Annex A > Chapter 27 - Concerns 1992 > Concerns
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Concerns
Concerns raised in relation to the position of Chair of Cardiac Surgery at the University of Bristol
1 In late 1991 Mr Martin Elliott, a consultant cardiothoracic surgeon, was invited to apply for the Chair of Cardiac Surgery at the University of Bristol. The initial approach was made by Mr Wisheart and was followed by an approach from Professor John Farndon, Professor and Head of Division of Surgery. Mr Elliott was interested in the opportunity and visited Bristol on a number of occasions to discuss the position, including having a meeting with Mr Durie, the then Chairman of the Trust. [1]
2 Mr Elliott's discussions with Mr Durie concerned, amongst other things, the `split site' issue. [2] Mr Elliott was particularly concerned regarding the split service between the BRI and the Bristol Royal Hospital for Sick Children (BRHSC).
3 In his written evidence to the Inquiry, Mr Elliott stated:
`Mr Durie outlined the structure of the new Trust organisation, and the financial arrangements. He stated that there was no way that resources could be made available to correct the split site issue in the short or medium term (I can't remember whether we discussed what this meant). I had said that there might be a possibility of getting new business (more patients) from neighbouring regions (Wales, the South West) if we were able to develop a high quality service, but that would be impossible without the Children's Services being centralised away from the BRI. I also pointed out that this would free up resources to increase throughput of, and potentially income derived from, adult practice.
`Mr Durie made it quite clear that in his view it would be up to me, as the new incumbent, to generate the income to pay for the changes required. I thought that this was not going to be possible. Making the changes was the only rational way to improve both service and income, and the only way to generate a basis for safe, modern neonatal cardiac surgery. I thought it was wrong to place the burden of income generation from clinical practice on the new Chair holder. Changes had to be made BEFORE any income could be generated.
`In retrospect, I wish I had been louder and more obviously astounded. The approach suggested by Mr Durie now strikes me as absurd, particularly since the internal market has proved temporary. I should have made more of the quality issue, and been less seduced by the flattery of being offered a Chair and the negotiations surrounding it. Faced with a management ethos like this it is easy to imagine why the clinicians had failed to persuade the higher levels of the Health Authority that a change was required.' [3]
4 Professor Prys-Roberts gave his view of the thinking behind seeking to recruit Mr Elliott:
`... it was seen at that stage - how can I put it, it was a belief that there was a solution to what people already saw as a problem by appointing another paediatric cardiac surgeon who would be an academic and the resolution of both those events would improve paediatric cardiac surgery and some of the problems related to it like the moving from the BRI up to the Children's Hospital and so on.' [4]
5 On 3 January 1992 Mr Elliott wrote to Mr Wisheart indicating that he had decided not to apply for the Chair of Cardiac Surgery at Bristol. Mr Elliott wrote:
`I have decided not to apply. My reasons are as follows:
`... I have lingering doubts about the security of the paediatric volume for [sic] a worry about the separation of cardiology from cardiac surgery which would I think take some time to resolve.' [5]
6 At Mr Wisheart's request Mr Elliott wrote a paper setting out his reasons in full for declining the Chair. [6]
7 Mr Elliott said, as one of three starred bullet points in his paper, that:
`The separation of open and closed paediatric surgery must be inefficient, and is potentially dangerous.' [7]
8 Dr Roylance was asked about this paper in his oral evidence to the Inquiry:
`Q. If a consultant who has the respect of a number of clinicians, as Martin Elliott it would appear did, of the sort to attract him [to] ... a post, writes to the Clinical Director, or Associate Clinical Director of the service, and says, "I think this is dangerous or potentially dangerous in some respects", would you, as the Chief Executive, expect to be told of the danger or potential danger?
`A. Yes, I would expect Martin Elliott to tell me. I cannot perceive of the circumstance where somebody visiting Bristol and finding a service he thought was dangerous was not sharing that view with me. I do not understand the hypothesis behind that.
`Q. If he tells the Medical Director rather than you directly, would you expect the Medical Director to pass it on?
`A. If he had, yes.' [8]
`Q. ... this is a clinical expert in particular in the field of paediatric cardiac surgery, who is describing the present arrangement as potentially dangerous, is it not?
`Q. So if you had seen this, if you had known of this at the time, you would have taken the steps you told us earlier you would do if any respectable and reputable source identified an aspect of the service as being dangerous or potentially dangerous, would you?
`A. I certainly discussed this with them. It was used as evidence of the now urgent need to achieve the two steps we were doing. I think the advice at the time, which was rather late in the day in terms of we were already producing a solution, is that nobody was able to identify any child who had actually suffered from this potential danger. We were unable to establish any real danger. I do not know whether that sort of conversation - clearly it was the sort of talk we had, because Bristol was not the only unit in which that sort of separation exists.
`Q. Can I remind you of what you said earlier this morning? I asked: "Suppose you had a letter or document from a reputable and respectable source which suggested that the way in which paediatric cardiac surgical services was being delivered was dangerous, potentially dangerous, to the children, would you have taken some action as Chief Executive?" You said: "Absolutely. I would have activated the proper professional pathways to deal with that situation." I asked you what they would have been and you said: "They would have been the local people to start with, who would not have gone behind anybody's back, but in the sense that I think I understand your question, I would have referred it to the appropriate Royal College or Royal Colleges to get their professional advice, to ask them to advise me, because that, in my view, at that time was their responsibility."
`A. Yes, that is absolutely true.
`Q. So had you known of these words at the time they were written, because you did not see them for a while, is that the action that you would have taken?
`A. When I did see them, I did discuss what, in everybody's view, was potentially dangerous. It does not say it is dangerous, he says it is potentially dangerous. What was the potential? As I say, the advice I had, and was consensus advice, was that although the quality of care in terms of the peace of mind of parents and so on had a lot to be improved, in terms of patient outcome, there was at the time no evidence that the separation itself was an issue. And it was at a time when we were pushing through the solution to the problem. So I think in terms of timing and in terms of statements, clearly by the time any review had been set up and done, we would have actually changed the situation. There is a timescale to what you are talking about. I am quite sure by the time we had achieved any proper external review of the situation, the situation itself would no longer exist.
`Q. So the answer is, is it, that had you known of this at the time, you would have taken the steps you identified to me earlier this morning?
`Q. When you did become aware of it, you already had matters in hand and it would have taken so long to have the inquiry, that by then, anyway, the position would have been remedied.
`A. Yes, but I have to go back to your original concept. This says "potentially dangerous", it does not say "dangerous" and he could have said "dangerous", but he did not. He says there is the potential for danger. That is rather different from a clear statement that a dangerous situation is being tolerated. It is quite different.
`Q. I did put the questions to you in both terms of "dangerous" and "potentially dangerous" this morning.
`A. Well, if I had failed to observe at the time the difference, I would like to correct that omission now. I actually think that the suggestion that there are circumstances which are potentially dangerous is very different from somebody saying it is dangerous.
`Q. When you came round to assessing the potential for danger -
`A. I would not assess the potential danger. If I have given that impression, then I am sorry. I could not assess the danger; I could only take professional advice. There is a difference.' [9]
10 At almost the same time, Dr Bolsin again visited Professor Prys-Roberts:
`Early in 1992 Dr Bolsin again expressed to me his continuing concern about the results of paediatric cardiac surgery ... I told Dr Bolsin that I would speak informally to Dr Roylance ... .' [10]
11 The meeting with Dr Roylance was the subject of the following exchange between Counsel to the Inquiry and Professor Prys-Roberts:
`Q. Why was this data of a nature that you thought was appropriate to bring to the attention of Dr Roylance?
`A. Simply because Steve asked me whether I could intervene in some way, and I said to him "Well, I will be seeing Dr Roylance" - I cannot remember whether he was the Chief Executive or the Chief Officer of the Health Authority at that stage. [11] I knew we were going to have two meetings and I said "Well, look, I will talk to him and try and persuade him that there is something to be concerned about and you may wish me to do that" and he said "Yes". He was not willing for me to go and speak to Mr Wisheart directly because of the rebuff that he had had on a previous occasion.
`Q. You have described a series of meetings with Dr Bolsin and cautioned us against trying to put them into rigid boxes of particular dates when you saw him frequently. You appreciate, I am sure, that Dr Roylance on his part denies any mention being made to him of figures ...
`Q. ... when you went to see him. Why is it that you can be confident that you had seen some sorts of figures, albeit handwritten and tabulated by Dr Bolsin by the time you had seen Dr Roylance rather than seeing them at a later stage when there was further discussion of the need to conduct an audit?
`A. The main reason that I offered to speak to Dr Roylance was on the basis of the information that he had shown me and he could only have shown me data. I did not have a piece of paper to take to Dr Roylance, Steve did not want the piece of paper to go out of his hand. He had shown it to me, I was convinced. What I believe I said to Dr Roylance was "Dr Bolsin has data which I think you ought to look at and ought to be concerned about". My recollection is that he said he would do something about it.' [12]
12 Professor Prys-Roberts was asked about the nature of the data:
`Q. It follows, does it, whatever you had been shown by Dr Bolsin was only the most preliminary (if that) stage of assessing the performance of Bristol as opposed to that of other centres?
`Q. Was it genuinely, do you think, at a stage at which you could say that the data he was giving you was such as to raise a concern about mortality in Bristol?
`A. It raised a concern with me personally because I could see from the data at that time that things were clearly not as one would have liked them to be. On the previous occasion, 1989, when he first came to me, he had no data. Now he had some data, but the data, as I say they were not properly statistically analysed and so on, but one can look at a set of data and say "There is something there, we have to look at this" and my concern at that stage was simply to alert Dr Roylance to the fact there was something that really did need looking at rather than simply dismissing it.
`Q. But handwritten data of the sort you have just described with only tentative or preliminary conclusions and limited national figures available for comparison might be the sort of information that Dr Roylance would be justified in saying did not raise any concern?
`A. The fact that they are handwritten is neither here nor there.You can put the same data on a typewriter ... it does not alter the nature of the data, it is the data, the way it is presented in tabular form and (if necessary) in detail. No, it certainly would not be the sort of information at that time that one would have said "This is hard evidence that Bristol is doing far less well". What I was seeing was soft evidence that gave me concern and my concern supported Dr Bolsin at that stage, and I was very keen that he was not being pushed into a corner persistently by people who [would] not listen to him and so I volunteered that I would speak to Dr Roylance about it.
`Q. (the Chairman): Can I be clear on what exactly was your state of mind at the moment, Professor? You say in answer to Miss Grey - and I am reading from the transcript: "I could see from the data at that time that things were clearly not as one would have liked them to be".
`But you then say a little later on "My concern at that stage was simply to alert Dr Roylance to the fact there was something that did need looking at".
`Those are quite different propositions: one is there is a question; the other is there is a real need, real cause for concern. What is your evidence on that particular point?
`A. I think I would say there was real concern in my mind at that stage.
`Q. (the Chairman): Even though you have described the data as "preliminary"?
`A. Yes.' [13]
13 Asked about the possible involvement of Mr Wisheart at that stage, Professor
Prys-Roberts said:
`A ... 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.
`Q. (the Chairman): That is an intriguing response because, as regards the involvement of the surgeons, it did not seem to be your response to suggest "Let us have a meeting with Mr Wisheart"?
`A. 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 which you could then take either through - 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.' [14]
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Footnotes
[1] WIT 0467 0003 and WIT 0467 0007 Mr Elliott
[3] WIT 0467 0007 Mr Elliott (emphasis in original)
[4] T94 p.32 Professor Prys-Roberts
[5] JDW 0003 0102; letter dated 3 January 1992 from Mr Elliott to Mr Wisheart
[6] WIT 0467 0011 - 0027 ; Mr Elliott's paper `The Chair of Cardiac Surgery in Bristol'
[7] WIT 0467 0013; Mr Elliott's paper
[10] WIT 0382 0002 Professor Prys-Roberts
[11] Dr Roylance was by then the Chief Executive, UBHT
[12] T94 p.15-17 Professor Prys-Roberts