Annex A > Chapter 27 - Concerns 1992 > Further events in 1992
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Further events in 1992
170 Shortly after the appointment of Professor Gianni Angelini, as Professor of Cardiac Surgery, in October 1992, Dr Black and Dr Bolsin presented him with the results of their collection and analysis of data. [211]
171 On 19 November 1992 the Regional Adviser of the Royal College of Physicians, KR Hunter, wrote a report: `Regional Adviser's Visit' to the BRI. The report stated:
`There are major problems due to the great increase in work load in emergency medicine without commensurate increase in resources. When a full complement of staff is present, the system is just able to cope, but if anyone is on leave those remaining can be stretched to the limit and the level of cover is inadequate to ensure proper training. It seems probable that, at times, the quality of patient care may fall below safe levels. In my discussions with Managers, it was clear that they are aware of these difficulties ...' [212]
172 Professor Jarman asked Dr Roylance about the report:
`Q. ... their comment is that it seems probable at times the quality of patient care may fall below safe standards?
`A. Yes, well, that would have been taken very seriously and addressed. There is always a tension, I have to say, between professionals who want to do as much as possible for as many people as possible, and of sustaining safe standards. There are times when some would feel that poor care was better than no care. I do not expect you to share that view and I do not share that view, but that was a tension. This was a very helpful and I believe successful monitoring programme. If every report said "things are perfect", then everybody would have been wasting their time. They actually did pick up matters that were difficult. I believe that they are referring probably to a time when junior staff were working excess hours and it was becoming recognised that this was unacceptable and of course a major initiative was undertaken to correct that.' [213]
173 In December 1992 Mr Dhasmana visited Birmingham with Dr Masey in order to observe Mr William Brawn, a consultant paediatric cardiac surgeon at the Children's Hospital, Birmingham, at work. The operation which they observed was recorded on video and Mr Dhasmana was given a copy. Mr Dhasmana stated:
`I was particularly impressed with the organisation. As a result of this I arranged for theatre nurses and other perfusionists to visit and learn the workings of the Birmingham set-up ... I believe that the whole team received further training as a result of these visits.' [214]
174 Given Dr Hammond's view, expressed in articles in `Private Eye' in 1992, that concern about the performance of the paediatric cardiac service at Bristol was widespread in the area, even if only to the extent of rumour, the Inquiry wrote to referring paediatricians. Their evidence is set out fully in Chapter 11 - Referrals. The Inquiry heard from six paediatricians in Bath. [215] Dr Lenton, a referring paediatrician, who was in Bath throughout the period of the Inquiry's Terms of Reference, stated:
`I was only aware that there might be a problem with the cardiac services offered in Bristol due to indirect feedback via SHOs [Senior House Officers] and Specialist Registrars who had previously worked in UBHT.'
175 Dr Lenton did not suggest that he had any direct evidence of poor standards at Bristol and stated that he `had assumed that the ... service ... was about average'.
176 The only other concerns expressed were by Professor Osborne, who was in Bath throughout the period, and Dr Tyrrell who was in Bath from 1992. Both stated that they were aware that Bristol had a split site. [216]
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Footnotes
[211] WIT 0080 0114 Dr Bolsin
[212] WIT 0032 0259 `Regional Adviser's Visit'
[214] WIT 0084 0112 - 0113 Mr Dhasmana
[215] Dr T Hutchinson (REF 0001 0016), Dr S Lenton (REF 0001 0017 - 0018 ), Dr A R R Cain (REF 0001 0019), Professor J P Osborne (REF 0001 0020 - 0021 ), Dr P T Rudd (REF 0001 0023 - 0024 ) and Dr J Tyrell (REF 0001 0025 - 0026 )
[216] This evidence is difficult to place in the chronology of events, because no specific time period was indicated when the views expressed were held. All Bath paediatricians continued to refer children to Bristol during the rest of the period of the Inquiry's Terms of Reference