Annex A > Chapter 30 - Concerns 1995 and after > Concerns 1995 > March
<< previous | next >>
March
158 On 6 March 1995, the NHS Executive arranged a meeting between the Regional Health Authority, the UBHT and NHS Executive representatives, to take place on 9 March. [179] The minutes of that meeting record Mr McKinlay as saying that he:
`... believed that the Trust had the situation under control from the middle of 1994 but, following an unsuccessful "switch" operation on an older child in January this year, earlier concerns had resurfaced. It was then decided that external paediatric cardiac experts should be brought in to analyse the paediatric surgical audit results and make recommendations.' [180]
159 At the meeting, the UBHT representatives, Mr McKinlay, Mr Nix, Professor Vann Jones, Dr Laszlo and Dr Joffe, indicated that they felt that:
`... some sections [of the report] could have been better worded and the conclusions to be drawn were open to interpretation.' [181]
It was also noted that disappointment was expressed that more detailed analysis had not been performed on the data, but it was acknowledged that such analyses would have taken much longer. Mr Nix is recorded as saying that, because of the wording of parts of the report, wider circulation within the UBHT was not desirable. [182]
160 The representatives of both the Region and NHSE stated at the meeting that they would not support the report's being kept confidential and that the UBHT should be prepared to make it public. [183]
161 It was agreed at the meeting that the approach set out in Dr Roylance's letter to Dr Doyle of 26 January 1995 would be adhered to, namely that:
`... the Trust has decided not to carry out complex neonatal or infant open heart surgery until there has been resolution of the conflicting professional advice.' [184]
162 At Mr McKinlay's request, Mr Nix organised two meetings of all relevant consultants to discuss the report. These were held on 13 and 14 March. Mr Nix stated in his written evidence to the Inquiry that:
`... both of the meetings were attended by... Mr Hutter, Mr Bryan, Mr Dhasmana, Mr Wisheart; Drs Davies, Bolsin, Pryn, Masey, Underwood, Joffe, Wilde; Prof. Angelini, Prof. Vann Jones. Dr Gabriel Laszlo also attended, as Chairman of the Hospital Medical Committee. Mr McKinlay chaired both meetings. I prepared the overheads for the meetings, which were of copies of the report.' [185]
`At each meeting, we went through the report paragraph by paragraph. Everyone was encouraged to say what they wanted to say, and they did so. There were a number of issues that were raised in the course of the discussions. These included a debate about the naming of individual clinicians in the report ... There were concerns about the accuracy of the data set out in the report ... There were some concerns about the wording of the report, including matters of emphasis and use of particular words ... It emerged in the course of the meetings that a number of consultants had not seen Dr Bolsin's data. ... It was also noted that Mr Wisheart had already agreed to stop operating on paediatric cases when Mr Ash Pawade took up his appointment.' [186]
164 Mr Bryan stated in his written evidence to the Inquiry:
`... those invited were shown acetates of selected passages from the original report ... The meeting was asked to endorse the findings of the report. A number of people at the meeting, including myself, found the request to endorse the original report unacceptable since we were asked to endorse a report we had not read. Professor Angelini expressed this view most vociferously, but it was my impression that it was the general view of the meeting that people wished to read the report.' [187]
165 Mr Nix explained in a statement to the Inquiry that:
`... it was not appropriate to distribute widely copies of the report in its current form. ... [so we] instead arranged for [the consultants involved] to read a copy of the report in Mr McKinlay's office ... There was some disquiet about this, but in view of the various concerns raised, it was felt at the time that this was the most appropriate way to deal with it, until some of the concerns and anxieties could be addressed.' [188]
166 Professor Angelini said that he felt Mr McKinlay was asking them to `underwrite' the report. He continued:
`After a longer argument, the people were allowed to look at the report. This was literally for less than five minutes. In my case, with Dr Laszlo looking over my shoulder, I could take no notes whatsoever. I did not have more than five minutes to read it and this created, obviously, a lot of dissatisfaction and complaint.
`After that, Mr McKinlay decided then that the full report was going to be shown to this group of 10 or 15 people, and there were two meetings ... during which the report was discussed literally word by word. None of us had the opportunity to actually have the report copy in front of us, but there were acetates which discussed the report word by word.' [189]
167 Mr Bryan in his written evidence to the Inquiry recalled discussion about the future of the Switch programme:
`There was a lot of emotional discussion, principally from Dr Joffe and Mr Dhasmana, that the "switch" programme should continue with Mr Dhasmana continuing to lead the paediatric cardiac surgery service up to and following Mr Pawade's arrival. I expressed my view clearly that no further "switch" operations should be performed in any age group before Mr Pawade's arrival.' [190]
168 Professor Angelini told the Inquiry:
`To me that report was absolutely shocking. In a way, if you like, it was a vindication of what people like me had been saying for a very long time. Despite that report, I felt that particularly myself and Dr Bolsin, we were very much victimised by Mr McKinlay and some of the other people present, almost like accused of having been responsible, of having dragged the Trust into this situation and we were responsible for this report and everything else.' [191]
`Dr Bolsin and Professor Angelini were admonished for their involvement in this affair by Mr McKinlay. I found this both inappropriate and unacceptable.' [192]
Mr McKinlay told the Inquiry that Professor Angelini was `being a little sensitive there'and that Professor Angelini `had a slight tendency to ignore some of the statistics'. [193]
The revised draft Hunter/de Leval report
170 Dr Bolsin stated in his written evidence to the Inquiry that when Dr Roylance returned from holiday he immediately stopped the circulation and reading of the first report and insisted that the report was an interim document, to be used as a draft from which a final report would be produced. [194]
171 Dr Roylance told the Inquiry that when he returned from holiday, and found that the report had achieved a wide circulation in his absence and had been promised to Harlech Television (HTV), he:
`... informed the authors that a decision had been made to make their report public and asked them whether they would wish to modify it in that knowledge.'
Dr Roylance told the Inquiry that release to HTV `would not have been a proper step', given the terms upon which the report was commissioned and written. [195]
172 Dr Roylance was asked by Counsel to the Inquiry whether he had objections to the information about the report being in the public domain:
`I had no objection at the time to the fact of the review, the fact of the independent inquiry and the nature of the response, in other words the report being in the public domain, no anxiety about that at all.
`I did have an anxiety that I could not place the authors in a position of risk by breaking my word to them.
`... I was a Chief Executive of a public organisation which lived in the public sector. ... There was never any question that the issue was to be debated in public. At the absolute minimum, it would have been debated at a public meeting of the Health Authority:
`The reason for two reports was nothing to do with publication or not publication; it was because I had not asked them for a report which was fit for public view.' [196]
173 He told the Inquiry that Professor de Leval was responsible for deciding what parts of the report were to be changed. [197]
174 Mr McKinlay in his written evidence to the Inquiry stated:
`... the Trust's endorsement of a report with conclusions based on unreconciled data could constitute defamation of Mr Wisheart. I recall that Dr Roylance communicated this to Mr de Leval, whereupon Mr de Leval altered the report.' [198]
175 Professor de Leval told the Inquiry that he did not think it was fair:
`... to have a public document which is making a very strong comment ... without having this confirmed by the people most involved with the patients, who are the anaesthetists, the surgeons and the cardiologists and intensivists ... . I spoke with Mr Wisheart and Mr Nix after the first report, some discussions I think over the telephone, not in writing, that I have to make some amendments.' [199]
176 Changes were made to the report. Professor de Leval explained that:
`The main reason for changing the document was that we did not expect this document to be part of the public domain as it stood. ... I think that the truth is that I did not expect to have to change the document if it had remained within the knowledge of the Chief Executive. The reason for changing it is that the nature of the document had changed, in my view, after it had been sent to the Chief Executive.' [200]
177 Dr Laszlo in his written evidence to the Inquiry stated that some of the minor amendments emanated from within the UBHT:
`... Mr Nix and Mr Wisheart showed me a few amendments to the Report which they hoped to have made in the event of the Trust being asked to publish the document. These were only minor, and in one or two places they asked for some of the phrases to be softened and made less colloquial. ... I was assured that Professor de Leval himself had made the major changes, on the basis that he had not expected the original report to be made public.' [201]
178 Dr Hunter told the Inquiry that Professor de Leval telephoned him and said that he had spoken to Mr Nix about softening some of the statements in the report. Dr Hunter said that Professor de Leval made the changes and sent the report to Dr Hunter for his approval. [202]
179 The Inquiry was unable to establish precisely when the amended report was sent to the UBHT.
180 Dr Bolsin in his written evidence to the Inquiry described the amended report as a `much more benign document.' [203] He said:
`When I read the revised report I immediately asked for an appointment to see Dr Roylance to explain my unhappiness with this conclusion and the removal of the critical elements of the first report.' [204]
181 The full revised report, with the amendments made to it noted, is reproduced below: [205]
`VISIT OF CARDIAC SERVICES DIRECTORATE OF THE UNITED BRISTOL HEALTH CARE NHS TRUST. FRIDAY, 10 FEBRUARY 1995
`To advise the Trust on the best action to take following recent recommendations received by the Department of Health to stop complex neonatal and infant open-heart surgery to resolve conflicting professional advice in the field of paediatric cardiac surgery in general and, in particular, complex neonatal and infant open-heart surgery.
`To make recommendations on the future of the paediatric cardiac services in the Trust.
`Following a welcome meeting by the Chief Executive, Dr Roylance, who briefly outlined the problem, we met first the two paediatric cardiac surgeons, Mr Dhasmana and Mr Wisheart, who were then joined by two of the paediatric cardiologists, Dr Martin and Dr Hayes. We then met Dr Bolsin, consultant anaesthetist, Dr Monk, clinical director of anaesthesia, Sister Thomas, clinical nurse manager, and Professor Angelini, Professor of department of cardiac surgery. After lunch we met Dr Hughes, clinical director, and Mr Barrington, general manager, of the Bristol Children's Hospital, and then we met Dr Prynn, consultant anaesthetist. The visit was closed by a general meeting that attempted to put forward a satisfactory proposal for the immediate future.
`CURRENT PAEDIATRIC CARDIAC SERVICES
`Paediatric cardiac services are currently provided on the two sites, the Bristol Children's Hospital and the Royal Infirmary. The paediatric cardiology services are in the Children's Hospital where closed-heart surgery is performed. Open-heart surgery is carried out at the Royal Infirmary. The operations are done by two surgeons, Mr Wisheart and Mr Dhasmana. The latter seems to have has taken over the greater bulk of the paediatric practice since Mr Wisheart became Medical Director of the Trust. Anaesthesia is provided by three anaesthetists working on both each of two sites. The postoperative care in the Children's Hospital is done by the surgeons, supported by paediatricians, cardiologists and anaesthetists. The junior staff on site is a paediatric SHO. At the Royal Infirmary the postoperative management is dealt with by the cardiac surgical team (adult) and the anaesthetic team. The person on site on a 24-hour basis is a surgical SHO. During the daytime there are currently two or three anaesthetic sessions which are dedicated to postoperative care. The paediatric cardiologists help with the postoperative management of the children at the Royal Infirmary. The overall postoperative management at the Royal Infirmary appears to be highly disorganised with conflicting decisions less organised with multiple decision making processes between the surgical senior registrar and the SHO who do rounds at 8.00 am, the anaesthetists who see the patients at 9.00 am, and the intensivists who work three days a week. Consultant surgeons appear to have the last say in management.
`BACKGROUND OF CURRENT PROBLEM
`This calendar of events was obtained in part from the interviews but mainly from a detailed report written by Dr Bolsin.
`From 1989 concerns about the surgical results of the paediatric cardiac surgeons have been raised by members of the anaesthetic department. Dr Bolsin undertook an audit of the paediatric cardiac surgical results from 1990-92. The auditing showed: (1) that the results of the arterial Switch operation were poor; (2) and that the results of Bristol for more classical conditions, such as tetralogy of Fallot, AV Canal and VSD, were worse than the national average; and (3) that one surgeon had results statistically worse than the other one.
`In 1993 one paediatric cardiac surgeon went to the Children's Hospital in Birmingham to improve his technique on the Switch operation.
`Professor Angelini, who joined the Trust in 1992, was informed as well as Professor Farndon (Professor of Surgery) of the results of the audit. A joint meeting between the cardiac surgeons, the paediatric cardiologists and the cardiac anaesthetists was called and the surgeons reassured their colleagues that the results were improving.
`Several members of staff who were interviewed during the visit confirmed that the surgeons failed to report and update their results until the day before our visit. Meanwhile, the results of the neonatal arterial Switch failed to improve and sometime in 1994 four cardiac anaesthetists agreed that they could no longer anaesthetise patients for neonatal arterial Switch.
`On 19 July 1994 Dr P Doyle (Senior Medical Officer, DoH) visited Bristol and was shown the results of the audit (we assume that those were the 1990-92 results). Three Various alternatives were proposed by Dr Doyle: inform the Secretary of State, amongst them to ask Mr John Parker as President of the Cardiac Society to conduct an inquiry, or ask the President of the Royal College of Surgeons to conduct an inquiry. We understand that Mr John Parker was contacted to deal with the matter.
`On 24 July 1994 Professor Angelini and Professor Farndon informed the UBHT Chairman of the problem with paediatric cardiac surgery.
`This calendar of events was obtained in part from the interviews but mainly from a detailed report written by Dr Bolsin.
`These events were followed in In January 1995 when a non-infant Switch was put on the surgical schedule. The wisdom of operating on this patient was discussed by a committee with representatives of all parties involved and an agreement was reached to proceed with the operation. The patient unfortunately did not survive and this allegedly led to the letter received from the Department of Health, advising to stop open-heart surgery for neonates and complex infants (we have not seen the letter from the Department of Health).
`The Trust has taken a number of positive steps to improve the paediatric cardiac services. They can be summarised as follows:
`From next October all paediatric cardiac services will be provided at the Children's Hospital where an operating theatre will be dedicated to cardiac work. The intensive care unit will expand from five to twelve beds Professor Peter Fleming will run the paediatric intensive care unit and provision for a round-the-clock service will be made.
`Mr Ash Pawade has been appointed as paediatric cardiac surgeon and he is expected to take up his post within the next two or three months with the intention of putting him in charge of neonatal and complex paediatric cardiac surgery. expectation that he will contribute to the future development of neonatal and complex paediatric cardiac surgery.
`The anaesthetic department will provide four paediatric cardiac anaesthetists. The fourth post will be created after the forthcoming retirement of a senior paediatric anaesthetist.
`Mr Wisheart has decided to divide his activities between adult cardiac surgery and administration and to give up paediatric cardiac surgery when Mr Pawade starts.
`PERCEPTIONS COLLECTED DURING THE VISIT
`1. Although well intentioned, the auditing activities of the surgical results by the anaesthetic department was lacking the collaborative attitude that such a delicate endeavour would have required.
`2. The surgeons' reticence to produce and analyse their own results has obviously contributed to tension and eventually conflict between the department of cardiac surgery and the department of anaesthetics.
`3. The channel that was followed by those concerned about the problem that led to the Department of Health before professional bodies is unfortunate. Admittedly, Dr Doyle has rectified this situation in suggesting to approach the Cardiac Society or the Royal College of Surgeons.
`4. The members of the anaesthetic department were unanimous in claiming that not only by and large claimed that the mortalitybut the and the morbidity was were excessive. Mortality figures will be discussed later. There was no hard data on morbidity.
`5. The tension which has arisen from this long saga has created an atmosphere of distrust and lack of confidence, which has made the working conditions for the surgeons nearly untenable very difficult indeed.
`Two sets of data were displayed during the meeting. The data produced by Dr Bolsin were the results of the 1990-92 audit which compared the results of Bristol with the national average performance of 1991. They concluded that the results of tetralogy of Fallot (all ages), ventricular septal defect (all ages) and atrioventricular canals (under one year) were significantly worse in Bristol than the rest of the UK. Leaving aside the neonatal arterial Switch operation, "the data for other procedures do not show any statistically significant differences"(Dr Bolsin's report). Dr Bolsin also produced the results of the arterial Switch operation up to July 1994: there were thirty-three arterial Switch operations with a mortality of 66% (eight out of twelve) under one month of age, and 42% (nine out of twenty-one) over the age of one month. He also summarises the results of AV canals operated by Mr Wisheart between 1992 and 1994.
`The second set of data received from the cardiac surgeons and the paediatric cardiologists included a detailed report of the results of the neonatal arterial Switch operation, the results of closed heart surgery from 1990 to March 1994 and the results of open-heart surgery from January 1992 to January 1995.
`There were nine deaths out of thirteen neonatal arterial Switches: one patient had an undiagnosed coarctation of the aorta, two patients had the whole coronary system arising from the same sinus, one of them with an intramural pathway: neither of those patients survived. Two patients had a circumflex coronary artery arising from sinus 2 (known to be a risk factor in a multi-institutional study); one of these patients died.
`The results of closed-heart surgery that is carried out at the Children's Hospital are excellent with a mortality of 5.3% for patients under one year of age and a mortality of 2.8% for patients over the age of one year.
`For the results of open-heart surgery from January 1992 to January 1995, we have extracted the results of tetralogy of Fallot, VSD and AV canal repaired by Mr Dhasmana, who currently does the majority of these operations to compare them with the 1990-92 results produced by Dr Bolsin and we individualised the two surgeons (Consultant 1 and Consultant 2).
`Consultant 1 has a mortality of 0% for ventricular septal defects, 13.5% for tetralogy of Fallot and 87% for AV canals.
`Consultant 2 has a mortality of 0% for ventricular septal defects, 0% for tetralogy of Fallot and 8.6% for AV canals.
`There was 0% mortality for ventricular septal defects (41 patients), 0% mortality for tetralogy of Fallot (25 patients) and 8.6% mortality for AV canals (23 patients). The current results of the other UK units for individual units in the UK are not available to us. There is little doubt that Consultant 2 would certainly , however that the above results compare very favourably with the best UK institutions. Consultant 1 would be amongst the higher risk surgeons.
`WEAKNESSES AND DEFICIENCIES OF THE ANALYSIS
`1. We assume that the mortality figures relate to the hospital mortality, though we have not specified this.
`2. There is no recommended standard against which the performance of a unit can be compared. This emphasises the great need for a proper audit of the performance of each UK unit dealing with paediatric cardiac surgery. The use of the average UK results may be misleading. If one postulates, for example, that two or three larger units have better results than two or three smaller units, the poor results of the latter will be hidden, so to speak, by the average figures.
`3. It is therefore not possible to make any objective and fair recommendations to a unit without knowing what the performance of every single unit in the UK is, so as to set up a standard.
`4. Performance assessment should also take into consideration morbidity. Dr Bolsin's report includes an attempt to compare the performance of the two surgeons assess surgical performance in looking at bypass time, extubation time, ITU time and hospital time for tetralogy of Fallot and AV canals. Here again, those data suffer the lack of standard to which they should be compared.
`CONCLUSIONS AND RECOMMENDATIONS
`The following has to be taken in the context of the above described deficiencies of this report.
`1. On the basis of the mortality figures presented to us, there is a significant improvement between the 1990-92 results and the 1992-95 results.
`2. The results of the neonatal arterial Switch operation should improve. It is not possible to determine the cause of these poor results. To blame surgical skill as the sole reason would be shortsighted. It is most likely a multifactorial and multidisciplinary problem. An arterial Switch procedure fulfils all the criteria of high-technology activity with complex sociotechnical interfaces. Some of the deaths were probably related to patients' risk factors (presence of a coarctation in the patient, single coronary system in two patients). The excellence of the results obtained for closed-heart surgery even in sick neonates in the Children's Hospital may suggest that the paediatric environment provides more appropriate skills for the overall management of those patients. The interface between the various teams has probably suffered from the recent conflictual events. Last but not least, whatever the causes of the failures, there is an inevitable lack of confidence amongst those at the sharp end which in itself could become a vicious circle.
`3. Leaving aside the neonatal arterial Switch repairs, based on the mortality figures for 1992-1995, the results produced by Consultant 2 are, we believe, comparable to the results of the so-called low risk institutions (although the hard data for the UK are not available).
`4. We understand that Consultant 1 has decided to concentrate his activities on adult cardiac surgery when the new appointee starts.
`5.3. We believe that it would be a great mistake to ask the new appointee to do all neonatal and complex cardiac surgery using Mr Dhasmana as a "spare wheel". We would recommend that both surgeons help each other for the most complex pathologies. For this Mr Dhasmana should be relieved from part of his duties in adult cardiac surgery. The Trust may have therefore to consider appointing another adult cardiac surgeon should their workload justify it. This might be the case as the move of the paediatric cardiac surgery to the Children's Hospital will create more facilities at the Royal Infirmary.
`6.4.There is a great need for improving communications between the various departments. We would strongly recommend to organise multidisciplinary meetings (at least monthly). We would also recommend joint cardiac conferences, attended by the cardiologists, the anaesthetists, the intensivists and the surgeons weekly to discuss cases which have been investigated and those who are on the operating schedule for the following week.
`7.5.An atmosphere of cooperation and understanding between the various departments is essential, so as to alleviate the tension, the distrust and the present untenable unhappy atmosphere which without any doubt could jeopardise the outcome of the patients.
`8.6.We believe that it would be inappropriate to do neonatal arterial Switch operations before the new appointee takes up his post. From the mortality figures presented to us, we have no reason to believe that Mr Dhasmana should not continue to carry on operating on the other conditions. This, however, would be possible only if he receives the full support he deserves from his colleagues. This requires a change of attitude to alleviate the stressful conditions under which he has had to work in the past.
`9.7.It is hoped that the new appointee will be more successful with the arterial Switch repair and that when the failure rate has returned to low values Mr Dhasmana will start afresh with the operation.'
182 Various changes had been made to the report. In particular, references in the first version of the report to Mr Wisheart as a `higher risk surgeon' had been removed.
183 The second version of the report also omitted reference to Mr Wisheart's AV canal results. [206] Professor de Leval told the Inquiry that he thought that he:
`... should have left in comments on the poor results for AV canal requiring full investigation'. [207]
Dr Hunter told the Inquiry that he was surprised, on seeing the second version of the report again while he was giving evidence, that the adverse comments in the first version about Mr Wisheart's AV canal series had been removed. [208]
184 The Chairman asked Dr Hunter about this further:
`Q. When you said you thought something had been left in, ... who are you saying took it out?
`A. I am assuming that Mr de Leval felt that that was one of the points where we had been over-strong in what we said. I was not aware of the fact that it was out until I looked at it earlier today ... .' [209]
185 There was also a change in the description of the role that Mr Pawade would play. In the first version, mention was made of his being `in charge of neonatal and complex paediatric surgery.'The second version removed reference to his being `in charge'.
Protocol for paediatric cardiac surgery
186 After the meetings with the consultants, Mr Nix and Mr McKinlay stated that they set out what they believed was the consensus view of the way forward in the department, in a draft protocol dated 15 March 1995. The draft protocol was circulated under cover of letters of the same date, to clinicians [210] and to Professor de Leval and Dr Hunter [211] for their approval. Professor de Leval indicated his satisfaction in a letter dated 21 March 1995. [212] Dr Hunter did likewise by a letter of 27 March 1995. [213]
187 Mr McKinlay sent a copy of the protocol to Ms Fritchie inviting comment. [214] Avon Health's officials were also notified, and discussed the proposals with Dr Roylance. [215]
188 The protocol stated that for the period until the arrival of Mr Pawade on 1 May 1995:
`1.1 No arterial switch operations will be undertaken at the Bristol Royal Infirmary by either Paediatric Cardiac surgeon.
`1.2 Mr Dhasmana will continue to operate on all other conditions in neonatal, infant and older children.
`1.3 Mr Wisheart will continue to operate on children over 1 year of age for all conditions excluding the AV canal.
`1.4 Mr Wisheart will continue to see new paediatric referrals up to 1 May 1995.' [216]
189 For the period after Mr Pawade's arrival (from 1 May 1995), the protocol stated:
`2.1 Mr Wisheart, Mr Dhasmana, Mr Pawade and the Paediatric Cardiologists will discuss Mr Wisheart's outstanding waiting list, and the transfer of patients will be agreed. Mr Wisheart will continue to operate on a few children, in the couple of months following the 1st May, where the parents, children and cardiologists wish.
`2.2 Mr Dhasmana and Mr Pawade will discuss the resumption of the arterial switch operation; timing at their discretion. It is recognised that such a resumption of service will follow discussion with the Paediatric Cardiac Services Team of paediatric cardiologists, paediatric anaesthetists, paediatric radiologists etc.' [217]
190 The protocol further provided:
`3.2 Any member of staff who has concerns that they consider are not being actioned should, after discussion within the group, contact the Clinical Director or Chief Executive and, if appropriate, the Chairman of UBHT.' [218]
191 Dr Roylance agreed that Mr Wisheart should no longer continue as a paediatric cardiac surgeon. [219] Dr Roylance told the Inquiry that this had been Mr Wisheart's:
`... intention for some considerable time and he merely implemented his stated intention. There clearly was not room for three paediatric cardiac surgeons with the workload that was there ...' [220]
192 The protocol contemplated that Mr Dhasmana would continue to carry out paediatric cardiac surgery. As matters turned out, once Mr Pawade arrived, Mr Dhasmana ceased to do paediatric work. [221]
Public and press attention
193 UBHT's first draft press statement in relation to the performance of the paediatric cardiac surgery team was dated 3 March 1995. [222] The final version of that statement was dated 6 March 1995. [223] It stated:
`As a result of the need to increase adult cardiac surgery at the Bristol Royal Infirmary (BRI) and a wish to develop paediatric cardiac surgery at the Bristol Royal Hospital for Sick Children (BRHSC) the Trust took the following actions during the summer of 1994:
- `Appointed a new paediatric surgeon, already distinguished in the field of neonatal cardiac surgery, due to commence in May 1995.
- `Planned expansion in the theatre and intensive care provision at the BRHSC to accommodate open heart paediatric cardiac surgery transferring from the BRI. This project will be complete by September 1995.
- `During 1992/3 the doctors involved in paediatric cardiac surgery had expressed some concerns that the results of one particularly complex operation (the neonatal switch) were not as good as would be wished. This operation involves treating a complex congenital heart abnormality shortly after birth.
`The Trust took the following action:
- `In October 1993, as a result of these concerns, the Trust decided to stop this particular operation and to refer the small number of cases that arise to another hospital. This is standard practice for rare and complex conditions.
- `No operations of this type have been performed in neonates since then.
- `In January 1995 a case conference was held regarding whether to conduct a switch operation on [an] older child (18 months) - the decision was taken to go ahead and unfortunately, there were additional complications and the child died.
- `endorses the work being done by the paediatric cardiac surgery team and states that this work should continue;
- `supports the action already proposed and implemented by the UBHT (as above);
- `made some additional suggestions. These are:
- `increased regularity of multidisciplinary clinical audit;
- `improved liaison within the paediatric cardiac team;
- `developing the provision of neonatal switches locally when the new surgeon takes up his appointment and the new facilities at the Children's Hospital are ready for use.
- `All other paediatric cardiac operations continue to be performed with excellent results.'
<< previous | next >> | back to top
Footnotes
[179] WIT 0106 0104 - 0106 ; note of meeting on 9 March 1995. Those attending were Ms Fritchie, Mr McKinlay, Mr Nix, Professor Vann Jones, Dr Laszlo, Dr Joffe, Dr Gabriel Scally, Dr P Doyle, Isabel Nisbet, John Churchill and Billy Flynn
[180] WIT 0106 0104; note of meeting on 9 March 1995
[181] WIT 0106 0106; note of meeting on 9 March 1995
[182] WIT 0106 0106; note of meeting on 9 March 1995
[183] WIT 0102 0032 Mr McKinlay
[184] WIT 0106 0106; note of meeting on 9 March 1995
[185] WIT 0106 0073 Mr Nix
[186] WIT 0106 0073 - 0074 Mr Nix
[187] WIT 0081 0029 Mr Bryan
[188] WIT 0106 0075 Mr Nix
[189] T61 p.194-5 Professor Angelini
[190] WIT 0081 0029 Mr Bryan
[191] T61 p.195 Professor Angelini
[192] WIT 0081 0030 Mr Bryan
[194] WIT 0080 0129 Dr Bolsin
[196] T89 p.111-12 Dr Roylance
[198] WIT 0102 0032 Mr McKinlay; see also T89 p.84 -5, where Dr Roylance told the Inquiry that he took the advice of the District Solicitor, who stated that the contents of the report as they stood might be libellous; and UBHT 0332 0001 (letter from Osborne Clark, solicitors, which contained advice to the same effect)
[199] T60 p.88 Professor de Leval
[200] T60 p.81-2 Professor de Leval
[201] WIT 0100 0026 Dr Laszlo
[203] WIT 0080 0129 Dr Bolsin
[204] WIT 0080 0129 Dr Bolsin. The Inquiry received no confirmation that such a meeting actually took place. Dr Roylance was able to recollect only one meeting with Dr Bolsin in 1995 (see T89 p.87)
[205] UBHT 0061 0378 - 0387 . The parts removed from the previous version of the report are struck through, whilst the additions are underlined
[206] See Chapter 3 for an explanation of clinical terms
[207] T60 p.95 Professor de Leval
[210] WIT 0106 0125 - 0126 ; letter from Mr Nix dated 15 March 1995 to: Dr Hughes, Mr Dhasmana, Professor Vann Jones, Dr Monk and copied to Mr Wisheart, Dr Joffe, Dr Laszlo and Mr McKinlay
[211] WIT 0106 0133 and WIT 0106 0132; letters from Mr Nix to Professor de Leval and Dr Hunter dated 15 March 1995
[212] WIT 0106 0135; letter dated 21 March 1995
[213] WIT 0106 0136; letter dated 27 March 1995
[214] WIT 0106 0075; letter from Mr McKinlay dated 15 March 1995 to Ms Fritchie, copied to Dr Scally and Mr Nix
[215] WIT 0038 0035 - 0036 . Ms Pamela Charlwood, Chief Executive of Avon Health Commission and Avon Health Authority from 1994, told the Inquiry: `On 15 March 1995 the Deputy Chief Executive of UBHT wrote to Cardiac Services Directors ... Dr Baker and I had meetings with Dr Roylance during April 1995. On 21 April 1995 Dr Morgan circulated a briefing note to members of the Avon Health Commission. On 27 April 1995 Avon Health Commission heard an oral report from Dr Morgan about concerns about paediatric cardiac surgery at BRI. ... This was the first notification to the Health Authority at a formal meeting that there was a concern about paediatric cardiac surgery at BRI.' See WIT 0038 0036. See further: WIT 0074 1465; letter from Dr Roylance to Dr Baker dated 2 May 1995, and WIT 0074 1467; memorandum from Dr Baker to Ms Charlwood dated 5 May 1995
[216] WIT 0106 0127; protocol
[217] WIT 0106 0127; protocol
[218] WIT 0106 0128; protocol
[219] The District Health Authority held meetings with Dr Roylance in April 1995. Pamela Charlwood stated: `Following a meeting on 10 April, I wrote to the Chief Executive of the UBHT asking specific questions on the arrangements ... He replied on 2 May [WIT 0074 1465]. On 9 May 1995, I wrote to Dr Roylance approving arrangements to relieve Mr Wisheart's paediatric workload, appoint an Associate Director of Cardiac Services for children within the Directorate of Children's Services, and to set up a multi-disciplinary audit supported by the Health Authority's contract for clinical audit with Dr Baker. I noted that other purchasers using UBHT would be informed of our view of service development.'(WIT 0038 0036)
[222] PAR2 0001 0116; draft press statement dated 3 March 1995
[223] PAR2 0001 0137; press statement dated 6 March 1995