Annex A > Chapter 29 - Concerns 1994 > Concerns
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Concerns
January
1 During the latter part of 1993, Dr Alison Hayes, a consultant paediatric cardiologist at Bristol Royal Hospital for Sick Children (BRHSC) from October 1993, had been asked by those in the paediatric cardiac mortality meeting to collate the figures for the Arterial Switch operation. Dr Stephen Pryn, a consultant in anaesthesia and intensive care at the BRI from August 1993, was also asked, by his Clinical Director, [1] to prepare figures on paediatric cardiac outcome data, which he did for the chronological year ending 31 December 1993. [2]
2 It was planned that Dr Alison Hayes would present the data, and that Mr Dhasmana would speak about them, at a meeting on 20 January 1994. At the meeting were a number of anaesthetists: Dr Davies, Dr Pryn, Dr Underwood, Dr Masey, Dr Bolsin and Dr Monk; surgeons: Mr Wisheart, Mr Bryan, and Mr Hutter; and cardiologists: Dr Hayes and Dr Martin. [3] The meeting was held in the seminar room of the Department of Cardiac Surgery on Level 7 of the BRI. In the event, Mr Dhasmana did not attend the meeting, [4] Dr Hayes did not produce data, Dr Pryn presented some figures and Mr Wisheart presented from memory figures for the previous year. [5]
3 Various witnesses described the meeting. Dr Monk, in his oral evidence to the Inquiry, stated that the meeting arose:
` ... because Professor Angelini and I were discussing how we would create a forum for the issues and problems of data to be discussed ... I suspect that the actual timing and venue of the meeting came from the Professor's office ... that ... would have been ... because Professor Angelini felt that the issues that they talked about in bringing forward the figures on the paediatric cardiac service had not achieved what he wanted, he, and I, may have said, "Then we must try a different route and we will have a meeting in Level 7 of all the cardiologists, surgeons and anaesthetists, and get the figures presented". So it may have been that the January meeting was a direct consequence of Professor Angelini's feelings that enough had not been achieved between the meeting of these three surgeons [Mr Wisheart, Professor Farndon and Professor Angelini].' [6]
4 Dr Monk described the meeting further in the following exchange:
`A. There was no agenda produced and, as I noted, there was no Chair of the meeting ... I realise that was one of the reasons that the meeting was not as effective as it should have been. ... If [Mr Dhasmana] had been there, he would have chaired the meeting ... My understanding of the meeting was that it would give an opportunity for the surgeons to present their paediatric data and an opportunity for Dr Bolsin to raise his data and that afterwards we could try and find a way forward to get these two groups, or parties, together and that we could resolve the differences that occurred. ... The issue that I thought was going to be addressed was the overall performance ...
`Q. So is it your view, having been at the meeting, that the cardiac surgeons had some idea as to why they were there?
`A. I would have that view, yes.
`Q. Why do you think Mr Wisheart thought that he was there?
`A. I think because Mr Wisheart expected that he was going to present his data and he duly did.
`Q. Your perception from the time, please: why would it be that he should think he was being called upon as an unusual step in this ad hoc specially convened meeting to present his data?
`A. Because of the concerns that had been raised about the performance of the Unit. ...
`Q. ... from where would [Mr Wisheart] have understood ... the impetus for the meeting to have come?
`A. I would think that because Professor Angelini had discussed the meeting; it may well have come from him that he was activating the surgical group and I was bringing in the anaesthetic group.
`Q. So this may well be a case ... of the cardiac surgeon knowing that the anaesthetists were raising concerns about the performance of cardiac surgery?
`A. It could be an instance or circumstance, yes.' [7]
5 Dr Monk was questioned further about the meeting in the following exchange:
`Q. When you spoke ... to the anaesthetists to get them there ... did you tell them what was on the agenda?
`A. There was no agenda. But I think we would have discussed the fact that this was an opportunity to discuss the data, or the lack of agreed data. But we were still, at that time, trying to produce an environment where people could talk about the differences of data and we could find a way forward. To do that, it had to be presented.
`Q. This would have been a perfect opportunity, one suspects, for Dr Bolsin, had he thought his data presentable, to present his data.
`A. The whole point of the meeting was for the data to be presented. It seemed to me to be a time at which it could be presented, yes.
`Q. And for Dr Pryn to present the results of the work that he had been doing at your request up until then?
`A. I think that Dr Pryn ... may not have had adequate time to produce the data in a form that was useful. I think his data was lost to discussion ... because it did not match the format of the data that Mr Wisheart presented on a blackboard from memory. ...
`Q. And somehow Mr Wisheart begins the discussion, does he, by putting the figures on the board?
`A. Within that meeting, James Wisheart presented his data from memory, or the Unit's data from memory, on the blackboard. If I recall correctly, he had expected that Mr Dhasmana would be there because Mr Dhasmana had been collating data. So what you have are a number of threads which are all happening simultaneously, that we had hoped, or I had hoped, would come together at that meeting. ... There was some discussion [about Mr Wisheart's data], but the point of the meeting was to hear another side and to look at it in a constructive way. From that point of view, the meeting did not succeed.
`A. Because there was not a Chair of the meeting and there was not an agenda. ... it was done in a way which was not as clear as I would like to have done it if I did it tomorrow, then the meeting was already flawed. ... Dr Bolsin ... did not present his data. ... Dr Bolsin played a very minor role, if any at all.
`Q. Dr Pryn raised, did he, some of the figures that he had collated, and then fell into an argument as to whether he should have divided it between particular age groups?
`A. One of the issues that is very hard to deal with when you are looking at retrospective data, particularly in this field, is that the definition of the operation, the diagnosis of the operation, what epoch or age group you define them in, varies. Indeed, it even varies from the point whether you do it from January 1st, December 31st or whether you do it for a financial year. Whereas it seemed sensible for me to do it for a calendar year, in fact the data given centrally is for a financial year. In fact Dr Pryn discovered, to the cost of his data, that the way in which he presented it did not quite accord with the way other people were thinking and therefore, rightly or wrongly, it was dismissed as being inaccurate. But that was the atmosphere at that time, which was difficult, and his data was not in the correct format and he was unable to get his message across.
`Q. So the atmosphere was difficult?
`A. The atmosphere, as people have discussed, is where people were aware of criticisms, so it was a difficult meeting.' [8]
6 Dr Monk continued in the following exchange:
`Dr Pryn was not successful in putting forward his data.
`Q. And Mr Wisheart's was therefore the only data effectively presented to the meeting?
`Q. Did that show an acceptable picture of paediatric cardiac surgery in Bristol at the time?
`A. The determination of "acceptable" is very difficult, because we did not have a standard to say "that is acceptable" or "that is not acceptable". If we had a standard that was UK-wide and it said "you can accept this level of mortality or this level of morbidity" and you cross it, you can say it is unacceptable. You are talking about a judgment that is being made in the middle of the experience. So that is one of the cruxes of the whole problem.
`Q. Let me approach it this way: was there any challenge to the accuracy of the data that he produced, leave aside their interpretation?
`A. Mr Wisheart`s data was not challenged from the floor. ... You recall from these meetings the impact and what your actions were going to be afterwards, and I had great frustration because what I had hoped to achieve was that other data was presented and then you could say "We need to go forward and have an audit that looks at our work ..." When you have got that, we can sit down and talk about it and we can truly analyse the problem. We needed to try and bring everyone together.
`Q. Do you think, looking back on it, that perhaps part of the problem was that there had been insufficient time for preparation before the meeting, for those who might have presented rival data to get their tackle in order to present it?
`A. There are many things that should have been in place before that meeting, one of which was a joint opinion of the cardiac anaesthetists so we could say "This is what we as a group say". It would have been helpful if we had put an agenda on the table with a Chair to run the meeting, but we had not done it. The meeting happened in a very Latin way, as it were, in that Professor Angelini and I still recognised there was a problem and we had an idea, and we thought "Let us go and do it". It developed an impetus of its own. Yes, looking back, I should have, somebody should have, been more structured in the meeting, and because it was not structured the point you are making was not achieved. [9]
7 Dr Pryn, in his written evidence to the Inquiry, described the meeting as a regular audit meeting. He stated:
`In early 1994 I attended a regular audit meeting where Mr Wisheart presented the paediatric cardiac outcome data for the year (I believe ending March 1993). I clearly remember being most impressed by the fluency of his presentation, which was done without reference to notes. I have never seen a hard copy of the data that Mr Wisheart presented on that occasion. As he was presenting this data, I was trying to compare his figures with my data, particularly in relation to the outcome for AV canals. In part this was complicated by the fact that my data was compiled from January to December 1993 rather than for the financial year ending March 1993. I also had not appreciated the importance of distinguishing between children aged over 12 months and those under 12 months. I felt, at the conclusion of this meeting that one did need surgical expertise in order to categorise the data properly. I also thought that as the surgeons were collecting the data anyway, and they were in a better position to interpret it, my efforts were unlikely to be helpful. Although I had undertaken this study at Dr Chris Monk's request, he did not ask me about it again, and following this audit meeting, it did not appear to have any great relevance. I assumed, as I believe my colleagues did, that in due course the cardiac surgeons would present the figures for the year ending March 1994.' [10]
8 Later, Dr Pryn told the Inquiry that:
`... it probably was not a regular meeting, because Sally Masey [11] would not have been there if it was a regular audit meeting.' [12]
9 Dr Pryn described further his understanding and recollection of the meeting in the following exchange:
`A. I thought we were going to talk about the recent results.
`Q. Dr Bolsin's data was not presented to that meeting?
`A. No. ... It would have been a good opportunity to present it. It would have been a good opportunity to present my data, but I did not know the meeting was called for that purpose and my data was not ready. If I had been told a few days before, I might have been able to get it ready.
`Q. So what warning did you have of the meeting?
`A. It cannot have been that much, otherwise I would have made a big attempt to complete my data. ...
`Q. You do say your data was not comparable because it covered a calendar year, whereas the other one, Mr Wisheart's, was covering a financial year?
`A. His would not have been as up-to-date as mine, because basically I had cases on my list who were still in the intensive care ward; they had only just been operated on, so there were some outcomes we did not know yet.' [13]
10 Dr Pryn's oral evidence to the Inquiry included this:
`Q. He [Dr Monk] [14] says at the meeting there was no effective Chair. What is your comment on that?
`A. I think that is true. I think somebody at the back said "James, can you present your data?" and he got up and presented it, but nobody was questioning him on that data and nobody was chairing the meeting to bring in other people's comments and discussions.' [15]
11 Dr Pryn expressed the following view about Mr Dhasmana's absence from the meeting:
`I would have thought it was really important for him to play a part ...' [16]
12 The pattern of the meeting, as seen by Dr Pryn, emerged from the following exchange:
`Q. It says here that the main data presented was presented by Mr Wisheart on a blackboard, or a whiteboard, and then it suggests there was something from you: some of the most recent data available on the 1993 operations. Does that overstate the nature of your contribution?
`A. I think it does, a little bit. Whilst Mr Wisheart was presenting his data, I was looking down through my very rough workings and was trying to count in my mind. I particularly chose the AV canals, because I think Mr Wisheart had said, "Here are the realities for the AV canals; they are not good but they are tolerable", and I wanted to cross-check that with my data. So I was counting the AV canals and I got a little confused between children who were aged over 1 and under 1, and at the end I made some comment about, I do not know, mortality in children with an AV canal over 1, and both Mr Wisheart and Alison Hayes, the cardiologist, actually said to me, "Your data must be rubbish because we do not do AV canals in the over 1s". So that was it. So I sat down again: basically, I had not prepared for a presentation. I was not in a state to do it. So I got what was coming [to] me.
`Q. Can you remember whether Mr Wisheart's figures covered the range of operations and procedures within the BRI, or whether it was related to one or two procedures only?
`A. No, I believe that he covered the entire range, which is what impressed me, because it all came off from memory and he could write down all these figures, even for tiny groups. He must have known the figures particularly well to do that.
`Q. If we go on back to [Dr Monk's] statement: "The meeting resolved little as there was not a frank discussion on outcome, and I believe it did more to consolidate difficulties and differences than start a process to address the problems". What do you have to say about that commentary?
`A. I think there you come down to the problem that I think Mr Bryan highlighted, where difficulties were often explained away by poor cases such that when Mr Wisheart presented his data, it was all in small subsets of procedures or diagnoses, and it was difficult to see the overall picture of the Unit performing poorly for small children. So the conclusion that Mr Wisheart drew and that we all came away from the meeting with was that "Bristol is not brilliant, but some things are quite good; other things are okay; some things are pretty poor, but you know, that is the way all units are and we are no worse than any other unit".
`Q. Which things were pretty poor?
`A. I cannot remember the specifics, but I would have imagined he may well have drawn AV canals, saying they are not good, because that is why I was looking through AV canals.
`Q. Would the Switch operation have featured in discussion?
`A. It may well have done, but I am not sure whether he presented it as a Switch or just mixed the Switches up with Atrial Switches and just had them in diagnostic categories as opposed to operative categories. I cannot remember how he presented his data. In fact, there was no hard copy for us to take away from that meeting.' [17]
13 Dr Bolsin gave his account of the meeting in the following exchange:
`Q. ... At that meeting, Mr Dhasmana is supposed to present the results of the Unit but he is operating so he does not?
`Q. And the meeting is there. Everyone goes to Level 7. That is unusual, is it?
`Q. So there was particular interest in the results?
`Q. Particular interest by you, because you had been carrying out your work with Dr Black and you had shown that to some of your anaesthetic colleagues?
`Q. So here was Mr Wisheart coming forward, presenting the results of [the] Fontan operation?
`A. Yes. ... I can remember a few figures being put up on what I think was a whiteboard, but I am not sure there was an enormous amount of discussion.
`Q. And open to you, had you wished, to say, "Look, we, the anaesthetists, have a bit of concern about the overall outcomes. Can we have a fuller review? We were going to review the figures here today. We have not had them because Mr Dhasmana is elsewhere, can we be circulated because we are concerned from individual experiences that something may need to be improved"?
`A. Yes. ... I specifically did not have any concerns about the Fontan procedure, because we had audited the Fontan procedure.
`Q. But the purpose of the meeting would be to look at the results generally?
`Q. If you had a general concern, which you say you did ... why not raise it at that meeting in some appropriate terms?
`A. I think I was still expecting concerns about results to be raised directly with the surgeons by those people who were empowered to do so, and that was really the Clinical Director and possibly Professor Angelini. ...
`Q. ... is it right that you understood at the time of this meeting, 20th January 1994, that Chris Monk was calling you and your activities "trouble"?
`A. I think probably for me to say that definitely at this time that had been said may not be true, but certainly, I was aware of a groundswell within the department or possibly the organisation that this was seen as troublesome activity. ...
`Q. ... if you had felt free in 1991 to raise the issue, after the 1990 events, to raise the vigilance of the anaesthetists and drawing attention to the mortality figures and so on, put your head above the parapet, as it were, then why did you not do it at this meeting here in January? ...
`A. ... There were also two very different meetings. I think the meeting in 1991, at which I had been prepared to say that the "vigilance of the anaesthetists" was something sitting in an armchair, much more informal. I think in a formal meeting, such as the one on Level 7, I was much less prepared to raise formal criticisms of the paediatric cardiac surgery mortality ... Saying this indicated the vigilance of the anaesthetists in keeping their morbidity and mortality data is not the same as raising a service problem of mortality in that unit in a formal setting. ...
`Q. So you had a feeling, at this stage, that if you had pushed the issue - let us suppose that you had said something at the meeting of 20th January 1994 ... to the effect, "This data is disturbing, we must do something about it and I propose X and Y"? ...
`A. I am not sure I would not have had support. I would have been worried about the consequences from other people.
`Q. Both Dr Pryn and Dr Monk seem to recollect that at this meeting, 20th January 1994, it was not just the Fontan results which were presented, that in fact the results for the Unit were presented, even though they might not have been presented as Mr Dhasmana might have wished. Are they right or are they wrong about that?
`A. As I remember the Fontan results, I do not remember the whole results of the Unit.
`Q. Might they have been presented?
`A. It is possible, but I just remember Mr Wisheart standing and writing figures down, and I think it would have been almost impossible for him to have written down all the results of the Unit.
`Q. Had you wished, and had you not felt vulnerable as a result of the influences you told us of, you could, I take it, have presented the data?
`A. Yes, I could if I had wished.
`Q. And if you had done, you would have urged the meeting to carry out a full and thorough review?
`A. Yes. I think my hope was that this meeting was going to be the full and thorough review that we had been aiming at for a long time, so to a certain extent, although it had taken a long time and we had had our data for about two years, my hope was that by going around the various routes that we had gone to, we had actually now achieved the full and open review that certainly I, and I think Andy [Black] working with me, had always wanted. So I expected at this meeting on 20th January, it was actually the goal, the destination that our data was the signpost towards.
`Q. Did you contribute to the meeting at all?
`A. No, I was very disappointed that we were not at this destination.
`Q. So you have a very disappointing meeting on 20th January?
`A. Yes, in terms of data, yes.' [18]
14 Mr Dhasmana gave his view of the meeting in the following exchange:
`Q. ... it had been intended that you would present the results, the annual results?
`A. No, that is wrong. That [meeting of 20 January 1994] was an extraordinary meeting, a paediatric cardiac club meeting, not an audit meeting of the department, because I had already presented my yearly audit figure in December 1993, but this was called because I had stopped my neonatal Switch in October 1993. Dr Alison Hayes was asked to have the data prepared ...' [19]
15 Mr Dhasmana's evidence also included this:
`Q. ... The meeting ... was a meeting for you to present results, particularly in relation to Switch, you say?
`A. It was not just for me, really. It was for Dr Alison Hayes to present her figures on Arterial Switches and of course, I would be there in a way to present whatever I could really say on my behalf, but I was told "You are too much involved with this thing, let somebody else do the audit and you be there to answer whatever questions are there". So that is how it was. ...
`Q. As it happens, you were not able to go because you had commitments elsewhere?
`A. Well, I was operating. I got held up so I started getting worried and I made enquiries, what is going to happen? I was quite shocked to find out Dr Alison Hayes had already presented that data during the first week of January in the Children's Hospital, one of these Monday morning meetings, and I was at that time on holiday to India. I returned only 15th/16th January, and she had presented just after the Christmas break. So that was already presented.
`Q. That would be to the cardiologists, would it?
`A. That would be the cardiologists, the cardiac surgeons, and I was told Dr Masey and Dr Underwood also ...
`Q. Were you worried about the Arterial Switch?
`A. I stopped. That is why I stopped the neonatal Switch programme. ...
`Q. So you had made your decision about that, so that was it?
`A. In a way I was not going to, but Dr Joffe said "Let Alison Hayes analyse this and find out if we learn anything more". She came back to almost the same type of answer which I already knew, that there was a higher percentage of coronary abnormality in the series and of course, you know - I think that is what I remember. I think she may have mentioned one or two other things, I am not sure.
`Q. But in any event, nothing in that to make you reconsider your decision?
`Q. ... knowing that Alison Hayes had presented data to the cardiologists and surgeons earlier in January, knowing that Mr Wisheart had presented data to the meeting of 20th January ... what need did you see to present any further data to the Unit?
`A. I did not.' [20]
16 Mr Dhasmana told the Inquiry that he had subsequently learned that:
`A. ... Mr Wisheart presented what he had on last year's figures, and because he saw me preparing, I always thought that he knows and by that time, I would have thought that he also had a copy of my Unit's figures which I had already sent to the register [UKCSR [21]]. So he would have had the data for 1992/93, but I was quite surprised why he should be doing that, because I have already presented that, but this was a different forum. ... I asked him what did they talk about, Arterial Switches and various things? Then he said that "The Arterial Switches were already discussed before as you know, but it was mentioned again in the meeting, and I presented what I could remember from your figure".' [22]
17 The overall effect of the meeting was explored by the Inquiry Chairman with Dr Pryn:
`Q. (The Chairman): ... this is a meeting called by your Clinical Director. He said here in front of us that he believed it did more to consolidate difficulties than to start a process. I was just wondering about your reflection on whether that is particularly surprising. If you did not know about the meeting until just before it was called, you were not in a position to present proper data, not everybody who should have been there could have been there, and so on and so forth, no one is in the chair. If this is a meeting called to address what is deemed by some to be a serious matter, what was your view, did the meeting as it proceeded achieve anything like the objectives claimed for it?
`A. I did not know the objectives at the time, but in retrospect, it did not address the issue of whether there was a serious problem going on in Bristol at the time.
`Q. (The Chairman): What does that tell you about organising meetings?
`A. Organising meetings with clinicians is phenomenally difficult, because we all have other commitments. It is very difficult during working hours. We often end up organising meetings in our free time in the evenings. That is just about the only way we can all get together. ...' [23]
18 Dr Pryn went on in the following exchange with Counsel to the Inquiry:
`Q. So did anyone suggest that the results were not good enough, or needed dramatic or substantial improvement?
`A. I cannot recall it, unless Chris Monk spoke from the back and said "Mr Wisheart, there have been some concerns, can you tell us the most recent data that you have?". He may have done it like that.
`Q. But once Mr Wisheart presented the data, there was no comeback and argument with that, or conclusions?
`A. I think there might have been a discussion about some of the diagnostic groups, for instance, the Fallots, who had had some particularly poor outcomes in the years preceding, but I think the surgeons had changed their operative techniques and the results were a lot better. So there may have been some discussion about that sort of improvement, but not as a Unit as a whole.
`Q. Dr Monk talks about consolidation of difficulties and differences. What was the overall "temper" of the meeting?
`A. It is hard to tell that because I did not know what the objectives were at the time. It was amiable and professional. I felt somewhat humiliated because I had not prepared properly. It was a professional meeting.
`Q. Did Dr Bolsin speak at any point?
`Q. If we go back to your statement, page 41, [24] you say there that after this meeting your audit was effectively abandoned?
`A. Yes, I put it to one side. I did not think it would be that useful, because I thought it would be very difficult to actually categorise the children and I realised that the surgeons were actually collecting this data anyway and were in a much better position to do it, and I thought they were also presenting it regularly. So I did not think that my efforts would be particularly useful.' [25]
19 When asked by Counsel to the Inquiry about the approach that Dr Bolsin might have adopted, Dr Pryn said:
`I think he [Dr Bolsin] should, first of all, have presented it [his audit] to us, to the cardiac anaesthetists at a cardiac anaesthetic meeting, and we would all then have got an appreciation of its strengths and its weaknesses, and its meaning, and then, depending on the relative balance of strengths and weaknesses, I think we should have presented it at a joint audit meeting, and the one in January 1994 would have been a prime example when he could have done that.' [26]
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Footnotes
[1] Dr Monk
[2] WIT 0341 0041 Dr Pryn
[3] It is not clear whether Dr Joffe attended
[4] Mr Dhasmana was operating at the time
[10] WIT 0341 0041 Dr Pryn. See Chapter 3 for an explanation of clinical terms
[11] Consultant anaesthetist
[14] WIT 0105 0022 Dr Monk
[17] T72 p.147-50 Dr Pryn. See Chapter 3 for an explanation of clinical terms
[18] T82 p.158-72 Dr Bolsin. See Chapter 3 for an explanation of clinical terms
[21] UK Cardiac Surgical Register
[24] WIT 0341 0041 Dr Pryn. See Chapter 3 for an explanation of clinical terms