was being improperly maligned.' [26]
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Footnotes
[1] WO 0001 0315; minute dated 18 August 1987 from Mr Gregory to Ministers
[2] WO 0001 0315; minute dated 18 August 1987 from Mr Gregory to Ministers
[3] WO 0001 0361; `Meanwhile our Children are Dying'
[4] WO 0001 0361; `Meanwhile our Children are Dying'
[5] WO 0001 0315; minute dated 18 August 1987 from Mr Gregory to Ministers
[8] `Heart Surgery - the Second Class Service', BBC Wales 1987
[9] `Heart Surgery - the Second Class Service', BBC Wales 1987
[10] `Heart Surgery - the Second Class Service', BBC Wales 1987
[11] UBHT 0349 0010 UBHT
[13] UBHT 0133 0029; letter dated 3 August 1987 to the Royal College of Physicians from the Bristol cardiologists
[14] UBHT 0133 0029 - 0031 ; letter dated 3 August 1987 to the Royal College of Physicians from the Bristol cardiologists
[22] A copy of that letter was not available to the Inquiry: Mr Johnson of Osborne Clarke, solicitors, was writing on behalf of the cardiologists