Annex A > Chapter 28 - Concerns 1993 > Concerns > Further concerns expressed at Bristol
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Further concerns expressed at Bristol
44 Mr Alan Bryan, consultant cardiac surgeon specialising in adult cardiac surgery, took up his post as Senior Lecturer in Cardiac Surgery at the University of Bristol on 1 July 1993.
45 He stated in his written evidence to the Inquiry that:
`Prior to taking up my senior lecturer appointment, I had formed the general opinion that paediatric cardiac surgery in Bristol may not meet contemporary standards. This opinion was based on general professional knowledge within the field of cardiothoracic surgery and my own perceptions dating from the time of my senior house officer post in Bristol. I was aware that attempts had been made to recruit Mr Martin Elliott ... to a Chair in Bristol which had failed. I had also seen disturbing articles in the magazine "Private Eye", I had briefly discussed this question with Professor Angelini [British Heart Foundation Professor of Cardiac Surgery, University of Bristol] prior to taking up my appointment.' [47]
`Having taken up my appointment in July 1993, some time in autumn 1993, Dr Stephen Bolsin presented to me outcome statistics in relation to specific diagnoses in paediatric cardiac surgical practice, namely Tetralogy of Fallot and Ventricular Septal Defect. I found these results disturbing since the data suggested that the operative mortality of one of the surgeons, Mr Wisheart, in relation to certain operations was well above the national average from the UK cardiac surgical register and was significantly higher than that of his colleague, Mr Dhasmana. At the time, I had no immediate way of clarifying whether the results presented to me were accurate or not since I had only just taken up my appointment. I was also aware at the time that there was considerable concern being expressed by a number of senior colleagues including Professor Angelini, Professor Prys-Roberts, Professor Farndon and Dr Monk. I have subsequently learned from Mr Wisheart that some of this data, in particular that relating to VSD, was incorrect.' [48]
47 Dr Bolsin said that, in September 1993, he spoke to Professor Angelini regarding the data which had been collected. Dr Bolsin said that he did this because:
`... I discussed it with Andy Black and we both felt that the peculiar sensitivity of the surgeons may have been related to the fact that there is, as you may or may not know in medicine, rivalry between specialist groups. There is a particular rivalry between surgery and anaesthesia because probably they work so closely together. Surgeons do not like to be told what to do by anaesthetists and anaesthetists do not like to be told what to do by surgeons and it is legendary and it exists.' [49]
48 In his written evidence to the Inquiry, Dr Monk stated that:
`After a number of personal requests, SB [Dr Bolsin] brought his data to me in the Department of Anaesthesia, I believe in October 1993.' [50]
In his oral evidence, Dr Monk put the number of requests at three or four. [51]
49 Dr Monk said that he did not take the data to either Mr Wisheart or Mr Dhasmana because `the audit I got was not verified', [52] but said that he: `spoke to them both about my concerns'.
`I did not feel that it [the audit data] was strong enough, robust enough, that I could take it directly to Mr Wisheart and say: "Here you are", because I think that he would have raised points that I could not answer about: "How did the audit take place? How was it performed? What were your criteria for selecting these epochs?" Therefore, very quickly I would be unable to make the point I wished to make.
`... What I wanted was to produce a forum where initially the cardiac anaesthetists spoke about the data, and I asked Steve, and we discussed the need to present the data to the cardiac anaesthetists, and he appeared to agree with me, but we did not achieve it. We had meetings and Dr Bolsin did not come ...' [53]
51 Dr Bolsin was asked in the following exchange about presenting his data to colleagues:
`Q. ... did he [Dr Monk] or did he not suggest to you that it would be appropriate to present your data to a meeting of the anaesthetists?
`A. I do not think so because if he had said that I would have prepared overheads and I would have been prepared to go to a meeting that anybody arranged.
`Q. He has suggested that there were meetings and you did not come.
`A. What sort of meetings has he suggested they were?
`Q. He is talking about meetings of the anaesthetists, as I understand his evidence. I have read you out the passage and you will have to rely on that.
`A. Yes, I mean they were not formal meetings. Certainly I never received a request to present this data to the paediatric cardiac anaesthetists.' [54]
`Q. Do we leave it like this; you had data in a form which could have been appropriately discussed at a meeting. That, as it happens, you did not take any initiative to go to a meeting of anaesthetists to discuss it?
`A. Yes, I think that is a fair summary.' [55]
53 Professor Angelini told the Inquiry that in November 1993 he had talked to Mr Jaroslav Stark, Consultant Cardiothoracic Surgeon at Great Ormond Street Hospital, (amongst others) about the data which Dr Bolsin had given him:
`Q. ... Did you compare the data that Dr Bolsin had given you with the returns to the cardiothoracic register?
`A. No. I cannot remember if I did. Probably I did not.
`A. Yes, I could, but I did something even better than that.
`A. I went to see Mr Stark at Great Ormond Street because I was aware of the fact that Mr Stark had information on what the performance of various units in the country were, and this was for two reasons: (1) because somehow he had been part of some government panel; (2) because he had recently given a speech at the European Association of Cardiothoracic Surgeons. He was the honorary guest of the President, where he had presented data, albeit anonymous, on cardiac surgery in the United Kingdom and he had specifically pointed out how centres which were not doing enough cases had worse performance and so forth. So he really was the person, in my view, who knew everything of what was going on in the UK in paediatric cardiac surgery.
`Q. So you went to see Mr Stark at Great Ormond Street?
`Q. I think you said at the GMC that that was in November 1993?
`A. Yes, that is correct, 17th November, something like that.
`Q. Did you actually physically show him the data Dr Bolsin had shown you?
`A. First of all because I did not think it was fair to take stuff which in a way had been given to me in a sort of confidential matter, and also because I knew that Mr Stark was fully informed of what was going on. He had pictures of information of all the United Kingdom data.
`Q. You said that this data had been given to you in a confidential matter?
`A. Yes. I mean, "confidential"; "do not take it out of your own institution and show it to everybody". ... Incidentally, even at a later stage I was accused of having done this.
`Q. How did you know how confidential the data was that Dr Bolsin gave you?
`A. I mean, I guess it was relatively confidential because if it had been given to 5 or 6 people, I do not know, how can you describe "confidential"? But I thought that it was really not appropriate at that stage to take it out of what was our institution. I had gone to see Mr Stark to ask advice from a senior paediatric cardiac surgeon who was well informed of what was going on nationally on how I should act, if anything, in trying to resolve this problem.
`Q. Did you discuss with Dr Bolsin how secret this data was?
`Q. Did you tell Dr Bolsin you were going to see Mr Stark?
`A. I do not think I did until I came back. When I came back, I told Dr Bolsin and I told Professor Farndon, and my senior lecturer, Mr Bryan.
`A. The conversation took place in his office and effectively I said to him that I have come to him for some advice as a senior person, since he was a very senior person in the business. I said that there had been data suggesting that the mortality was high. Also, my perception, after having spent a year in Bristol by that time, was that mortality and morbidity was a much different story to what I was accustomed to. He said that he was aware of those problems. Indeed, he showed me some of the slides which he had presented at the European meeting, saying "You are not telling me anything new because I have done an analysis" and demonstrated that centres which do not do a great volume of work, like Bristol, will have worse results than specialised centres which do a lot more operations. We discussed these aspects, after which I said to him, "What would you advise? You are a senior man, what would you advise me to do?" He said he thought the best way would have been for me to go back to Bristol, to my head of department -
`A. - the Professor of Surgery, Professor Farndon, and in a way present him with the problem, telling him I had discussed things with Mr Stark, and he said, "I am sure you can resolve this matter in-house. Failing that, you may have to ask for some external help." There were some other issues discussed -
`Q. Just pause there a minute. What did you understand by "external help"?
`A. I mean somebody senior like Mr Stark coming in and having a look at what we were doing.
`Q. Did he mention anything about sending patients from Bristol to Great Ormond Street in the meantime?
`A. No. What he said, I think, it was that if we have a problem with a patient that needed urgent treatment, certainly this could have been done at the GOS.
`Q. Did he mention the ability of clinicians in Bristol to go with those patients to GOS?
`A. I think he said that, also because in the case of Mr Dhasmana, he had already worked for a year at the GOS.' [56]
54 Mr Stark, in a written comment on Professor Angelini's written evidence, stated:
`I do remeber [sic] meeting with Prof Angelini. He came to see me at GOS to discuss Congenital Heart Surgery at Bristol. I do not recall the exact date
`It is correct, that I did not offer formal retraining for the Bristol team. Retraining as such was not organised by the Colleges nor by the Sociaty [sic] of Cardiothoracic Surgery at that time. Although today there is much talk about retraining, the practical aspects of retraining have not been worked out yet.
`I do recall that I have suggested that my coleagues [sic] and myself would be happy to operate [on] children with the diagnoses, with which the Bristol team was experiencing problems. I have mentioned, that if they decided to send some patients to us, the surgeons or any other member of the team would be most welcome to come with the patient to see the way how we handled such problems at GOS.' [57]
55 Professor Angelini responded to Mr Stark's comment in the following exchange:
`A. ... What he did not mention - I am sorry, what we did not discuss - I have not seen this yet, I am seeing it now. What we did not discuss, which was highlighted at the GMC trial, was the fact that he never offered to retrain people and I stand to what I said: there was never any offer from him to retrain people. What he said is correct -
`Q. Have a look at the previous paragraph, Professor, that may help.
`A. "It is correct that I did not offer formal retraining", yes, that is right, I am glad he said that.
`Q. So are you and Mr Stark on the same wavelength?
`A. I think so, yes. I do not have any problem with this.
`Q. The suggestion that patients and clinicians might go to Great Ormond Street, that Mr Stark made to you, to whom did you communicate that offer in Bristol?
`A. To Professor Farndon, but if you read this through, this does not mean the surgeons go there and they do the operation. The surgeon and their staff go there and see what the people in the GOS do, which to a certain extent is the same that happened when Mr Dhasmana and some other member of the surgical team went to Birmingham.
`Q. All right, take it slowly. To whom did you communicate this suggestion?
`A. I think to Professor Farndon, but quite honestly, I do not know if I did.
`Q. You did not do it in writing, did you?
`Q. You did not communicate it to Mr Wisheart?
`A. No. I did not see any point in sending patients to the GOS with everybody going in and observing. Quite honestly, I do not think that would have helped Bristol in any way whatsoever.
`Q. But is it not the case that going to observe a centre that is a recognised centre of excellence can assist a surgeon to -
`Q. - to retrain. For example Mr de Leval and the "Cluster of failures" and the Arterial Switch operation?
`A. Yes, but also what we say in surgery is "Watch, do it and teach it". Watching on its own is not a solution to the problem. You can take your registrar and ask him to help you on a million cases. The first time he does it, there will not be much difference if he helps you on a million cases or 100, 000 cases. Therefore, what I am reading in this letter is that although they were prepared to take this patient in the interests of the children, they were not going to do anything to really retrain the people because they could not retrain the people.
`Q. So you had no faith in the ability of Great Ormond Street or anyone else to retrain the Bristol surgeons?
`A. No, I did not say that. To retrain people, you have to take these people, not just to watch. Training means you are standing on the side of the assistants and the trainee does the operation. That to me is training. Otherwise just watching by itself is not what I regard as training. That is part of the training, but it cannot be the whole training, if you are not allowed to do things at the first operating surgeon.
`Q. You took it upon yourself to sweep Mr Stark's offer under the carpet?
`A. I do not know what you mean.
`Q. You did not tell anybody about it?
`Q. You accept that was a mistake?
`Q. Because did you consider Great Ormond Street to be a better centre than Bristol for paediatric cardiac surgery?
`A. Yes, absolutely, but I also considered that Birmingham was a much better centre, particularly for the Switch, than the GOS.
`Q. Later on we will see that you were suggesting, at the time of the Loveday operation, that if it was truly urgent, the case might be sent to Mr Brawn in Birmingham, for example?
`Q. Might there not have been patients between your visit to Mr Stark in November 1993 and Joshua Loveday's operation in January 1995, who, in your opinion, would have benefited from being operated on elsewhere?
`Q. And Mr Stark's offer would have provided for that?
`A. Yes. Why did not I refer the offer? Very simple: because my main concern was to stop the surgery from taking place in Bristol, because in Bristol we were no good at this kind of surgery; therefore it should not have been carried out. I do not think that I was in any position to influence anybody's decision for these children to be sent to another institution because in fact, as demonstrated, even in the last Switch case, nobody gave a toss about what I was saying. Therefore, they were not listening.
`I accept with you that I should have related this particular information that Mr Stark had given to me to the surgeon and to the cardiologists, and it was a mistake on my part not having done so.
`Q. This is not a case of not listening, this is a case of not hearing because you were not telling them?
`A. In this case, that is correct.' [58]
56 On 16 November 1993 Dr Bolsin went, by appointment, to see Professor Vann Jones who had become the first Clinical Director of the newly created Directorate of Cardiac Services in the preceding month. [59] Professor Vann Jones described his meeting with Dr Bolsin as follows:
`Dr Bolsin came to my office on 16th November 1993 ... He showed me results from four different types of operations carried out on children [in the BRI]. They were four specific operations and the point that he was trying to make was that the performance [at the BRI] was well below the national average for these conditions. One of these conditions was ventricular septal defect which is a relatively simple congenital defect and, because of my background ten years earlier in paediatric cardiology, I could tell that the data for that particular operation must have been flawed. A very high mortality was reported for a very low risk procedure and it just could not have been possible that these data were true. I expressed my concern about this to Dr Bolsin and asked him to go away and check his figures. Obviously, this led me to doubt the validity of the data on the other three operations. Dr Bolsin did not seem to me to be particularly concerned and the data were presented in a very matter of fact way. However, because I was convinced, at least, one set of data was flawed I expected him to go away, check the figures and to return. He never did return.' [60]
57 Professor Vann Jones was asked about his reaction to the results:
`We have to envisage the situation in which I found myself. At that stage I had 12 years of very good service from Mr Wisheart, and from Mr Dhasmana, although not so many years. For many years these chaps operated on some extremely sick patients of mine, and the patients survived, the patients did well and were very grateful, and so was I. In front of me was a set of figures which said three operations were worse than the national average, one was not significantly different, and one I could see was blatantly flawed, so I actually wanted some further clarification of this information ... .' [61]
58 Professor Vann Jones was asked further about the meeting with Dr Bolsin in the following exchange:
`A. It was a totally amicable meeting. It is absolutely right that people should express concerns about the management of cases. That is what they are all there for. Our job is to look after patients in the best possible way. So it was a perfectly amicable meeting. I was somewhat worried about the Tetralogy of Fallot figures. I was hoping he was a bit worried about the VSD figures, but I have to say, it was only four operations, one was not significantly different. Three were and one set of results was obviously quite wrong. I most definitely mentioned that to him, but just how strongly or what message he got from it, I do not know. I think if you are taking sets of figures around and someone actually questions the validity, and it is a very, very important issue you are raising - I mean, we all know how important it is now - I think the least you should do is go and make sure you have your facts right. And I did expect him to come back and he did not.
`Q. What did Dr Bolsin ask you to do, if anything?
`A. He asked me to do absolutely nothing. He purely and simply said "Look at these tables, John. I think this is worrying." That was it.
`Q. Did he suggest that any particular action needed to be taken on those figures?
`Q. Because again, his account is that he explained to you that this was as thorough and as complete an audit as he could carry out, and that he believed that there needed to be a full investigation into the paediatric cardiac surgery service on the basis of the figures that you were given?
`A. Well, I have no recall of him being anything like as positive as that.
`Q. What was his manner to you, as you recollect it?
`A. As I have already indicated, it was a very bland, no sense of urgency type meeting that we had that morning. He presented those very sheets of A4, we talked around them for an hour, but there was no question of "This is a national tragedy brewing, John", absolutely nothing of that. There was a concern about some of these operations and it was expressed at that sort of level, no emotions involved, no tears, such as has happened subsequently.
`Q. Does it need emotions or tears to translate the sort of figures that you are being given into the proposition that children's lives were being unnecessarily endangered?
`A. No, it does not, but you have to remember that if you are talking about 4 per cent of the paediatric cardiac programme, and we are talking about a very small percentage of the cases, then I would want to have seen the whole picture. If the whole picture was one of uniform, you know, worse performance, then that obviously would have been a very, very major cause for concern, but I have not the slightest doubt that had people taken my angioplasty results for 1985, let us say, and compared them with elsewhere, I may well have looked worse than Southampton and I may well have been worse for two vessel disease than for single vessel disease. We all have runs of procedures where we get to the stage where we think we cannot do them any more, and have bad runs. In paediatric cardiology, in particular, the investigations are very complicated.' [62]
59 Dr Bolsin in his written evidence to the Inquiry described the meeting as follows:
`Professor Vann Jones did not ask me to return having checked the figures. I explained that this was as thorough and complete an audit as we could carry out and that I believed there needed to be a full investigation into the paediatric cardiac surgery service on the basis of the figures I gave to him that morning.' [63]
60 Dr Bolsin stated that he had approached Professor Vann Jones in his capacity as Director of Cardiac Services:
`I approached Prof Vann Jones as the new Director of Cardiac Services. I assumed that he had some control over the events in the Associate Directorate of cardiac surgery.' [64]
61 Professor Vann Jones stated:
`It was obvious from my conversation with Dr Bolsin ... that he had shown these figures to a number of other more relevant people.' [65]
62 When asked why, in his view, Dr Bolsin came to see him, Professor Vann Jones said that he:
`... would have expected to have been well down the pecking order of people that [Dr Bolsin] should have been reporting his concerns to ... That may well have been erroneous ... but why he should elect to come to an adult cardiologist who had been Clinical Director of a non-existent directorate for three weeks and regard me as an important player in this ... .' [66]
`Would have expected [Dr Bolsin] to at least have gone to his Chairman of Division of Anaesthesia.' [67]
64 Professor Vann Jones said that it was his understanding that Dr Bolsin had not approached the surgeons concerned, Mr Wisheart and Mr Dhasmana, with his data:
`I think [Dr Bolsin] owed the two surgeons a courtesy to say he had concerns about their performance. ... I think you are obliged to go and discuss with people how they were performing ... I would have thought if one consultant was really concerned with the performance of another two consultants, that he should go and say "I have serious concerns about this and I must go and raise the subject with the relevant parties". I think it would have been courtesy. Then we would not have people running about with different sets of figures and we could perhaps have sat down and got the whole thing clarified.' [68]
65 In his written evidence to the Inquiry, Professor Vann Jones stated that a day or two after Dr Bolsin went to see him, Mr Wisheart also came to visit him:
`He had quite a different set of figures and certainly as far as ventricular septal defects were concerned the figures he presented were much more what I would have expected.' [69]
66 Mr Wisheart set out the reasons for his visit to Professor Vann Jones:
`A short time prior to my visit to Prof. Vann Jones, Prof. Dieppe [70] had come to see me in my office. Dr Bolsin had just been to see him and had expressed concerns about paediatric cardiac surgery which he [Professor Dieppe] came to discuss with me. I do not remember whether or not Prof. Dieppe mentioned any specific operations. He did not have, or mention to me, any actual figures, or give me any indication that audit figures existed ...
`On reflection, I considered that if Dr Bolsin was expressing concerns to people in the Trust and the University, that Prof. Vann Jones, Clinical Director of Cardiac Services in which Directorate I did most of my work, should know and have the accurate results of paediatric cardiac surgery. Therefore I went to see him. I did not know that Dr Bolsin had already been to see him.
`Prof. Vann Jones did tell me that Dr Bolsin had been to see him but did not tell me about, or show me, any figures or audit. I continued in ignorance of the existence of Dr Bolsin's audit.' [71]
67 Professor Vann Jones expressed the view, after speaking to Mr Wisheart, that:
`At the end of the day, something as important as this should have been a matter that the Chief Executive should have attended to. I do not mean personally, but certainly he should have set in place some form of investigation.' [72]
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Footnotes
[47] WIT 0081 0023 Mr Bryan
[48] WIT 0081 0023 - 0024 Mr Bryan
[50] WIT 0105 0020 Dr Monk
[56] T61 p.73-7 Professor Angelini
[57] WIT 0073 0111 Mr Stark
[58] T61 p.78-82 Professor Angelini
[59] WIT 0115 0002; Professor Vann Jones stated that he regarded himself as responsible for an adult, rather than a paediatric, service
[60] WIT 0115 0019 Professor Vann Jones. See Chapter 3 for an explanation of clinical terms
[61] T59 p.107 Professor Vann Jones
[62] T59 p.115-18 Professor Vann Jones. See Chapter 3 for an explanation of clinical terms
[63] WIT 0115 0025 Dr Bolsin
[64] WIT 0115 0025 Dr Bolsin
[65] WIT 0115 0019 Professor Vann Jones
[66] T59 p.119 Professor Vann Jones
[67] T59 p.122 Professor Vann Jones
[68] T59 p.122-3 Professor Vann Jones
[69] WIT 0115 0020 Professor Vann Jones
[70] Dean, Faculty of Medicine, University of Bristol
[71] WIT 0115 0026 - 0027 Mr Wisheart