Annex A > Chapter 27 - Concerns 1992 > Concerns > `Private Eye'
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`Private Eye'
25 In 1992 a number of articles were published in the `MD' column of `Private Eye' magazine. [29] These contained various criticisms of the cardiac services at the BRI. The author of the articles was Dr Phillip Hammond, then a GP trainee in Taunton. He described himself in his written evidence to the Inquiry as a `whistle-blower's advocate'. [30] Although the `MD' column did not identify the author, Dr Hammond stated that he made no secret of his identity. [31]
26 Dr Hammond acknowledged that his evidence to the Inquiry was `entirely second hand, as a journalist writing for "Private Eye".' [32] He told the Inquiry that he was not willing to identify the sources of his information. [33]
27 Dr Hammond stated that in 1992 and 1993 he received information from a number of sources both within the UBHT and outside. The sources within UBHT included `a senior nurse, a middle grade nurse, two consultants and at least half a dozen junior doctors ...'. [34]
28 Dr Hammond stated that these sources suggested that problems with the paediatric cardiac service at Bristol were so grave that he should attempt to alter the referral pattern of the general practitioners he knew, to stop them sending children with complex heart conditions to Bristol. Dr Hammond was told that pressure was being put on referring doctors to support the Bristol Unit although they `probably wouldn't send their own children for heart surgery in Bristol'. [35] Specific problems which were highlighted to him included:
- no action being taken to protect patients despite high mortality rates;
- no defined minimal standards;
- no obligation to conduct audit that allowed meaningful comparisons between units;
- no mechanism within or outside the profession to identify and act on unacceptable results;
- concerns not acted on in a way that would protect patients, despite the problems in the Bristol paediatric cardiac surgery Unit being well known in 1992, and despite concerns having been raised with Dr Roylance;
- parents of children undergoing heart surgery given information about success rates that did not reflect the Unit's own figures;
- operations taking a very long time compared to other units, and this was a factor that could adversely affect the outcome of operations. [36]
`Further information specifically related to cardiac surgery was gathered from doctors at other hospitals I either knew personally or met during 1992 at conferences, after dinner speeches and performances of "Struck off and Die".' [37]
30 Dr Hammond stated in his written evidence to the Inquiry that he did not know how those outside Bristol would have come to hear about what was said to be the problem at the UBHT, but it was his impression that:
`... senior members of the specialty were discussing it amongst themselves and with their more senior juniors, especially those considering their next career move.' [38]
31 Dr Hammond stated that the fact that there were problems at Bristol `was also well known amongst cardiac anaesthetists/intensivists I spoke to.' [39]
32 On 14 February 1992 [40] and 27 March 1992, [41] articles were published in `Private Eye' that referred (amongst other things) to a lack of funding for cardiology and cardiac surgery in Bristol.
33 On 8 May 1992 a further article was published that read:
`Before the DoH bestows its mark of excellence on UBHT, it may wish to ponder the perilous state of its paediatric cardiac surgery. In 1988, mortality was so high that the unit was dubbed the "Killing Fields". Despite a long crisis of morale among intensive care staff, the surgeons persistently refuse to publish their mortality rates in a manner comparable to other units. And although Dr Roylance and the DoH are well aware of the problems, they won't recognise them officially. Recently, the unit failed to provide a paediatric cardiac surgery nurse for post-operative care because it was assumed the baby would not survive the operation. And although Liverpool surgeons have successfully operated on 160 babies with Fallot's tetralogy, a congenital heart abnormality, the Bristol mortality is between 20 and 30 percent. Hardly the stuff of commendations.' [42]
34 Dr Hammond gave evidence about this article in the following exchange:
`Q. Did you have any material other than the fact of what is probably this report, [43] what I have just shown you, to suggest that the Department of Health was well aware of the problem?
`A. No, although I was told that there was another Working Party on behalf of the Department of Health going around at that time, in 1992. I was not sure what stage they had reached in their deliberations.
`Q. It did not report until later.
`A. Fine. My assumption was - one of my sources said, "This is a window of opportunity to bring it to the attention of this Working Party that is going around at the moment. They will read this, they will think we at least have to investigate this". When I am saying "Working Party" I assume it then goes back to the Department of Health, but I did not know at that time the dates at which the Working Party reported so in fact the only evidence I had was the 1989 report.
`Q. And "they won't recognise them officially". Did you know that they had been asked to do so?
`Q. The wording you use there might suggest that they had, might it not?
`A. They might have been, I am not aware of anybody asking them to do so, other than me in this column.
`Q. Because the "won't recognise" gives the impression just as perhaps the "persistently refused to publish" may give the impression, that there is some deliberate silence being kept?
`A. The official recognition would have come from the 1989 report when they said "these are very poor success rates but we are not going to look into it, we are just going to encourage them to increase the numbers". They were not recognising the problem.
`Q. You, for your part, were not an expert in cardiac surgery, or what results to expect?
`Q. And you would have imagined that whatever the Working Party constitution was, it would be composed of those who were?
`Q. If they had seen a problem themselves, you would have expected them to have drawn particularly focused attention to it, would you not?
`A. My experience, and this also goes with biliary atresia, is that decisions at that time were made largely on output and that people did not look at outcomes carefully. In fact, they did not seem to mention outcomes. You talk about results, but they were keen on throughput and centres being established for geographical reasons. It is only recently I think with this government that anybody has put quality on the agenda and stopped counting numbers and waiting lists and actually looked at the quality of the service. So I think in that culture then, they did not look at the quality of the service. They did not think, "If this was my child would I want them to be treated in Bristol?" ... You have to ask that question if you are on working parties like this.
`Q. The point I am going to ask you to comment on, if the Department of Health had commissioned a Working Party and the Working Party itself focused on throughput rather than outcome in terms of success rate, there would be no-one, would there, in the Department of Health who would be in a position to as it were, second-guess the doctors; or would there? The experts are saying, "Here we are, we need to increase the throughput", might the Department of Health officials at any rate not say, "Well, this is the medical advice we have; we are not in [a] position to know better"?
`A. You have put the graphs up on the screen, which presumably lay people around the country can see, certainly around the South West. You do not have to be a genius and have to have a degree in statistics to see a very significant outlier, one unit with very poor results.
`If I was in the Department of Health in a position where I was accountable for quality, I would say "I am not happy just to increase numbers here, I want that looked into". I do not think you need to be a specialist. The whole history of medicine is littered with specialists not getting the right answer. You cannot necessarily rely on expert opinion.
`Q. Can we go on to the next paragraph: "Recently the Unit failed to provide a paediatric cardiac nurse for post-operative care because it was assumed that the baby would not survive the operation." Where did that information come from?
`A. I honestly cannot remember.
`Q. "Although Liverpool surgeons have successfully operated on 160 babies with Fallot's Tetralogy". Just pausing there, where did that information come from?
`A. One of my sources has a handle on what was going on around the country.
`Q. One of your sources in Bristol?
`Q. "A congenital heart abnormality, the Bristol mortality rate is between 20 and 30 percent, hardly the stuff of commendations."
`Who gave you the Bristol mortality rate of between 20 and 30 percent for Fallot's Tetralogy?
`A. I cannot be certain. It could possibly have been Dr Bolsin, it could possibly have been someone else. I cannot be certain.
`Q. The someone else is "A N Other"?
`A. Yes. I had another source so I was able to check between two sources, which to me I felt was enough to publish a story. In retrospect, I wish I had gone to John Roylance and Mr Wisheart, but for reasons I outlined in my subsequent statement, I was too frightened to do that at the time, but I felt that the two of them saying there was a problem was enough.' [44]
35 Mr Peter Durie, Chairman of the Trust Board, told the Inquiry that he had seen and discussed the `Private Eye' articles informally with members of the Board:
`I do remember myself and some other members talking informally about the "Private Eye" articles. ... In general, there was concern that there was a criticism of what standards we were trying to produce.' [45]
36 Dr Roylance told the Inquiry he received a letter dated 22 June 1992 from Ms J Binding, Corporate Affairs, NHS Management Executive [46] enclosing a letter dated 24 May 1992 written by a parent whose child was about to have surgery at the BRI and who expressed concern about the reputation of the `paediatric cardiology' unit after having read a `recent edition' of `Private Eye'. [47]
37 Dr Roylance's evidence to the Inquiry included this exchange:
`Q. ... by the time you got this letter, if you had not seen [the article] you then saw it?
`Q. Because you needed to respond to it?
`A. ... I think before that I had seen it but I can guarantee when this [letter] arrived I would have seen [the article] then.' [48]
38 Dr Roylance explained that both he and Mr Wisheart `... were concerned about the misunderstanding that had been given to parents of the child ...'. [49]
39 Dr Roylance replied to Ms Binding in a letter dictated by Mr Wisheart and signed by Dr Roylance dated 23 July 1992. [50] Mr Wisheart said that the letter attempted to convey the view that results taken as a whole were acceptable. [51] The letter stated:
`I am happy to report to you that [the parents of the patient] met Dr Joffe and Mr Wisheart together with Mrs Helen Vegoda our Paediatric Cardiac Counsellor, on Tuesday 21st July and had a full and very frank conversation. Each item raised in "Private Eye" of 8th May was fully discussed; in particular the results of Paediatric Cardiac Surgery in Bristol for children in general in the late 80s and for Fallot's Tetralogy in particular were discussed in detail, and we were able to inform [the parents] of the outcomes in Bristol in relation to the outcomes in the United Kingdom as a whole.
`Further we were able to discuss the specific procedure which [the child] will undergo in the near future namely the Fontan operation in which our overall results for the last five years are comparable to the United Kingdom results and in the last 18 months our results have been particularly good ... our overall results are extremely close to the UK results ... our results for Fallot's Tetralogy appear to be less good than the National results, chiefly because of an excess number of deaths [52] occurring in the treatment of this condition in 1990.' [53]
40 The letter also suggested that it was likely that paediatricians whose patients were treated in Bristol would in future have sent to them a `regular report' on the results of Bristol's paediatric cardiac work. [54]
41 Dr Roylance accepted in evidence that the results for Fallot's Tetralogy enclosed with the letter to Ms Binding indicated that in 1990 mortality was high but he said he was reassured by clinicians (`probably' Mr Wisheart) that results had improved. [55]
42 Dr Joffe and Mr Wisheart were aware both of the article and the parents' concerns both before the letter from Ms Binding was received and before the meeting with the parents was arranged. [56]
43 Dr Hammond stated in his written evidence to the Inquiry that the figures that he quoted in the May 1992 article were provided by one of his sources within the UBHT. He would not identify the source, but said that it was not Dr Bolsin. [57]
44 Dr Hammond explained that he had put the figures that he had received from his source to Dr Bolsin, to confirm their accuracy, nine days before the May article was published. [58]
45 Contact between Dr Hammond and Dr Bolsin had come about after a junior doctor approached Dr Bolsin's wife, who worked in the Accident and Emergency Department at the BRI, because he was concerned about the mortality rates in paediatric cardiac surgery. [59]
46 Dr Bolsin stated that the junior doctor explained to Mrs Bolsin that Dr Hammond would be interested in hearing concerns about the BRI cardiac surgery department. [60]
47 Dr Hammond then contacted Dr Bolsin by telephone. As a result of that contact, Dr Hammond went to Dr Bolsin's house on the evening of 29 April 1992. Dr Bolsin showed Dr Hammond what he described as his `very provisional' [61] log book data and expressed his `impressions of high mortality in Bristol'. [62]
48 Dr Bolsin stated that he regarded it as possible that some of the data from the Bolsin-Black (Dr Andrew Black, Senior Lecturer in Anaesthesia, University of Bristol) analysis may have reached Dr Hammond from individuals with whom he had shared the analysis. Those possible sources included consultants at the BRI and Frenchay Hospital, local managers, local junior staff and Dr Bolsin's friends in Bristol `and further afield', as well as his relatives. [63]
49 Dr Bolsin explained that he regarded Dr Hammond as a concerned trainee GP who may have wanted to influence his local colleagues to change their referral patterns for paediatric cardiac surgery. [64]
50 Dr Hammond stated that he considered Dr Bolsin to be a reliable source of information `... not just because of his consistency and clarity, but because I was told he was an acknowledged expert in clinical audit'. [65] Dr Hammond's impression of Dr Bolsin when they met was that he was `clearly very stressed and under pressure' and `very patient-centred in his analysis of the problem'. [66]
51 In mid-1992 Dr Bolsin applied for a post in Oxford. On 22 June 1992 Dr Bolsin discussed his application with Professor Prys-Roberts and Dr Brian Williams, at that time the Clinical Director, Department of Anaesthesia, UBHT.
`The outcome was that we made a deal, a gentlemen's agreement, firstly he [Professor Prys-Roberts] said he would back me very strongly in Oxford, he would back me in Oxford; if I did not get the job, would I come back and collect the data on paediatric cardiac surgery in Bristol?
`Q. Is it the case that by the time you spoke to Professor Prys-Roberts you had already spoken to Andrew Black?
`A. I was working with Andy Black on the audit data collection.
`Q. So there was data collection in process, albeit adult?
`Q. It was not Professor Prys-Roberts's position, no doubt as you understood it, to commission any data, survey or anything of that sort?
`A. No. It was a gentleman's agreement.
`Q. Do I understand that the proposal to collect data, to see what the figures showed, came from you rather than from him?
`A. No, the proposal came from him and he said "On the basis of that data, you must either shut up or put up", and I remember that phrase indelibly.' [67]
53 Professor Prys-Roberts' recollection was different, as appears in the following exchange:
`Q. Can I ask you to comment on that account of events, firstly the comment from Dr Bolsin ... that the reference and data collection were a process of exchange of favours?
`A. I think that is an entirely inappropriate statement for him to make. He asked me to give him a reference for a job in Oxford. I would normally give references for any trainee that I knew and it was a very unusual thing to be asked to give a reference for a fellow consultant because by and large fellow consultants did not move around, so once you got your consultant job you stayed there, so this was an unusual thing. I do not like the comment he makes in terms of "exchanging favours". There was no favour done. I gave him a reference because that is an entirely proper thing for an academic professor to do for a fellow consultant or for a trainee.
`Q. He also suggests this is a request from you to start collecting the data as of that time, that is the beginning of this particular process; how does that ...?
`A. I do not recollect specifically asking him to collect data from that time. I think probably what I would have said to him was "If you do not get the Oxford job, what are you going to do? You are going to be back here in Bristol I think you should then concentrate more on collecting more data."
`Q. "A gentlemen's agreement" was what Dr Bolsin described ... in evidence to us, do you think that is appropriate?
`A. I do not know what he means by "a gentlemen's agreement", there was certainly not an official involvement, we did not set up an official research study, it was not an official involvement of the University Department with what he was doing, I was simply offering him Andy Black's services as a relative expert in statistics so ...
`Q. What do you mean, if I may stop you, by "offering Dr Black's services"?
`A. I suggested to Steve Bolsin: "the analysis of these data require[s] a statistical process. You may want to start by asking Andy Black about it because this looks to me like the sort of data collection which requires multivariate analysis in order to pick out the details. He is an expert in that. He may say "go elsewhere". He did not.' [68]
54 In his written evidence to the Inquiry, Professor Prys-Roberts stated that by that time Dr Andrew Black:
`... had agreed to assist Dr Bolsin with the statistical assessment of his data gathered between 1989 and 1992, and Dr Bolsin was proposing to collect further specific data relating to certain operations such as the "Switch" operation.
`While I was aware that Dr Black and Dr Bolsin were analysing what data they had available, I did not consider that these activities in any way constituted an official involvement of either the University Department of Anaesthesia, or the University of Bristol, in a matter which was essentially a problem relating to an NHS service. For these reasons I saw no reason, at that time, to discuss these matters with Professor Gordon Stirrat, then Dean of the Faculty of Medicine.' [69]
55 Professor Prys-Roberts was asked in the following exchange whether he had contacted Dr Roylance after the meeting on 22 June:
`Q. ... when you saw Steve in July 1992 did you have any further assurance to give him that the matter was being looked into or developed, investigated by the Trust?
`Q. Had you been back to Dr Roylance to check what was happening as a result of your conversation?
`Q. Did you ever at any time go back to Dr Roylance to follow that conversation up?
`A. I do not think that I did. It has been suggested, I think it was Dr Bolsin who thought that I had telephoned Dr Roylance after seeing him and Dr Black on one occasion. I do not recollect doing that and Dr Black supports me in that recollection.' [70]
`I was unsuccessful in my application for the post in Oxford and consequently returned to Bristol in the summer of 1992 and set about collecting the data, which Professor Prys-Roberts had requested.' [71]
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Footnotes
[29] Dated 14 February, 27 March, 8 May, 3 July, 9 October and 20 November. See later in this chapter
[30] WIT 0283 0001 Dr Hammond
[31] WIT 0283 0009; WIT 0080 0011; WIT 0245 0007; T69 p.33. Mr Dhasmana told the Inquiry that he was aware at the time the articles were published that Dr Hammond was `MD', T86 p.126. Others, who expressed a view to the Inquiry, gave evidence that they were not so aware: Dr Bolsin, T81 p.101; Professor Stirrat WIT 0245 0007 and T69 p.35; Sir Kenneth Calman, T66 p.82; and the implication of Professor Angelini's evidence was that he did not know, T61 p.58
[32] WIT 0283 0001 Dr Hammond
[34] WIT 0283 0008 Dr Hammond
[35] WIT 0283 0004 Dr Hammond
[36] WIT 0283 0003 - 0004 Dr Hammond
[37] WIT 0283 0008 Dr Hammond. `Struck off and Die': a stand-up comedy programme written and performed by Dr Hammond
[38] WIT 0283 0005 Dr Hammond
[39] WIT 0283 0005 Dr Hammond
[40] WIT 0283 0014 Dr Hammond
[41] JDW 0003 0141; `Private Eye', 27 March 1992
[42] SLD 0002 0003; `Private Eye' , 8 May 1992
[43] Interim Report of the Working Party July 1989
[46] JDW 0003 0134; letter from Ms Binding dated 22 June 1992
[47] JDW 0003 0135; letter to Mrs Virginia Bottomley dated 24 May 1992
[50] JDW 0003 0157 - 0158 ; letter from Dr Roylance to Ms Binding dated 23 July 1992
[52] T88 p.134; Dr Roylance gave evidence that his understanding of the meaning of the term `excess deaths' at the time was vague but that he now understood that: `from time to time there is a poor run ... in ... low volume, high risk series ...'. He added: `I do not think anybody quite knows whether there is a local cause for it or it is just distribution of risk factors. Well, I do not know'
[53] JDW 0003 0157; letter from Dr Roylance to Ms Binding dated 23 July 1992
[54] Neither Dr Roylance nor Mr Wisheart could confirm in evidence whether that suggested course of action was subsequently implemented: T88 p.133; T94 p.143
[56] JDW 0003 0147; letter from Mr Orme (consultant paediatrician, Exeter, Devon) to Dr Joffe dated 8 June 1992; SUB 0013 0266
[57] WIT 0283 0009 Dr Hammond
[59] WIT 0283 0009 Dr Hammond
[60] WIT 0080 0111 Dr Bolsin
[62] WIT 0080 0111 Dr Bolsin
[63] WIT 0080 0111 Dr Bolsin
[64] WIT 0080 0111 Dr Bolsin
[65] WIT 0283 0009 Dr Hammond
[66] WIT 0283 0009 Dr Hammond
[68] T94 p.51-3 Professor Prys-Roberts
[69] WIT 0382 0003 Professor Prys-Roberts
[70] T94 p.49 Professor Prys-Roberts
[71] WIT 0080 0112 Dr Bolsin