Annex A > Chapter 28 - Concerns 1993 > Concerns > Concerns about the Arterial Switch procedure
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Concerns about the Arterial Switch procedure
39 On an occasion in 1993, Mrs Mona Herborn, Sister in Cardiac Theatres at the BRI from 1988 to 1998:
`... expressed to Dr Masey, Consultant Anaesthetist, my view that Mr Dhasmana was not capable of performing the switch operation. She then explained to me that none of the switch operations had been straightforward, that many unexpected implications [sic] had only been found when the patient was "opened up", which made it very difficult for the surgeon. From this and other conversations with the medical staff, I had to concede that I could not substantiate my concerns with hard facts. I just knew that I no longer wished to be taking part in switch operations. I tried to avoid other paediatric cardiac surgery where I could, but as it was a part of my job, I was not always able to do so.' [42]
40 Mr Dhasmana had some initial success in carrying out the Arterial Switch operation on neonates on his return to Bristol following his visit to Birmingham in December 1992. His first two patients survived. The third died. The third patient had an abnormal coronary arterial pattern that was undiagnosed prior to surgery. Two further patients then died. This prompted Mr Dhasmana to revisit Birmingham for further retraining. He was asked what made him go back to Birmingham in July 1993:
`I lost two patients in succession and both of these patients had normal coronary arteries, so in a way, that raised doubt again in my mind that here I was, I did two successful operations, the third did not make it, but it was a highly abnormal coronary artery and probably could be explained in any centre. But the next one survived so I am still happy, I have got, you know, out of four, three survivals. And the next two did not, although of course, with one of them we did have evidence of myocardial infarction, but nevertheless, these two did not and they had a normal coronary artery.
`... During this period, between 1992 and this time, July 1993, I had operated on about 7 or 8 older Switches and they all survived. So that is why, really, I was very concerned that something is probably a little different in neonates which I have not still been able to transfer. That is what was quite worrying me.
`I told Dr Joffe that, "I am very sorry, it appears that I will not do anymore neonatal Switches" ... He said, "Well, it so happens that I was going to get in touch with you". I said "What for?" He said "I have got another patient admitted with a similar problem".
`Then I narrated again what happened during the day in theatre and he I think tried to probably comfort me, saying "Let us just wait for the post mortem examination and then we can really - ". I said, "Well, I am not taking that next case on".
`He said "Well, what should we do?" I said "I tell you what. We talk to Birmingham". He said "Well, why do you not do that?" So the next day, I ring Birmingham, I ask for Mr Brawn. It so happened he was nearby ... he said "No problem, you know, bring the patient and I will operate here, and I tell you, I have got another patient here, so you will see two patients operated on the same day".' [43]
`I re-visited Birmingham in July 1993 accompanied by Dr Undewood [sic] and a patient from Bristol that Mr Brawn had agreed to operate on. We had further discussion on the problem being experienced in the unit. We returned to Bristol, re-assured and prepared to re-start the programme. The next neonatal patient survived followed by a further fatality and the programme was ended.' [44]
42 Dr Underwood said that, due to the changes Dr Masey had put in place on her return from Birmingham in 1992, she did not see anything that was really different between the practice in Birmingham and in Bristol in relation to anaesthesia. She said:
`... when I went in the middle of 1993, it was to observe them doing that same thing which Dr Masey had described to me, and I do not remember adding anything different or extra after that particular visit.' [45]
43 Mr Dhasmana was asked what he expected to discover from a second visit to Birmingham:
`What I noticed over these cases is that somehow, from outside and even when I have gone back in, the coronary artery looked in the right place. There was no obvious kink from outside. So I started asking myself whether what I called at that time the "lie", the way they are lying over the heart, have I got the angulation right, and maybe, technically anastomosis fine, and when you are looking at the post mortem, it looks fine, no problem, but the heart did not work. One of the things with anastomosis I think is the coronary artery, which I think is very important.' [46]
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Footnotes
[42] WIT 0255 0016 Mrs Herborn
[44] WIT 0084 0113 Mr Dhasmana
[46] T85 p.50-1 Mr Dhasmana. See Chapter 3 for an explanation of clinical terms