Annex A > Chapter 26 - Concerns 1991 > Concerns > Autumn 1991
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Autumn 1991
31 Professor Prys-Roberts, Professor of Anaesthesia, University of Bristol, stated in his written evidence to the Inquiry that in October 1991 Dr Bolsin had a further discussion with him:
`Dr Bolsin ... showed me some preliminary data which he had gathered between 1989 and 1991. These data, for paediatric cardiac operations at the Bristol Royal Infirmary, appeared to show a higher mortality than in other cardiac units. I cannot remember precise details because Dr Bolsin did not give me a copy of the data. I suggested that he should continue to keep accurate records of prospective cases, and their outcome; and that he would then be able to make comparisons between his data, and those of other anaesthetists, who were known to him, who were involved in paediatric cardiac surgery in the UK and elsewhere. I did not regard this as a "secret" or "confidential" audit, as has been suggested by others, nor did I "sanction" such a process in any official capacity. I had no authority to do so.' [40]
32 Dr Bolsin was asked about the date of this meeting and replied:
`I am not going to deny that this conversation took place, but I cannot remember it. I mean, it fits in with the events. I was collecting data and showing it to just about everyone. I showed it to Dr Clements and a lot of other people and this is consistent with my actions at that time.' [41]
33 On 11 October 1991 Professor John Norman, Department of Anaesthetics, University of Southampton, wrote to Professor Prys-Roberts:
`Three of your younger cardiac anaesthetists have approached Tom Abbott - one of our cardiac team - to say they are extremely worried about the results of cardiac surgery in Bristol and the conduct of bypass. They claim the mortality in Bristol is very much higher than that in other centres. I believe some concern has also been expressed in other quarters. The anaesthetists are apparently unsure as to how to proceed.
`Without instituting any formal enquiries, Tom Abbott is very willing to help. From his private discussions with the team, it seems to be partly a matter of establishing good protocols and standards.
`Would you be willing to use your good offices to get your cardiac team to discuss matters with Tom. It may be that if they, as individuals, could come over and see how things are done here and for Tom to spend some days across in Bristol. Some advice may resolve the problems.
`I hope you don't find this intruding into local affairs but your colleagues are worried about the service and if it can be helped by advice from Tom, we are only too willing to help.' [42]
34 Professor Prys-Roberts described Professor Norman as:
`... a Professor of Anaesthesia in Southampton who was a close colleague of mine in the sense we have worked together in the Royal College of Anaesthetists a great deal and he was expressing here a view that had concerned him.
`John Norman, as you can see in the letter, expressed the concern and offered the help of Tom Abbott who was a senior consultant involved in cardiac anaesthesia in Southampton, which was one of the centres which was reputed at that stage to have very good results especially in paediatric cardiac surgery, and I did not show the letter, but I discussed the contents of the letter with Dr Peter Baskett.' [43]
35 As a result of the letter, Professor Prys-Roberts had a conversation with Professor Norman:
`I had a discussion with John, an informal discussion about it, and he said he did not know who the three specific people were, but that Tom Abbott had approached him.' [44]
36 Professor Prys-Roberts said that he did not speak to Dr Abbott personally. [45]
37 After considering the letter Professor Prys-Roberts said:
`I spoke to Dr Peter Baskett who is one of the senior cardiac anaesthetists and said I had this letter from John Norman and that Tom Abbott, who Peter Baskett knew perfectly well, had offered to be of assistance if assistance was needed and Peter said, yes, he would contact Tom Abbott and that is the last I heard of it.' [46]
38 Professor Prys-Roberts said he did `not specifically' ask Dr Baskett what he had done in response to the issue that had now been raised. He said that if any further follow-up needed to be made it would have had to be made through Dr Baskett. [47]
39 Professor Prys-Roberts described his reaction to the letter:
`It simply made me more aware of things that I knew were concerning Dr Bolsin and I was not sure - when it said "three of your young cardiac anaesthetists" I was not sure whether that was people who were existing in Bristol at that time or people who had been in Bristol and moved to Southampton. It was simply another expression of concern.
`I had spoken to Steve Bolsin, I had spoken with the other cardiac anaesthetists off-the-cuff in the corridor and said "There is a growing perception of a problem; do you think there is any aspect of this which is directly related either to the anaesthesia which is being given or to the intensive care of the patients afterwards?" and the answer was a resounding "No" from all of them. My perception was there was a problem which was manifest in, not only a death rate but a complication rate within the Unit which was causing concern to the people in the Unit. As I was not a cardiac anaesthetist and not involved in the clinical service, they were not asking me to become involved other than simply to keep Steve Bolsin advised as to how to go about things.' [48]
40 In response to a query from the Chairman as to whether Professor Prys-Roberts had drawn a conclusion about surgical involvement and disregarded without sufficient evidence the possible involvement of other specialties, Professor Prys-Roberts said:
`No, I would not want to give that impression that I was saying there was not any other involvement, I simply asked my colleagues "Do you believe that there is any reason why this should be an anaesthetic problem?" In that event if they had said "Yes", one of my first reactions, I would say we ought to have a meeting about it and set up a research programme to try and find out what mechanisms relating to either anaesthesia or intensive care might be responsible for such events.
`The reason I did not suggest having a meeting with Mr Wisheart was that at that stage I was largely concerned with helping Steve Bolsin to get his own act together, find data ... I mean I was aware (I cannot be specific about it) that the cardiac anaesthetists in general had expressed concerns and that those concerns had not been fully appreciated, irrespective of the concerns Steve Bolsin was expressing to me.
`The cardiac anaesthetists at that time would have been Dr Geoffrey Burton who was certainly doing paediatric anaesthesia, Dr Baskett to my recollection was not, he was mainly doing adult stuff. Dr Sally Masey had recently arrived, Dr Bose, Dr Short - they were not involved in the paediatric side. There was a cardiac team.
`I think all of them had expressed concerns at some stage. You know one meets over coffee or after a departmental meeting and somebody would say "Steve is going on about this process, what do you think about it?" and so on ... I cannot be certain they were not expressing their own concerns as well. Geoffrey Burton I knew rather better than the others in the sense being a paediatric anaesthetist myself I would see him and I was sharing some lists with him on previous occasions so that I would have discussed it with him. But I cannot recall precisely the details that you are trying to find out at this stage.' [49]
41 Dr Bolsin was helped with processing the information he had collected by Dr Andrew Black, senior lecturer in anaesthesia at the University of Bristol. Dr Black stated in his written evidence to the Inquiry that he had some knowledge of past concerns:
`... Professor Jean Golding told me that, when she took up her Chair in paediatrics in Bristol in the mid 1980s, it was widely recognised that Bristol Paediatric Cardiac Surgery was not all that it should have been.' [50]
`... I became involved in the issue of paediatric cardiac surgery in Bristol through my friendship and working collaborations with Dr Stephen Bolsin ... .' [51]
`By late 1991, I became aware of Dr Bolsin's substantial concerns over standards of performance. At about the same time, Dr Ian McKenzie, a staff specialist paediatric cardiac anaesthetist from the Royal Children's Hospital in Melbourne, was spending a sabbatical in Bristol and was working with me on a study of postoperative pain in adults. He visited the paediatric cardiac surgical theatres on a number of occasions and seemed surprised and alarmed by what he saw.' [52]
`I have an interest in the application and interpretation of multivariable modelling approaches in medicine, having published, amongst other things, one of the relatively early (1980) accounts of the application of multiple logistic regression to a medical topic. Logistic regression is now heavily used for identifying explanators of outcome for the purposes of risk stratification and outcome prediction. I cannot now recall whether my discussions with Dr Bolsin began with his general interest in setting up an audit system for risk-stratified accounting for variations in outcome from Adult Cardiac Surgery between cardiac surgical centres ... or with his specific concerns over paediatric cardiac surgery in Bristol. In either case, discussion of the one led fairly quickly and naturally to discussion of the other.' [53]
45 Before embarking on the exercise with Dr Bolsin, Dr Black indicated that he:
`... made a point of discussing with Dr Bolsin the desirability or otherwise of informing Mr Wisheart and Mr Dhasmana of what we intended. Dr Bolsin gave reasons why this would only impede what we both believed was a necessary task. Our prime objective in setting out to compile our own figures was simply to force more open and honest discussions within our Trust. We believed this would inevitably follow the disclosure of our results, however they turned out.' [54]
`Q. ... is it right that you never directly, or personally, showed the data which you had collected and analysed, together with Mr [Dr] Black, to any of Mr Dhasmana, Mr Wisheart, Dr Joffe, Dr Jordan, Dr Martin, at least before February 1995?
`A. Yes, that is true.' [55]
47 Referring to the sources of information that he used, Dr Black indicated that there were two sources: `... that could very easily have been accessed by anyone who is minded so to do'. [56] He stated that:
`... The principal source was a notebook started in October 1991 by the Bristol Heart Circle ... The second and complementary source was the computer print out of the perfusionists' log. Between them, these two sources contained the patients' names, dates of birth, hospital numbers, types of operation, details of the conduct of cardiopulmonary bypass and outcome of almost all of the paediatric cardiac surgical operations carried out at the Bristol Royal Infirmary since October 1991.' [57]
48 In addition, Dr Black stated that the operations registers in theatre and the intensive care admissions book were checked `to ensure completeness of case inclusion' [58] and hospital notes were retrieved from the Medical Records Department in Bristol and checked when it was necessary to fill in any details missing from the two principal registers.
49 Helen Stratton, Cardiac Liaison Nurse at the BRI, said that to assist in her work she kept details of patients in a book which included `... the date of the operation, the date the child was extubated or taken off the ventilator, the date they were moved through to the nursery, the date they went home and the date they died, if they had died.' [59]
`I lent it to Dr Bolsin when he was collecting his audit, as he was finding it quite difficult to find accurate information, data, dates of birth, dates of operations, and I lent it to him and Andy Black and one of his assistants when they were collecting their audit.' [60]
51 Mr Edward Caddy, who retired as Chief Clinical Perfusionist in June 1994, also supplied information to Dr Bolsin:
`I gave Dr Bolsin access to the perfusionist records for each individual patient, which were kept in my office at that time. I was aware that he was looking at by-pass times and outcomes. I was not involved in the actual analysis. I was interested to see what information he might obtain from other centres, for example, as to their by-pass times, but I never saw such information. In other words, I thought that Dr Bolsin was looking at comparative data between Bristol and other centres, but I did not see any such data, I did not know what data Dr Bolsin actually obtained, and I did not see any analysis.
`I believe that Dr Bolsin was drawing the conclusion that Bristol had relatively long by-pass times, especially in the more complex operations. I was not aware of the detail as to which procedures, I cannot now recall exactly what I may have known at that time.
`I am unable now to recall when it was that I lent the perfusion records to Dr Bolsin.
`I did not discuss with anyone else what Dr Bolsin was doing.
`I never saw Dr Bolsin's results, even in draft. I do not know when he did his audit, or when it was completed, or to whom he may have shown it. In other words, apart from giving him practical assistance by giving him access to the records that I had, I was not involved to any further extent in what he then did with that information.' [61]
52 Sometime in 1991, probably in the autumn, Dr Bolsin spoke to Dr John Zorab, Director of Anaesthesia and Medical Director at Frenchay Hospital, Bristol. In his written evidence to the Inquiry Dr Zorab described the meeting and its outcome:
`It was sometime in the autumn of 1991 that a colleague of mine at Frenchay (who was a friend of Dr Bolsin) told me of his (Dr Bolsin's) anxieties at the mortality rate of children undergoing cardiac surgery at the BRI. At the time, I had not met Dr Bolsin but my colleague had apparently suggested that he (Dr Bolsin) might like to have a word with me as I had had some experience of "medical politics". In due course, and quite by chance, I met Dr Bolsin. We introduced ourselves and I said something to the effect that I believed he wanted a word with me.
`I have no detailed recollection of the conversation except that Dr Bolsin expressed his anxieties and asked if I had any advice. I pointed out that the problems were completely outside my "patch" as I worked at a different hospital and had little or no contact with those in the BRI Paediatric Cardiac Unit. In addition, I had no facts or figures. Although Mr Wisheart and I were both the Medical Director of our respective Hospitals, our occasional meetings were confined to management matters.
`At that time, however, I was the representative of what was then the Board of the Faculty of Anaesthetists (now the Royal College of Anaesthetists) on Council of the Royal College of Surgeons (RCS). As such, I had come to know Sir Terence English who was President of the RCS and, of course, a distinguished cardiac surgeon. I told Dr Bolsin that I knew Sir Terence well enough to appraise him informally of the problem but that I could not see that there was anything else I personally should or could do.
`Therefore, I did not take the matter up with anyone else and, in accordance with the request from Sir Terence (letter, 27 July, 1992), I treated the matter as confidential. As I said in my letter to Dr Bolsin (27 March, 1995), I thought I had done as much as was appropriate for me to do.
`As regards the outcome of my "efforts", I thought that the letter from Sir Terence to me (27 July, 1992) indicated that the matter had been referred to the appropriate authorities and that I had taken appropriate action.' [62]
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Footnotes
[40] WIT 0382 0002 Professor Prys-Roberts
[42] WIT 0382 0006; letter from Professor Norman to Professor Prys-Roberts dated 11 October 1991
[43] T94 p.25-6 Professor Prys-Roberts
[44] T94 p.26 Professor Prys-Roberts
[45] T94 p.26 Professor Prys-Roberts
[46] T94 p.26 Professor Prys-Roberts
[47] T94 p.27 Professor Prys-Roberts
[48] T94 p.27 Professor Prys-Roberts
[49] T94 p.28-30 Professor Prys-Roberts
[50] WIT 0326 0012 Dr Black
[51] WIT 0326 0008 Dr Black
[52] WIT 0326 0012 - 0013 Dr Black
[53] WIT 0326 0009 Dr Black
[54] WIT 0326 0013 Dr Black
[56] WIT 0326 0014 Dr Black
[57] WIT 0326 0014 Dr Black
[58] WIT 0326 0014 Dr Black
[61] WIT 0143 0036 - 0037 Mr Caddy
[62] WIT 0296 0002 - 0003 Dr Zorab (emphasis in original)