Annex A > Chapter 29 - Concerns 1994 > Concerns > June
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June
51 Kay Armstrong, Sister in Cardiac Theatres at the BRI, stated that she had been reassured by the expected movement of children's services to the BRHSC and the appointment of a paediatric cardiac surgeon:
`... the reassurance began to wain [sic] when the prospect of a paediatric cardiac surgeon being recruited seemed further away after Professor Angelini came instead of a paediatric cardiac surgeon. The move to the Bristol Children's Hospital also seemed quite distant. As time passed, theatre staff felt that something more positive had to be done to address the concerns about the service. As a result, in the middle of 1994, myself and other theatre nurse colleagues stopped scrubbing for complex paediatric cardiac surgery cases. Out of approximately 9 members of staff, only 2 nurses, Alison Reed and Onyx Berwin, would scrub for children's cardiac theatre.' [63]
52 On 21 June 1994 a letter was signed by six anaesthetists at the UBHT expressing concern about the Arterial Switch programme being undertaken at the BRI. Dr Davies, consultant anaesthetist at the BRI from 1993, stated in his written evidence to the Inquiry:
`In mid-1994 Dr Bolsin drafted a letter addressed to Dr Monk, the Clinical Director, [64] and had asked a number of the anaesthetists to sign it. ... The letter went through a number of drafts.' [65]
The first draft of the letter was addressed to Dr John Roylance. [66]
53 In the first draft of the letter, Dr Monk had been a co-signatory. In its final form, he became the addressee. Dr Monk told the Inquiry how this came about in the following exchange:
`If I had signed the letter, it was difficult to take forward and to discuss it, so it was felt, and supported by some of the others, that it should be addressed to me; that I should not sign it and I could then take it forward. I agreed to that. It may have been better if I had signed the letter and posted it.
`Q. What did you mean by "taking it forward"?
`A. My intent was to approach the Chief Executive with this letter and use it to explain that we, as consultant anaesthetists, had concerns about the Switch programme, and, in addition, the paediatric cardiac surgical programme. It says quite clearly that there should be a confidential review and that it should take place amongst the entire multi-factorial process and the clinicians involved to look at what the figures were.
`Q. So, having got this letter, what was it intended you should do with it?
`A. My intent was to visit the Chief Executive with the letter. Whether they had other intents for it, I am not aware.' [67]
54 Dr Masey told the Inquiry that it had initially been thought that the letter would be addressed to Dr Roylance, and would be signed by Dr Monk, in addition to others. [68]
55 Dr Underwood told the Inquiry of her understanding of the use to which the letter would be put:
`I was aware only that we were sending it initially to Dr Monk, with the understanding that he would then be able to use it.' [69]
56 The letter in its final form was signed by six anaesthetists and had the approval of the person to whom it was addressed, Dr Monk. It raised concerns about the Arterial Switch programme currently being undertaken, expressed the view that mortality for that operation was apparently high, referred to the recent death of a 14-month-old child following an Arterial Switch procedure, and sought a review of the results achieved thus far. The letter referred to the Arterial Switch programme without drawing any distinction between neonates and older children, although it referred to results being particularly bad in the neonatal period.
57 The first of the drafts in which the letter was addressed to Dr Monk, rather than signed by him, began:
`We wish to express our [increasing] concern about the Arterial Switch programme currently being undertaken in this hospital.
`The mortality for this operation is apparently [unacceptably] high, particularly for those operations undertaken in the neonatal period, but the recent death of a 14-month-old child following the Arterial Switch procedure must now lead to an open and thorough review of the results so far. It is our belief that this review should be confidential and take place between all the cardiac anaesthetists, all the cardiac surgeons, all the paediatric cardiologists and the Director of Cardiac Services. This responsible approach to (our) [70] [what is obviously an unacceptable] clinical practice would defuse many of the criticisms of this programme in this institution expressed privately and publicly.' [71]
58 The words set out in square brackets in the letter quoted above appeared in this draft but were removed following further discussion. Four anaesthetists had been prepared to sign the letter in its original draft form. [72] Dr Masey, however, stated in her written evidence to the Inquiry:
`I was happy to co-sign this letter, as I felt that this was the first time that Dr Bolsin had involved his cardiac anaesthetic colleagues. I viewed this as an open and transparent approach to the voicing of concerns. I asked Dr Bolsin to make a minor change in the letter before I was willing to sign it, changing the phrase "unacceptable results" in Switch procedures to "apparently unacceptable results", as I did not believe that at that time we had accurate enough figures for the results of this procedure in older children to make this statement.' [73]
59 In her oral evidence to the Inquiry, Dr Masey said that it was:
`... not the word "apparently" that I wished to have added but the word "unacceptably" that I wished to have removed'.
She had been unable to agree to the emphasis of the first letter. [74]
60 Dr Underwood saw the letter as amended. The letter with the words in square brackets removed became the final version. The signatories were Dr Davies, Dr Baskett, Dr Pryn, Dr Bolsin, Dr Masey and Dr Underwood. No single copy of the letter had all six signatories, although the signatures of all six appeared on one or other copy of the final version of the letter.
61 Dr Underwood stated in her written evidence to the Inquiry that by the winter of 1993 there was growing concern amongst cardiologists, cardiac surgeons and anaesthetists over the mortality of the neonatal patients undergoing the Switch operation. [75] She told the Inquiry that she signed the letter because she believed that the mortality for the operation of neonatal Switch was `apparently high' and:
`... in order to get the group working as a team, to have an open review, I felt that this was a suitable letter to sign. We did refer to a thorough and open review of the results so far, and I felt that that was the key issue in this letter.' [76]
62 Dr Masey told the Inquiry that she agreed with the terms in which the letter was sent. [77] Its purpose, she said, was:
`... to actually make this into a much more open and transparent mechanism for looking at any criticisms and trying to gain more information to see whether there was any basis in these criticisms'. [78]
63 Dr Monk told the Inquiry that the letter reflected `the strong feeling that Drs Davies, Pryn, Bolsin and myself had already expressed about the Arterial Switch programme'. [79]
64 On 30 June, nine days after signing the letter, Dr Underwood anaesthetised a non-neonatal patient undergoing a Switch operation. She told the Inquiry:
`I did not think this letter prevented me from continuing with that routine work, and indeed, my experience from my own records was that the cases of older children having Switches, which I had done with Mr Dhasmana, had generally survived.' [80]
65 On 29 June 1994 Mr Dhasmana wrote to Dr Martin. In his letter he stated that he had seen a patient named Joshua Loveday along with his parents earlier that day at his clinic. Joshua was then 12 months old. He stated that:
`I have recommended Arterial Switch repair with coronary transfer and patch repair for VSD. The nature and risk of this operation has been explained to his parents to which they have agreed. I hope to operate on him within the next four to six months.' [81]
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Footnotes
[63] WIT 0132 0057 Ms Armstrong
[64] Clinical Director of Anaesthesia from January 1993 to December 1995
[65] WIT 0455 0003 Dr Davies
[66] No copy of this draft was produced to the Inquiry
[70] The word `our' appeared in the later drafts when the words in square brackets were removed
[71] GMC 0004 0064; letter from Dr Underwood, Dr Davies, Dr Pryn, Dr Masey, Dr Bolsin and Dr Baskett to Dr Monk dated 21 June 1994
[72] UBHT 0061 0006; letter of 21 June 1994 signed by Dr Davies, Dr Pryn, Dr Bolsin and Dr Baksett, but not by Dr Underwood or Dr Masey
[73] WIT 0270 0015 - 0016 Dr Masey
[75] WIT 0318 0011 Dr Underwood
[80] T75 p.152 Dr Underwood. This was the last such Switch before the operation on Joshua Loveday on 12 January 1995, which is described in Chapter 30
[81] MR 0164 0033 Joshua Loveday's medical records. See Chapter 3 for an explanation of clinical terms