Annex A > Chapter 26 - Concerns 1991 > Concerns > Audit meeting 28 July 1991
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Audit meeting 28 July 1991
6 On 28 July 1991 there was a meeting of the Paediatric Cardiac Surgical and Anaesthetic Group. Dr Christopher Monk, consultant anaesthetist, described this as one of a series of meetings which had been held at which the paediatric cardiologists, paediatric cardiac surgeons and paediatric cardiac anaesthetists met to discuss the performance of the Unit and the treatment protocols for children. He told the Inquiry that the meetings were used as a forum to look at ways in which they could develop the service and to reflect upon any problems encountered in the past year. [9] This particular meeting was between the surgeons and the anaesthetists to discuss the specific problem of pulmonary hypertension. [10]
7 Dr Jordan expressed the view that such meetings were `regular but infrequent informal meetings' which took place in people's houses, which were not ever minuted. [11] On this occasion, however, Dr Stephen Bolsin, consultant anaesthetist, produced minutes of the meeting. The introduction to the minutes stated:
`By way of introduction to the meeting, Mr Wisheart provided tables of open and closed cardiac surgery results for the Bristol Paediatric Unit. Comparisons were made in this data for mortality in the Bristol Cardiac Unit in 1990 and the UK national average in 1988. Mr Wisheart said that he thought that the tables demonstrated that the problem which had thought to have been reaching crisis proportions in the Bristol Unit, when put in context, was actually not as serious as had been thought.
`Dr Bolsin said that he thought that the data in the tables in which the Bristol mortality was higher than the UK average for 2 years prior, vindicated the vigilance of the anaesthetic staff in recording their mortality data and vigorously pursuing requests for a combined meeting. This point of view was supported by Dr Burton, Dr Masey and Dr Monk.' [12]
8 Dr Bolsin described his approach to the meetings as follows:
`The meetings in people's houses did not have agendas and I was trying to formalise this type of discussion because I felt this was a point at which we could actually begin to constructively decide what we were doing well and what we were doing badly and if we were doing something badly then to make sure we did not keep on doing it badly.' [13]
9 Dr Bolsin said that the Group did not accept the minutes. He explained that by saying `vindicated the vigilance of the anaesthetic staff in ... vigorously pursuing requests for a combined meeting' he was indicating that he was pleased that, as anaesthetists, they had been able to bring about this combined meeting where they had been able to share figures. [14]
10 Asked about the terminology of his minute, Dr Bolsin said:
`I think I am summarising certainly the feeling of Dr Burton, Dr Masey, Dr Monk and myself that the anaesthetists had now managed to get hold of some data which indicated we were probably improving some of our operative records but it may be some of the others were staying the same.' [15]
11 Dr Bolsin said that the position he took at the meeting was that he would not, on his own, want to put forward data, make a complaint, or make a criticism. He said this was because he had been advised that was not the way to go about it and, following what he saw as his having been warned off by Mr Wisheart, [16] he had been advised to keep his head down. He said that he was happy to take the lead in representing a common point of view with the other anaesthetists:
`I was not prepared to say it on my own, I was only prepared to document it with the support of the others.' [17]
12 Dr Bolsin said that the phrase attributed to Mr Wisheart, `Mr Wisheart said that he thought the tables demonstrated that the problem which had been thought to have been reaching crisis proportions in the Bristol Unit, ' referred to the fact that in 1989 the results showed that, for open-heart surgery on children under 1 year, Bristol had a mortality rate which was twice the national average: [18]
`I think what that was referring to was the fact in the preceding year there had been this very clearly expressed concern which had got to the level of the District General Manager about a national average mortality in the under 1 years - mortality at Bristol which was twice that of the national average and we now had figures presented at this meeting for the first time in which the mortality rate had dropped down to ... probably a third ...
`This was very reassuring and I think that moves us into paragraph 2 where we are talking about this vindicating the vigilance of the anaesthetic staff in recording their mortality data and Dr Masey and I both recorded our mortality data in logbook form and also minuted their "vigorously pursuing requests for a combined meeting".' [19]
`There was a degree of satisfaction on my part. I think we come back to the point that these minutes were not accepted by the Group, but certainly what I wanted to document was my satisfaction at having identified a problem which may have been of crisis proportions or certainly close to, that vindicated the vigilance of the anaesthetic staff in recording their mortality data and asking for meetings and that this seemed to have improved the mortality rate.' [20]
14 Dr Bolsin was asked about the fact that the minutes were not accepted by the Group:
`I thought I was reflecting what the Unit told me, but I was subsequently told after producing these minutes that they were not representative and I was not to produce them ever again.' [21]
15 Dr Bolsin was asked whether it was phrases such as `vindicated the vigilance' and `vigorously pursuing' that led to the minutes not being accepted:
`It is a very long minute, it goes over three or four pages and I am not sure what it was about the minutes that were particularly offensive to the people who objected to it to me, which were Mr Wisheart and Dr Masey. What I was trying to do was encapsulate a meeting that probably went over three or four hours and I felt they were useful phrases in encapsulating the feelings that certainly I was expressing and I thought I was capturing in other people at that meeting.' [22]
`I do not think any particular phrases were picked out, I think it was "We do not want this minuted and we do not want you to take minutes in future", that was the message that I received from Dr Masey and Mr Wisheart.' [23]
17 Asked whether the minute may have been viewed as provocative, Dr Bolsin said:
`I do not think it is particularly provocative in view of the historical context in which the data that was presented at the meeting was placed. If you say "Here is a mortality rate twice the national average, here is a mortality rate that is a lot better", certainly something has to be vindicated in bringing down that rate and if it happens to have been the anaesthetists who believed that their data collection has helped them to achieve that fall in mortality rates along with other changes in management, which are discussed later in the minutes, then I would not see that as being provocative, I would see that as what you said earlier on, as being self-congratulatory and I would allow that group to be self-congratulatory.' [24]
18 In his written statement to the Inquiry Dr Bolsin stated that:
`The first [PCS audit] meeting I attended was unminuted with no agenda and consisted mainly of a general overview of progress within the Unit without addressing key areas of under performance. At the next meeting I attended I took notes and circulated minutes of the meeting at a later date ... The minutes were deemed by Mr Wisheart and Dr Masey to have not corresponded with their memory of the audit meeting and I was told that I would not be required to take minutes of audit meetings in future. This rebuff to my constructive approach to the problem of performance in the paediatric cardiac surgery unit led me to believe that there was unlikely to be a constructive approach to audit in the near future. My attendance at the meetings was reduced as I did not believe they were a useful path to quality improvement for the future and my efforts to achieve constructive change were neither recognised nor welcome.' [25]
19 Mr Wisheart commented on Dr Bolsin's statement:
`I do recall the unease with which his minutes of the meeting of 28th July 1991 were received ... At the subsequent meeting, as I remember it, this was expressed by his anaesthetic colleague or colleagues but not by me, although I did agree with them. The reason for unease was that the minute contained a partisan element which had not been present at the meeting. To describe this incident as a "rebuff" leading to the conclusions referred to above, is to magnify a minor incident out of all proportion.' [26]
20 Dr Bolsin responded in his oral evidence:
`Mr Wisheart obviously has a good memory for minor incidents and I think that being asked not to take minutes again of that type of meeting is more than just a minor incident, that is actually a major change in policy and I think that to me could be interpreted as a rebuff.
`I think we are moving into the area of semantics but here we have the senior paediatric cardiac surgeon saying that he remembers there was some unease at that meeting about the taking of minutes or the future taking of minutes and I think that confirms what I said, which was that I believe I was seriously ordered not to take minutes of future meetings.
`I think if somebody says at a meeting "This is simply not good enough" I think that is probably a phrase that is worth documenting. I personally do not necessarily support the production of anodyne minutes, I produce minutes which reflect the conclusions and the opinions expressed at the meeting and I think that is just me and my minute taking. I think if you want me to change my minute taking, fine, tell me what you think is wrong with my minutes, but do not say "We do not want these meetings minuted" or "We do not want these meetings minuted by you".' [27]
21 When Dr Sally Masey, consultant anaesthetist, was referred to the minutes during her oral evidence to the Inquiry, she told the Inquiry that they `do look familiar' and it was `my impression that I have seen them before', although she could not remember whether it was an agreed minute of the meeting or not. [28]
22 Concerning Dr Bolsin's statement that he was told not to produce any further minutes, there was the following exchange with Dr Masey:
`Q. If I suggested to you that Dr Bolsin has said that he was asked not to produce any more of these notes, what would you say?
`A. I would have no comment to make on that. I do not recall myself asking him not to do this.
`Q. Do you recall asking him to do it or not to do it?
`A. I do not recall either of those.' [29]
23 Mr Janardan Dhasmana, consultant cardiac surgeon, agreed that the introduction to the minutes was expressing a sense of relief that was held by the whole Unit that the figures for 1990 showed a considerable improvement, the success being ascribed to the management of pulmonary hypertension. [30] He disagreed, however, that there was a `crisis' in the Unit:
`Q. ... is it right until the 1990 results came out there had been a sense that there was something of a crisis in the Unit because the outcomes were not as good as they should be?
`A. No, I would not say that. I would say concern, but not "crisis".
`Q. So you take issue with the words "crisis proportions"?
`A. I think "crisis" is a little bit of an exaggeration, I would say, but of course there is a concern, and the concern would be there, if you have the mortality which appears to be on the high side, even if you put a statistical range on it.
`Q. If we look on, the problem, when put in context, missing the words "crisis proportions", was not actually as serious as had been thought. Is the problem referred to there the problem that Bristol's results were out of step with the UK's if one looked at the 1989 data and earlier?
`Q. The context is the context provided by the 1990 results?
`A. The improvement noticed, yes.' [31]
24 Mr Dhasmana reflected on the accuracy of the minute:
`Q. ... when you read the minute through, did you think that it was a fairly accurate record of what had been discussed, or not?
`A. I mean, looking back, what I know now and various things, I am getting into looking very critically about the use of the word "crisis" and the use of the word "vigilance" and things like that. But at that time, I mean, I saw it and I did not really notice any difference, or -
`Q. So it did not strike you at the time as being out of place?
`A. No.' [32]
25 Mr Wisheart was asked whether at the meeting he had used words to the effect that the problem had reached crisis proportions. There was the following exchange:
`A. The quick answer is that I cannot remember, but I think it is probably unlikely. I think that this is probably an interpretation of what I said. But I mean, I cannot recall, so I cannot be sure.
`Q. Had you, then, allowing for an element of hyperbole, been suggesting that the results had been grim but now looked as though they were better?
`A. I think what is reflected by this phrase, whether I used the words or not, is the fact that in 1988 and in 1989 the results in the under-1s had been disappointing, previous years having been as we discussed, I believed, acceptable.
`So we had been recognising and discussing those particular problems and that is what is reflected here. Whether the words are accurate or not I do not think is particularly important, but that is what we had been dealing with.' [33]
26 Dr Monk was asked whether the words `thought to have been reaching crisis proportions' were an accurate reflection of what was said at the meeting. He replied:
`I do not recollect that we were describing it as a crisis, and I think that this is a recollection put in the terms of Dr Bolsin's own thoughts on that meeting. It was not a meeting of such heat or emotion that we would be going around saying: "We have a crisis", and, therefore, that would not be my recollection of the tenor of the meeting.' [34]
27 Dr Monk did not agree that Dr Bolsin's minute was saying that, if there had been a crisis, it was now over, and people were more prepared in retrospect to talk about it. Instead, he said that what he took the minute to be saying was that the problem was not as serious as had been thought. [35]
28 He did, however, agree that, from the fact that they were at this meeting discussing how to improve outcome, it could be deduced that Mr Wisheart was aware of the figures and of the problems of high mortality rates. [36]
29 Dr Monk was asked if he knew how poor the surgeons or anaesthetists had thought, prior to this meeting, that the figures probably were:
`The anaesthetic opinion on the performance of the Unit varied between individuals. There was a spectrum of opinion, and it was expressed by the anaesthetists differently, and there was a range with, I suspect, Dr Bolsin on one end of the spectrum and others at the other end, and, therefore, our own perceptions of the performance varied markedly.
`Q. Where were you in the spectrum?
`A. I was closer to the Bolsin end than the other side.' [37]
30 Dr Jordan, who was not present at the meeting, said that he himself never saw any data about paediatric cardiac surgery in Bristol compiled by Dr Bolsin, either directly or through a third party. [38] He was asked whether he could think of anything that might have been happening at the time that could justify the reference to a problem as reaching `crisis proportions', but actually was not as serious as was thought. He replied:
`I was not aware of anything that could remotely be described as "assuming crisis proportions" ... that related to cardiology or cardiac surgery at that time.' [39]
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Footnotes
[11] WIT 0099 0019 Dr Jordan
[12] UBHT 0061 0146; Dr Bolsin's covering letter and distribution list is at UBHT 0061 0145
[16] See Chapter 25
[25] WIT 0080 0108 Dr Bolsin
[26] WIT 0080 0319 - 0320 Mr Wisheart