Annex A > Chapter 24 - Concerns 1989 > Concerns
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Concerns
1 In 1989 Dr Stephen Bolsin approached Professor Cedric Prys-Roberts, Professor of Anaesthesia at the University of Bristol, about his (Dr Bolsin's) developing concerns. In oral evidence Professor Prys-Roberts indicated that while he was unable to give a precise date:
`I can remember clearly the encounter in 1989 because Stephen Bolsin had only recently been appointed.' [1]
2 Professor Prys-Roberts stated in his evidence that Dr Bolsin:
` ... expressed his concerns to me about problems in managing small babies following cardiac surgery by Mr Wisheart. He was concerned that the mortality in this group of patients was much higher than he had been accustomed to as a Senior Registrar at the Brompton Hospital, in London. I advised him that rather than create waves with little credible evidence, he would be better advised to collect prospective data on babies and children who he anaesthetised for cardiac surgery in Bristol, so that he could develop a clearer picture of what was going on.' [2]
3 In oral evidence Professor Prys-Roberts confirmed that Dr Bolsin's concerns were `based on his experience of anaesthetising patients'. [3]
4 Asked about the phrase `create waves', Professor Prys-Roberts said:
`Steve was a person who wanted to broadcast everything and make the whole world aware of what was going on right from the outset. He was not somebody who was introspective about these things. My concern at that stage was that he would say something which he might later regret without having the evidence to back it up and I suggested to him - because I think this is proper medical practice - that what he should do would be to keep records of what he was doing so that at a later date, if things turned out to be as they certainly have done, he would have evidence in the form of a logbook, in the form of other data that he may have collected on a prospective basis, but this was a personal thing. We all keep - I say ``we all'', I keep a personal logbook of every anaesthetic that I give and I follow up the patients. I think this is proper medical practice and I was advising Steve to do the same.' [4]
5 Dr Bolsin said that he could not remember the date of the 1989 meeting but speculated:
`I suspect it may have been possibly at the time of the Annual Report, or something like that.' [5]
6 Dr Bolsin issued a report of his first year in post on 18 September 1989. [6] He said:
`... I think that what I was interested in, in the Annual Report, was producing a mechanism whereby we could all constructively review results as they were presented on, let us say, an annual basis, and I think that one of the things that I would have expected, the kinds of meetings that I had outlined as being required in that first Annual Report would have been, ``Let us look at bypass times and cross-clamp times and see how they compare with neighbouring centres or centres somewhere else''. So I was looking for a framework of acceptability, I was not looking at a hostile document that was going to point up all the serious shortfalls in the Unit as I saw it, because I did not see that as being necessarily a constructive stage at the end of the first year of my contract.' [7]
7 He described the development of his concerns:
` ... which would have included some mortality data and I suspect probably the report for 1989/90 which you have just shown us, which would have, I think, probably confirmed the concerns that I had. I think what developed in Bristol, in my mind, was the perception of a service that was under-achieving in terms of the outcomes that it should have expected for its paediatric cardiac surgical operations, particularly in the under-1 age group. That was not something that came as a flash of light, it was not a sudden examination of a statistical table, it was not suddenly looking at confidence limits not overlapping; it was a gradual growing awareness of a potential or real problem.' [8]
8 In a letter dated 27 September 1989 Dr Robert Johnson, consultant anaesthetist and Chairman of the Division of Anaesthesia, acknowledged the report and offered support to Dr Bolsin on matters such as `... combined morbidity and mortality meetings between anaesthesia and cardiac surgery'. [9]
`... throughout my training I had kept a logbook of the patients that I had anaesthetised. I now began to record the outcomes on the patients that I was anaesthetising in the cardiac surgery unit in order to attempt to find the nature of the problem (if there was one) in the results of paediatric cardiac surgery. The audit commenced in September 1989 and provided some initial assessment of the mortality rates for operations within the paediatric cardiac surgery unit.' [10]
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Footnotes
[1] T94 p.1-2 Professor Prys-Roberts
[2] WIT 0382 0002 Professor Prys-Roberts
[3] T94 p.3 Professor Prys-Roberts
[4] T94 p.5 Professor Prys-Roberts
[6] UBHT 0061 0011 - 0017 ; `1st Annual Report of Dr SN Bolsin'. (This was the only such report issued)
[9] UBHT 0061 0018; letter from Dr Johnson to Dr Bolsin dated 27 September 1989
[10] WIT 0080 0108 Dr Bolsin