Annex A > Chapter 25 - Concerns 1990 > Concerns
<< previous | next >>
Concerns
Concerns raised by Dr Stephen Bolsin
1 Dr Bolsin, consultant anaesthetist, agreed that his memory for dates and details was not always reliable. [1] He thus could not give the Inquiry any certain date at which he began to gather data about the paediatric cardiac surgical services.
2 Dr Brian Williams, consultant anaesthetist and Chairman of the Division of Anaesthesia 1990-1992, referring to a meeting between himself and Dr Bolsin in the summer of 1990, stated in his written evidence to the Inquiry that Dr Bolsin: `had no data at the time'. [2]
`... there was the 1989 [3] data, which indicated that we had twice the national average mortality, and it became apparent that there was a possible link between what I had observed as a distinct comparison between the Brompton and Bristol performance and a mortality rate and we then needed to start to look at what were the operations in this mortality rate in which we were achieving a higher mortality rate.' [4]
4 On 7 August 1990 Dr Bolsin sent a letter to Dr Roylance, then the District General Manager, Bristol & Weston District Health Authority (B&WDHA). [5] The second and third paragraphs of this letter dealt with statements which Dr Bolsin considered to be misleading in the appendix to the application for trust status made by the United Bristol Hospitals (UBH). In the fourth paragraph, Dr Bolsin wrote:
`Finally, as a paediatric cardiac anaesthetist, I would have thought that the management directive to improving quality of patient care should have attempted to address the unfortunate position of the South West Regional Cardiac Centres' mortality for open heart surgery on patients under one year of age. This, as you may or may not know, is one of the highest in the country, and the problem should be addressed.'
`I look forward to your reply, which I hope will help to persuade me of the benefits of Trust status for the Cardiac Unit.' [6]
6 Dr Bolsin was asked whether, in writing this letter, his purpose was to question Dr Roylance on some of the aspects of the application for trust status. Dr Bolsin replied:
`I think it is more specific than that. What I am actually doing is saying: "You have made some statements in a document which is an appendix to an application for Trust status and deals specifically with cardiac surgery. I am an anaesthetist who has a particular interest in cardiac surgery. I think there are 2 wrong statements in the appendix and I also want you to know about another problem".' [7]
7 Dr Bolsin emphasised that the letter related to paediatric cardiac surgery, rather than being purely a response to the application for trust status. He said: `... it is all in the context of the application for Trust status with specific respect to the Cardiac Unit'. [8]
8 Dr Bolsin said that, by using the phrases `to address the unfortunate position' and `the problem should be addressed', the letter was asking for specific action to be taken over `the problem' with paediatric cardiac surgery. He expected Dr Roylance to confirm whether the allegation was true and then indicate any specific ways in which it could be resolved: [9]
`I think it [the letter] actually asks for a solution to a raised concern. Yes, there is a problem, or there is a perceived problem of a mortality rate in paediatric cardiac surgery in the South West Regional Cardiac Centre, and I think it should be addressed. So it is more than raising a concern, it is actually saying, "I think you should do something about this, please".' [10]
9 Dr Bolsin said that this was especially the case as he requested on two occasions in the same paragraph that the problem be addressed, thereby emphasising the request. [11]
`I think my expectation at that time was that this concern which is being raised - which is about a serious problem; it is not the length of a scar or the duration of a hospital stay, this is about the most serious outcome for a medical intervention - should have been taken up by somebody at the Executive level and they should have put it out on the table and said, "Okay what is the reality behind this concern?"
`... I think I would have expected possibly the cardiologists, probably the surgeons, possibly the anaesthetists, with the General Manager as he was then, or another independent person, to have said, "This is a very serious allegation, let us have a look at the results and see if there is any justification in the comment that is made".' [12]
11 Dr Bolsin said that he believed that, having had a chance to review all the documentation, he had seen the data from the 1989/90 Annual Report before writing his letter. [13] He therefore had the relevant information to make specific reference to the problem of excess mortality in the letter:
`I believe that what I am saying to the Chief Executive is not, "I cannot get any information", because that request is not made in the last paragraph; what I am saying to him is, "There is a problem and I have seen evidence of a problem, and I have seen evidence of a problem in the under-1 age group", and I am also saying, "You must address this problem".' [14]
12 Dr Bolsin addressed the letter to Dr Roylance, and sent copies to various others, probably on the advice of Dr Trevor Thomas, a consultant anaesthetist at UBH and Chairman of the Medical Audit Committee. [15]
`... a letter which Dr Bolsin was writing principally to point out deficiencies or errors in the application for Trust status.
`That was the primary purpose of the letter. I know that Dr Bolsin had been disappointed in not getting some equipment which he mentioned specifically in the letter, so he brought me the original to look at.' [16]
`He showed it to me and said he was going to send it to the Chairman of the Health Authority, and did I think that was right or an appropriate destination for it.
`I advised him on that draft. I changed the English a little and I said that since he was primarily concerned with the Trust status application, the letter should go to Dr Roylance who was the Executive [17] and who was in the process of putting together the application or who had put together the application for Trust status. [18]
`... I also advised him that he should send a copy to the then Chairman of the Health Authority, Mr Mortimer, because he had included as his final paragraph or sentence, a comment on the mortality ... for open-heart surgery on patients under 1 year of age.' [19]
15 Dr Thomas said that by addressing the letter properly, Dr Bolsin was pursuing the correct path in that he was discussing the matter with colleagues:
`He was alerting the District General Manager and the Chairman of the Health Authority, and so the people who could address the problem had been informed of it.' [20]
16 One of the parties to whom a copy of the letter was sent was Mr Christopher Dean Hart, a consultant ophthalmologist, as the Chairman of the Hospital Medical Committee. Mr Dean Hart stated in his written evidence to the Inquiry:
`I heard of no complaints or anxieties about cardiac surgery in Bristol in the course of Trust Board meetings. Nor had I previously at Health Authority meetings which I had attended. I am certain that had I done so, or had Dr Bolsin come to me with his concerns, I would have taken action, just as I had in other difficult cases where clinical performance had been in question. Dr Bolsin did not directly mention to me his specific concerns about the results of paediatric cardiac surgery at any time, whilst I was Chairman of the Hospital Medical Committee, or Medical Director, or subsequently.' [21]
`I believe that anybody receiving complaints about another colleague has an absolute duty to have the matter investigated.' [22]
`I was not aware at the time of anything that might have prevented a consultant expressing concerns about the performance of a fellow colleague; ... However, looking back on it, I can now see that it might have been a daunting proposition for a newly appointed consultant to have forced the issue of the surgeons concerned with the Chief Executive. I am only sorry that I was not consulted as Medical Director or Chairman of the Hospital Medical Committee.' [23]
`Within a short time of receiving the letter Mr Dean Hart telephoned me while I was working in cardiac theatres and asked to see me immediately. I left the operating theatre and met Mr Dean Hart in the medical staff coffee room in the Post Graduate Education Centre. He asked me what the meaning of the letter was and why I had written it. I explained that Doctor Trevor Thomas had helped me to draft the letter and was aware of the contents. I also confirmed that I was worried about the mortality rate for small children and babies in the BRI paediatric cardiac surgery unit. Mr Dean Hart explained that he had once been put in a similar situation as a junior consultant and that he believed I had been manipulated by a senior colleague.' [24]
`I believe that Mr Dean Hart has forgotten that he was consulted by a junior consultant, who did find it a "daunting proposition". Mr Dean Hart initiated that contact/consultation after I had sent a letter to Doctor Roylance and he had received a copy of that letter. ... as far as I know [Mr Dean Hart] undertook no investigation of the paediatric cardiac surgical performance.' [25]
21 Dr Bolsin also stated in his written evidence that the meeting with Mr Dean Hart concentrated on why he had sent the letter to Dr Roylance and the reasons for Dr Thomas' involvement:
`There was little recognition of a serious problem within the Department of paediatric cardiac surgery but there was much more concentration on a possible high-level game of medical politics involving me as a pawn.' [26]
22 Mr Dean Hart subsequently accepted, in his written comment on Dr Bolsin's statement, that he must have met with Dr Bolsin at the time, but stated:
`If Dr Bolsin had been very concerned at the time that I should be properly briefed about his concerns about paediatric cardiac surgery, then I think that he might well have considered using a stronger line of approach. A copy letter to two other colleagues, where the matters raised were in the last paragraph of a three paragraph letter mainly about his opposition to Trust status, did not suggest that the matter was the prime issue of his letter, but rather that it provided additional support on his views on Trust status.' [27]
Mr Dean Hart added that, had he wished to criticise Dr Bolsin, he would have seen him in his office at the Bristol Eye Hospital, rather than in the open, public forum of the Postgraduate Education Centre, which `... was not a venue for other than relaxed conversation'. [28]
23 Dr Bolsin agreed that the meeting was `relatively amicable', although he said that he was very much ordered out of theatre and was `in some dread' as to what might be said to him. He also agreed that since the meeting was held in the common room, there could well have been other people around, but said that in fact there were not. Dr Bolsin did not accept Mr Dean Hart's point that it was not the sort of forum in which he would expect to be criticised. [29] He stated:
`My disappointment was that he did not really take the concerns expressed in the letter seriously, and I think that that was again possibly a failing of mine in not saying to him, "Well, actually, Mr Dean Hart, you have completely misread the letter and I have serious concerns". But I was not senior enough or confident enough to be able to take that role in that conversation.' [30]
24 Dr Bolsin explained that, in his view, Mr Dean Hart had misinterpreted the letter as being about opposition to trust status:
`... I do not think he has interpreted it correctly, because the letter was not opposition to Trust status, it was dealing specifically with the appendix to the application for Trust status vis-a-vis cardiac surgery, so it was not in general opposition to Trust status, which is unfortunately it seems the sort of "dustbin" it has been put into ... It was a very specific letter dealing with the appendix to an application for Trust status with respect to cardiac surgery. I would have said that putting those three paragraphs into a letter, sending it to the District General Manager, to the Chairman of the Hospital Medical Committee and to the Chairman of the Health Authority was a reasonably strong expression of a problem which needed to be addressed.' [31]
25 Dr Bolsin said that Dr Roylance dealt with the letter in a similar manner to Mr Dean Hart, reading it in the same way as being to do with the application for Trust status rather than expressing a separate concern:
`I think he [Dr Roylance] phoned me up, and took possibly a similar line to Dr Dean Hart that Trust status was going to be good for the unit or whatever, but did not really deal with my perception of the problems, which was that there was a higher mortality rate in the under 1 year old children in Bristol compared to the rest of the country.' [32]
26 Dr Bolsin said that Dr Roylance's tone of conversation was `dismissive', and thus he was not able to press his concerns:
`... I was not really in a position to be able to say "Hang on a sec, I really think you should call a meeting of everybody involved and we really have to go through these results". It was not that type of conversation. It was a very one-sided conversation to me in a cardiac theatre at the time and I did not have a lot of input ... .' [33]
27 Dr Bolsin said that this was the only contact which he had with Dr Roylance on the matter of his concerns about paediatric cardiac surgery until 1994. [34]
28 Dr Roylance was asked about the letter in his oral evidence in the following exchange:
`I rang Bolsin up and talked to him about this letter and I asked him to talk to the Chairman of the Medical Committee about its contents. I knew at the time of a widespread wish to appoint a paediatric cardiac surgeon and to consolidate the service at the Children's Hospital.
`I told Dr Bolsin, as I did everybody, I tried to tell them very honestly about the influence and the impact of Trust status, that Trust status would neither facilitate nor hinder our attempts to improve paediatric cardiac surgery.
`Q. You saw this as a letter about Trust status?
`A. It was about Trust status. I spoke to him about it. You have to read the final thing: "I look forward to your reply which I hope will help to persuade me of the benefits of Trust status for the cardiac unit". It was part of a quite massive consultation with the consultant medical staff.
`Q. In that last large paragraph, the one beginning "Finally ... ", he is describing the comparative mortality at Bristol and the rest of the country. Was he, did you know, right to say that the mortality of the under-1s in Bristol was one of the highest in the country?
`A. No, I was accustomed to this sort of exaggerated statement to support the improvements that individuals wanted. Please, I did talk to him. If I misunderstood this as anything other than a letter about the effects of Trust status, he did not disagree with me at the time and I actually - I know this was about Trust status.' [35]
29 Dr Roylance was asked in the following exchange whether the matter referred to in the fourth paragraph of Dr Bolsin's letter was a separate matter which needed to be addressed:
`A. Yes, but the final paragraph is saying he would like me to reply to these three things to persuade him of the benefits of trust status; that is the thrust of the letter, and the answer is that I could not tell him that trust status was going to address the final issue.
`The first two issues were exceptions he took to the application that we had circulated for consultation because the appendix which had been written by the operational services, in other words, the cardiologists and the cardiac surgeons had written those appendices and he took exception to what they said. I could not arbitrate on that. I referred him back to his colleagues through the Chairman of the Medical Committee.
`Q. The reference to a specific category, the "open heart surgery on patients under 1 year of age", might suggest there were figures available, might it not?
`Q. It is a specific category, it has been singled out for some reason?
`A. I do not follow that, I am sorry.
`Q. The suggestion that it is one of the highest in the country led to your saying to him as I understand it "take your anxieties to Mr Dean Hart, the Chairman of the Hospital Medical Committee and explore them there"?
`Q. You understood that there were separate anxieties, anxieties which went beyond the question and issue of Trust status that he was expressing, did you?
`A. I knew of the anxieties beforehand, I did not need a letter to know that there was a wish widely through the Trust, not involving everybody in the Trust, but widely in the Trust, a wish to improve paediatric cardiac surgery. He knew that and I knew that.
`His question is "Will Trust status change our ability to address that?" I told him it did not, we still had the same issue.' [36]
30 Dr Roylance explained in the following exchange that he did not ask Dr Bolsin for his evidence that mortality was `one of the highest in the country':
`A. Because we were discussing Trust status, not figures within paediatric cardiac surgery; that is the nature of the conversation. I have to say that he did not address the same issue to me again until halfway through 1995.
`Q. So you never thought because you took this letter as being about Trust status, that there was an assertion here in this penultimate large paragraph that needed either to be verified by statistics or figures or at any rate taken further by you?
`A. No, he did not ask me to, I mean, we were discussing at that stage solutions, not evidence to support solutions. What he actually said is "one of the worst". That meant to me - I am trying to find the exact words - "it is one of the highest in the country", "one of the highest".
`That suggests to me that there are several in the band of outcome as Bristol. In other words, we were one of those units. Of course he and I would always want us to be at the gold standard or above it. I mean I understood that and I understood the solution and he understood the solution.
`Q. You say the solution was a paediatric cardiac surgeon and the amalgamation of the sites?
`A. Yes, that was the advice I had at the time and I accepted it, yes.' [37]
31 Dr Bolsin described in his written evidence to the Inquiry the response which his letter evoked from Mr Wisheart:
`A couple of days later Mr Wisheart asked to see me in his office and when I went in I noticed my letter to Dr Roylance was on his desk. On the basis of this letter he proceeded to advise me that I would not be secure in my future in Bristol if I continued to take information about the paediatric cardiac surgery unit to outsiders and he considered Dr Roylance to be an outsider. The tenor of the meeting was of an angry Mr Wisheart rebuking a young consultant who had dared to complain about his unit outside unit Meetings.
`The effect of this meeting on me was to confirm my impression that I would not be able to take complaints about the performance of paediatric cardiac surgery through this route in future. This was a very lasting and deep impression on a young and impressionable consultant. There was little doubt in my eyes that Mr Wisheart was prepared to carry out his threats and this belief has been demonstrated to be justified by subsequent events.' [38]
32 According to Dr Bolsin, the meeting lasted about ten minutes or so. [39] Dr Bolsin told the Inquiry that:
`The tone of the meeting was that Mr Wisheart was very angry that a young consultant had taken results of the unit outside of the unit and expressed them to non-cardiac colleagues ...' [40]
33 Dr Bolsin referred to: `... a red-faced Mr Wisheart talking very angrily to me about the consequences of taking incidents outside the Unit'. [41]
34 Dr Bolsin said that he understood that in saying if he valued his career in Bristol he would not undertake `that type of action' again, Mr Wisheart was referring to raising concerns about results and raising them outside the Unit as two specific matters. [42]
35 It was Mr Wisheart's evidence that this meeting did not take place. [43] Dr Bolsin expressed the view that there was a possibility of some `corporate amnesia' beginning to develop about some of the events in the late 1980s and early 1990s, citing Mr Dean Hart's not remembering his meeting with him (Dr Bolsin) as an example. [44]
36 Dr Bolsin referred [45] to the evidence of Sister Kay Armstrong. This was in relation to a change of attitude she perceived between Mr Wisheart and Dr Bolsin. In her written evidence, Sister Armstrong said:
`I was aware, because Dr Bolsin told me, that when he first raised his concerns about our results there was a confrontation between him and Mr Wisheart, which is perhaps not surprising given the concerns that Dr Bolsin had. Dr Bolsin was subdued for a while after this. Although operations were always carried out in a professional manner, there was a frostiness between them both in threatre and there was not the usual "chit-chat" that they would sometimes engage in.' [46]
37 Mr Wisheart told the Inquiry that Dr Roylance did not telephone him, and neither did any of the others to whom copies of Dr Bolsin's letter were sent. [47] When asked whether he thought that the letter was an appropriate route by which to express the concerns raised in it, he replied:
`It was certainly a route. I would have thought it would have been appropriate also for him to raise it with his more immediate colleagues. I certainly would not dream of saying he should not have drawn it to the attention of Dr Roylance. I think what I would say is, I would have been surprised that he would have done that without drawing it to the attention of his more immediate colleagues, I think that would be the right way to put it.' [48]
38 Mr Wisheart confirmed that when he talked of drawing the letter to the attention of `his more immediate colleagues' he meant to his attention. [49]
39 Mr Wisheart told the Inquiry that, for his part, he had: `... absolutely no recollection of seeing this letter or any of the consequences that I have since become aware of that are stated to have followed it ...'. [50]
40 Mr Wisheart was asked about Dr Bolsin's account:
`Q. It is suggested by Dr Bolsin that indeed he did speak to you some time in the autumn after this letter was written and you were hostile to him with a copy of the letter on your desk, in effect telling him off for approaching matters in this particular way. That is his recollection; did it happen?
`A. I do not believe it did.' [51]
41 Mr Dhasmana, who at the time shared an office with Mr Wisheart, told the Inquiry that he had no knowledge of the letter and that Mr Wisheart was very open regarding matters which concerned the Unit. [52] Mr Dhasmana said:
`I believe if he had any concern with paediatric cardiac surgery, expressed to him directly or indirectly, he would have mentioned it to me.' [53]
42 In particular, Mr Dhasmana said that had Mr Wisheart received such a letter as the one from Dr Bolsin to Dr Roylance, he believed that Mr Wisheart would normally have discussed it with him. [54]
43 Dr Roylance told the Inquiry, in the following exchange, that he did not show the letter to Mr Wisheart:
`Q. Mr Wisheart was not one of the nominated recipients; did you send him a copy?
`Q. Did you tell Mr Wisheart of the letter?
`Q. Did you speak to anyone else as you recollect about that particular letter?
`A. I think the then Chairman of the Division of Anaesthetics spoke to me some time later, Dr Brian Williams.' [55]
44 The other two people to whom copies of the letter were sent were Mr Geoffrey Mortimer, as Chairman of the Bristol & District Health Authority (B&DHA), and Dr Brian Williams, as Chairman of the Division of Anaesthesia.
45 Dr Bolsin said that Mr Mortimer did not speak to him about the letter. [56] Dr Williams did. Dr Bolsin described Dr Williams' reaction:
`He was pretty horrified by the letter and wanted to know why on earth I had done it. He did not understand that I had spoken to Trevor Thomas about the letter before I had even sent it, and when I explained that, he still I think could not quite understand what I was doing sending off this letter. But I explained what was in the letter and he seemed more - I would not say contented, but he seemed to accept what I said.' [57]
46 In his written evidence to the Inquiry, Dr Williams stated that he `expressed concern' at Dr Bolsin's decision to send the letter without any prior discussion of the issues. Dr Bolsin had explained that Dr Williams was on leave at the time and that he had discussed the matter with Dr Thomas. [58] Dr Williams stated that:
`I confirmed my own and the Directorate's support for his objective to improve paediatric cardiac mortality, at the same time pointing [to] the difficulties we might face as a result of the somewhat confrontational style to his letter.' [59]
47 Dr Williams stated that he subsequently raised the subject of the letter directly with Mr Wisheart:
`When I met with Mr Wisheart he expressed annoyance at the content, style and distribution of Dr Bolsin's letter.' [60]
48 Mr Wisheart told the Inquiry that he had no memory of this conversation with Dr Williams taking place. [61]
49 Dr Williams further stated that he discussed the content of the letter with other cardiac anaesthetist colleagues, who also expressed concern at the level of paediatric cardiac mortality, and that he reported back to the Chief Executive, Dr Roylance, on the content of all his discussions. [62]
50 Dr Bolsin told the Inquiry that shortly after sending the letter, he was advised to keep a low profile, so far as raising questions about paediatric cardiac surgery in the way in which he had chosen was concerned:
`... in 1991, [at] a meeting of cardiac anaesthetists with the Director of Anaesthesia and the President of the Association of Anaesthetists, ... Dr Baskett, a cardiac anaesthetist, said "Steve Bolsin should not be the vehicle for criticism of the paediatric cardiac surgery service". Peter Baskett, who is a territorial army officer, actually said "Steve has to keep his head down. He has had enough flack from this letter", and Brian Williams and Chris Monk have to take this on.' [63]
51 Dr Monk told the Inquiry that the advice to Dr Bolsin was that the letter was an inappropriate way forward and one which had upset colleagues. [64]
`I cannot recall this letter being discussed at the meeting. The effect of the criticism of Dr Bolsin in raising it this way may well have been discussed and, therefore, Dr Bolsin's profile would have been higher than perhaps was thought suitable to raise the paediatric switch programme with Mr Wisheart.' [65]
`It was taken forward, and the task was given to Dr Williams and myself, as Liaison Consultant. The form in which it was taken forward was not discussed.' [66]
`My recollection is that no-one supported the way in which Steve Bolsin had raised the issue but all were fully supportive of his efforts to obtain appropriate data to assess the problem more accurately in an endeavour to improve results.' [67]
<< previous | next >> | back to top
Footnotes
[1] T80 p.3; T80 p.30; T80 p.140-1 Dr Bolsin
[2] WIT 0352 0026 Dr Williams
[3] This was not available within the Unit until after 31 December 1989. Dr Bolsin must therefore have been talking of a time which at the earliest was in 1990
[5] UBHT 0052 0290; also UBHT 0061 0019 which is an earlier draft of the same letter dated 25 July 1990. See T80 p.90-1 for Dr Bolsin's explanation of the differences between the letters
[6] UBHT 0052 0290; letter from Dr Bolsin to Dr Roylance dated 25 July 1990
[13] T80 p.107-12; this data is summarised at the end of this chapter
[15] T80 p.116-18; WIT 0080 0108 - 0109 Dr Bolsin
[17] In fact, he did not become the Chief Executive of the Trust until April 1991, but he was the District General Manager and the anticipated Chief Executive
[21] WIT 0093 0014 Mr Dean Hart
[22] WIT 0093 0015 Mr Dean Hart
[23] WIT 0093 0015 - 0016 Mr Dean Hart
[24] WIT 0093 0017 Dr Bolsin
[25] WIT 0093 0017 Dr Bolsin
[26] WIT 0080 0109; see also T80 p.121 Dr Bolsin
[27] WIT 0080 0099 Mr Dean Hart
[28] WIT 0080 0099 Mr Dean Hart
[38] WIT 0080 0109 Dr Bolsin
[46] WIT 0132 0060 Sister Armstrong
[58] WIT 0352 0026 Dr Williams
[59] WIT 0352 0026 Dr Williams
[60] WIT 0352 0027 Dr Williams
[61] WIT 0352 0038 Dr Williams; T94 p.132 Mr Wisheart
[62] WIT 0352 0027 Dr Williams
[67] WIT 0352 0037 Dr Williams