Annex A > Chapter 30 - Concerns 1995 and after > Concerns 1995 > April
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April
194 The UBHT was informed that the programme entitled `Close up West', to be broadcast on the evening of Thursday, 6 April, would refer to the results in paediatric cardiac surgery at the UBHT. As a result, it arranged for a helpline to be available for concerned parents following the broadcast. The line would provide direct access to a consultant cardiologist, plus additional back-up support to take details from callers when the cardiologist was already occupied by a call. [224]
195 It became evident during Tuesday, 4 April that the story would be broadcast by the media that evening. Accordingly, the plans for a helpline were brought forward and the number of the BRI switchboard was broadcast on both local news programmes. The BRI switchboard was instructed to pass any calls from the press to the Trust's Public Relations Officer at home, and calls from concerned parents to Dr Joffe, who would also be available on his home number. [225]
196 On 5 April 1995, the `Daily Telegraph' reported:
`100 baby deaths linked to errors
`A leading hospital announced yesterday that it had halted open-heart surgery on children after an anaesthetist claimed that 50-100 babies born with correctable heart defects may have died because of avoidable errors. ... Operations were stopped in October 1993 and cases were referred to another hospital although in January this year surgeons decided to operate on an 18-month-old child.
`Dr Stephen Bolton [sic], the anaesthetist who questioned the safety of open-heart procedures, said of that operation: "It was only at a clinical case conference preceding the operation that the team fully realised what its record for the switch was.
`"There was an institutional problem within the unit but everyone said we should go ahead. The child died the next day and, at that point the Department of Health said we should put a ban on switches."
`The incident prompted the hospital to commission experts headed by Mr Marc de Leval of Great Ormond Street Hospital, to investigate the high mortality rates.
`They produced a damning report criticising doctors and managers and recommended a regular audit of cases and better liaison within the surgical team.
`Hospital officials suppressed the report claiming that they feared legal action by those who were criticised.
`The senior cardiac surgeon at the Infirmary is Mr James Wisheart, who is also medical director of the trust.
`The Infirmary has already moved to appoint a new paediatric surgeon and improve theatre facilities at the Bristol Hospital for Sick Children which is now handling the infirmary's neonatal surgical caseload.
`The Infirmary has been doing 120-140 open-heart procedures a year. Dr Bolton [sic] said that the overall mortality for these operations has been twice the expected rate.
`Dr Bolton [sic] said that he became alarmed in 1990 when an audit of 14 neonatal switch operations carried out by one surgeon on babies under one month old in 1988 showed that nine had died.
`Figures for two other operations - hole in the heart, and a more complicated variant in which several defects are repaired - showed that death rates overall in the unit were twice the expected proportion.
`Dr Bolton [sic], then a newly-qualified consultant anaesthetist, claimed that his superiors brushed aside his protestations when he raised questions.
`He began to keep his own records, and, in 1993, audited them with the help of Dr Andrew Black, a senior lecturer in anaesthetics.
`"We found mortality rates were twice the expected average. But when I raised this I met only opposition, " said Dr Bolton [sic].
`He said he raised concerns with Mr Wisheart, and later showed the figures to Dr Peter Doyle, senior medical officer at the Department of Health, who was said to be "appalled". Further switches were then banned.
`Mr Robert McKinlay, chairman of United Bristol Healthcare Trust, which incorporates the Infirmary and the children's hospital, said: "In this situation with patients involved we would all wish things would have been done quicker."
`The Infirmary's spokesman said: "We had a successful switch then a series of failures, then some success then more failures. So we stopped. It is a complex operation and in some cases additional problems were not diagnosed in advance of surgery."' [226]
197 Dr Bolsin told the Inquiry about the article in the `Daily Telegraph' in the following exchange:
`A. What happened was, I was phoned up and I was given the story of what had happened at the Bristol Royal Infirmary and my error -
`A. "Have you got any comments to make?" My error was to say, "I am not in a position to comment but you seem to have got most of the story".
`Q. The only thing I then want to ask you about is this: having seen your name in print and comments attributed to you which you had not given, you merely endorsed in the way you described, did you write to the "Daily Telegraph" to complain about the fact that they had abused your trust in this way?
`A. I discussed it, I think - what I actually did, that morning I spoke to -
`Q. Perhaps it is easier if you answer the question, and then tell us what follows.
`A. The answer is no, I did not.
`Q. You were going to tell us why not. Because you discussed it and you were advised not to?
`A. I spoke to Dr Roylance and he said, "It is unlikely to do any good, and it is just going to make the whole thing more protracted; I am happy with your explanation, do not worry about it", sort of thing. "Yes, it is a difficulty but we can deal with it."'
198 Dr Bolsin was asked by Counsel to the Inquiry about the effect of the story in the `Daily Telegraph' on his relationships with colleagues within the Trust:
`Q. Did the fact that you were quoted in the "Telegraph" affect your working relationships within the unit, do you think?
`A. I think it may well have done, yes.
`Q. In what way do you think it did so?
`A. I think that there was probably a level of distrust of me personally for having now been associated with the paediatric cardiac surgical record getting into a national newspaper.
`Having said that, it was not necessarily my view, because I knew that the Trust had released the Hunter/de Leval report to a local television station and that they had been ordered to do so by the Department of Health.
`Q. But it is perceptions that I am concerned with. With whom do you think it may have affected your relationship?
`A. I think that the two paediatric cardiac surgeons, it would certainly have affected my relationship with them; however, I knew that Mr Wisheart knew that the Trust had been ordered to release the Hunter/de Leval report, therefore he should not necessarily have blamed me for any ensuing publicity.
`A. That was the perception I had, yes.
`Q. Based on anything he said, or upon your assumption?
`A. It was based on the assumption that we then went into reconciliation with consultant psychiatrists.' [227]
199 A number of further articles in the press and reports on television followed. [228] Dr Bolsin appeared on the BBC regional news programme on 6 April 1995. He sought advice from the British Medical Association, and was advised that his contract did not prevent him from speaking to the media. [229]
200 Mr Wisheart stated in his written evidence to the Inquiry that, even if Dr Bolsin had not sought to give information to the `Daily Telegraph':
`... in addition to the Daily Telegraph, and on the same day as its publication, there was a television programme on BBC locally. Dr Bolsin appeared on this programme, participated in it extensively and clearly had provided them with similar information. So I was in no doubt, and I have remained in no doubt, that Dr Bolsin had placed this information in the public arena and this was the basis for my feeling that the necessary trust between him and myself did not exist for the purpose of operating on patients.' [230]
201 Maria Shortis, mother of Jacinta who had heart surgery at the BRI, stated in her written evidence to the Inquiry that she had seen Dr Bolsin appear on a BBC news programme on 6 April 1995. As a result of this:
`On Friday April 8th I saw Dr Bolsin at his home and asked him if he would tell me what had led him to make his concerns known publicly.' [231] She stated that Dr Bolsin explained "in great detail" the events which had led him to speak publicly about paediatric cardiac surgery at the Trust. [232] She also stated that Dr Bolsin said: "... he would be a target for victimisation. He had already experienced some isolation from his colleagues. He also realised that he could probably not continue his career in Bristol and would have to look for another job."' [233]
202 Dr Roylance in his written evidence to the Inquiry gave this account of his approach to `whistleblowers':
`I repeatedly emphasized that "whistleblowers" would not be victimized in any way. It was over time increasingly clearly emphasized that members of staff with concerns were expected to make them clear to an appropriate person within the Trust and only to go outside in the event of a continuing problem. When external complaints were made the Trust did expect people to make clear that they were making a personal observation and not representing the views of the Trust. The Chairman joined me in requesting that before such a move was made they should ensure that he and I were aware of the nature of the complaint so that we could rectify it if that was appropriate.' [234]
203 He told the Inquiry that he made this policy clear from the early days of trust status. [235] He contrasted the UBHT's approach with the position of trusts trying to insert confidentiality clauses into contracts: `We made it clear that there was no way the Trust would or could prevent them [employees] expressing their views in public.' [236]
Meeting between Dr Bolsin and Dr Roylance
204 Dr Bolsin referred in his written evidence to the Inquiry to a meeting with Dr Roylance which it was agreed took place in 1995:
`... towards the end of the conversation he used an analogy to illustrate my position. He explained that the new chairman of the Trust board (Mr Bob McKinlay) had worked in the aircraft industry. I had recently had a patient under my care who had received an incompatible blood transfusion; although a recent coronial inquiry had exonerated my involvement. [237] Dr Roylance explained that the hospital was in the process of negotiating compensation for the patient's relatives and that in the aircraft industry if a worker was paid to bolt the blades on a helicopter and the blades fall off and passengers are injured, then that worker never bolts the blades on helicopters again.' [238]
`This very potent threat to a junior consultant from a chief executive was repeated later that week to Doctor David Coates, who was the British Medical Association place of work accredited representative ...' [239]
206 Dr Roylance in his written comment on Dr Bolsin's statement stated:
`I repeated the conversation that I had with Dr Bolsin to the place of work accredited representative, Dr Coates, in order that he could understand the policy which I was hoping to steer the Trust Board towards and so that he might also support Dr Bolsin's position whilst fulfilling his duties both to Dr Bolsin and the Trust.' [240]
207 Dr Roylance told the Inquiry that he telephoned Dr Coates to explain the position because `I was so concerned he was misunderstanding me ... .' [241]
208 Dr Roylance stated that, at that time, trust boards were developing their responses to the civil actions in negligence that had become a trust's responsibility, by virtue of the cessation of Crown Immunity. [242] He noted that:
`A patient under Dr Bolsin's care had received an incompatible blood transfusion and died. Dr Bolsin was, for a time, under investigation by the Police for a possible manslaughter charge and an inquest was held into the death. Subsequently, no criminal charges were brought. [243] In view of the serious nature of the potential manslaughter investigation, the Trust Board were aware of this particular case. [244] In addition, civil proceedings for negligence were afoot.' [245]
`At the time I saw Dr Bolsin, Matthew Hill of the BBC was preparing a programme for television, based on the report of Mr Marc de Leval and Dr Stewart Hunter. Dr Bolsin thought that this report criticized him unfairly and wished to make a personal contribution to the programme. [246] I was aware that Mr McKinlay was involved in detailed discussions with Mr Hill about the proposed content of the programme and I offered Dr Bolsin my advice that, if he became involved within the programme, he might be undermining the Chairman's discussions with Mr Hill and/or might be seen by Mr McKinlay to be doing so. This was simply meant as friendly advice and was not intended to be threatening, nor did Dr Bolsin give me any reason to believe he took it to be a threat. Indeed, he disregarded my advice, as he was entitled to do and appeared in person on the television programme.
`I used the analogy of the helicopter, which I may have chosen simply because this was the business that Mr McKinlay had been in prior to joining the Trust, because I wanted Dr Bolsin to understand that I did not want the Trust Board to adopt this "commercial" type approach to medical negligence and that I was trying to steer them in a different direction that would be supportive of and sympathetic to, doctors. I was concerned that Dr Bolsin's involvement in this programme at this time, when his own case was likely to be coming before the Board, might jeopardise my efforts to establish an appropriate policy at Board level.' [247]
210 Dr Bolsin recalled that he was telephoned by Dr David Coates, who was the place of work accredited representative for the BRI, and one of his consultant anaesthetist colleagues, on the evening of Dr Bolsin's meeting with Dr Roylance. Dr Coates told him that he had just received a serious threat to Dr Bolsin's career from Dr Roylance, in which the helicopter analogy had been used. [248]
211 It was put to Dr Roylance that:
`The natural interpretation from someone in ... Dr Bolsin's position, of the analogy that if a man was paid to bolt on helicopter blades and does not do the job properly, he will not do the job again, is that if he, someone in his position, makes a mistake, then he will get sacked.'
`Q. Was that part of the message you were trying to get across to him?
`A. That was a concern. I was endeavouring to ensure that it did not happen and did not arise. I used the analogy, I have to say, because I found Steve Bolsin rather difficult to communicate with.' [249]
212 When asked what message he wanted Dr Bolsin to take from the analogy, Dr Roylance replied:
`I wanted him not to irritate the Trust Board ... .
`Q. What was he to do to avoid irritating the Trust Board?
`A. Anything. I was appealing for his co-operation with me to ensure that we did not have any disruption of the normal relationships.' [250]
213 Dr Roylance accepted that he had spoken to Dr Coates, and repeated the analogy. The questioning followed:
`Q. So putting it in crude vernacular, what you were saying to him was, was it: "Nice little job you have here. Shame if anything were to happen to it. You ought to be careful it does not."
`A. No. You are converting this as a personal threat to Steve Bolsin. It was not. It was a personal request of mine to Steve Bolsin for help. It was not the reverse, as you have implied. It was because I was having difficulty in communicating with him that I asked his colleague to reinforce that message.' [251]
He added that what he was asking Dr Bolsin to specifically avoid doing was:
`Anything that would irritate the directors of the Trust Board which might precipitate them to take a posture I did not want them to take. Anything. There is no mention of any particular event. I did not want him to be a fall-guy. I wanted to protect him.' [252]
The cardiac anaesthetic rota
214 Dr Bolsin's anaesthetising rota was altered in April 1995. Following an initial meeting at which Dr Roylance raised the issue with Dr Monk, a meeting was held to discuss changes in Dr Bolsin's cardiac commitments, attended by Dr Bolsin, Dr Monk, Dr Trevor Thomas, consultant anaesthetist, and Professor Prys-Roberts. [253] Dr Bolsin in his written evidence to the Inquiry stated:
`Dr Monk presented the view that there were perceived difficulties with the staffing of paediatric and adult cardiac surgery. These were being contributed to by my request to maintain my adult cardiac surgical workload at two days per week. The situation that Dr Monk wished to communicate to me was that if I persisted with my request to maintain two days of adult cardiac surgery per week the Trust would consider that it was more likely to be able to dismiss one cardiac anaesthetist than two cardiac surgeons.
`I was shocked to hear this projection of Trust Board thinking and offered the information that nobody needed to be dismissed; all that was required was that I was allowed to work to my contract.
`... This meeting represented an undeniable threat to my employment at the Trust ... It now became a matter of considerable importance to me that I should leave the UBHT and find alternative employment.' [254]
215 Mr McKinlay, in his written comment to the Inquiry on Dr Bolsin's statement, stated:
`The Trust Board did not discuss the dismissal of Dr Bolsin and if "Trust Board thinking" was a projection by Dr Roylance it was not justified.' [255]
216 Dr Monk in his written evidence to the Inquiry stated:
`On many occasions following the early press coverage in 1995, it was necessary for me to defend SB [Dr Bolsin]. I was told, by JR [Dr Roylance] and JDW [Mr Wisheart], in JR's office that JDW and JD [Mr Dhasmana] had received legal advice that they should not work with SB on planned paediatric cases. I gained the impression that if this should occur the legal implications would necessitate the cancellation of the case and/or the removal of the anaesthetist concerned. To avoid this conflict between SB and the cardiac surgeons I had to adjust his clinical programme to avoid the threat of suspension ... .' [256]
217 Dr Monk stated that he was first told of the need to change Dr Bolsin's rota by Dr Roylance. [257] Dr Monk stated that if agreement to this effect could not be reached with Dr Bolsin:
`I gained the impression that the alternative solution would be the suspension of Dr Bolsin from his cardiac commitments. At this point I informed Dr Roylance that he should not suspend Dr Bolsin, that he had no grounds to do so and that Dr Bolsin would have a case for constructive dismissal. I offered to resolve the situation to allow time for the differing views on outcome to be addressed.' [258]
`At another time, after the press publicity, JR with JDW raised the suggestion of dismissing SB. I argued that this would be an inappropriate action and bore no relation to the problems within the paediatric cardiac service.' [259]
`In an attempt to underline the effect that the continued publicity was having on his [Dr Bolsin's] own future I arranged a meeting (25th April '95) to discuss this with him in the presence of Professor Prys-Roberts and Dr Thomas. I asked my two colleagues to attend as they had both supported SB in raising the issue of the P.C.S [paediatric cardiac surgery]. At this meeting I attempted to make SB aware of the feelings held in the Trust HQ and of the progress made in achieving changes in the P.C.S.' [260]
220 Dr Monk stated that at the meeting:
`I believed then that Dr Bolsin gained the impression that I was supportive of the position taken by the Trust. This was incorrect. My concerns were over the possible suspension of my colleague by the Trust, that the conflict over the audit remained unresolved and the publicity over a suspension would obscure the true problem of the PCSS. I regretted at the time that I was unable to communicate to Dr Bolsin my concerns and support for him and my desire to speedily resolve all the issues regarding the PCSS.' [261]
221 On 24 April 1995, Dr Bolsin had written to Dr Monk expressing his concerns about the `unofficial change' to his contract that had occurred in the previous two weeks, and stating that he was willing to work with all the cardiac surgeons. [262] Dr Monk replied two days later, i.e. the day after the meeting with Dr Bolsin. [263] Dr Monk asked Dr Bolsin:
`... to agree to flexibility in your work pattern, in site but not in time, to avoid interpersonal conflict in the theatre environment, this was on an informal, temporary basis.' [264]
`Great tensions remain unresolved between you and your colleagues and these conflicts can be viewed as an avoidable risk factor. This issue and many others have been discussed between us on a number of occasions, the action to temporarily change your programme had your active agreement in order to allow the "breathing space" to correct the breakdown in relationships, communication and trust. Your happiness at working with all the cardiac surgeons is not reciprocated and displays a lack of insight into the personal effects of recent events.' [265]
223 Dr Monk in his written evidence to the Inquiry described the changes which resulted in Dr Bolsin's rota:
`The initial change to Dr Bolsin's cardiac commitment was complicated by the daily commitments of the cardiac anaesthetists being planned in three monthly blocks around which clinical and personal plans are made. Therefore for the remaining weeks of the published rota an exchange between Dr Bolsin's Thursday cardiac commitment and Dr Masey's Thursday general surgery list was made, obviously this would not be needed if Dr Bolsin had no Thursday commitment. It resulted in a small decrease in his cardiac activity. The next rota was constructed by Dr Masey after my request to ensure that the cardiac workload of Dr Bolsin was restored whilst avoiding the need for the two paediatric surgeons and him working together with children. This was possible because of the flexible approach to the days worked in cardiac theatre by the anaesthetists i.e. they work two days each week out of three cardiac days defined in their job plan.' [266]
Dr Bolsin's departure from Bristol
224 Arrangements for counselling were made by the UBHT by the summer of 1995, to mediate between the cardiac surgeons and Dr Bolsin.
225 Dr Roylance stated in his written evidence to the Inquiry:
`The counselling sessions which I arranged with the agreement of the Trust Board for the two cardiac surgeons and Dr Bolsin were an attempt to reestablish a proper working relationship between them. Throughout the time that Dr Bolsin had apparently been making disparaging remarks outside the Trust about the two cardiac surgeons he had been happily working with them and anaesthetizing patients on whom the surgeons were operating. It was clearly essential that efforts were made to re-establish the necessary trust between anaesthetist and surgeon to restore a proper working relationship. The need for counselling was brought about by the mutual loss of trust and was not an attempt to persuade anyone to change their professional opinion.' [267]
226 Dr Bolsin stated in his evidence to the Inquiry that he was:
`... advised to attend ... The purpose of the contacts was to attempt to reconcile the differing opinions betraying [sic] myself and the cardiac surgeons concerning the outcomes for paediatric cardiac surgery.' [268]
227 Mr Wisheart stated in his written evidence to the Inquiry:
`The publication of his opinions in the "Daily Telegraph" ... in April and May 1995, some of which he has since acknowledged to be factually incorrect, destroyed the mutual confidence which is essential if a surgeon and an anaesthetist are to work together in the operating theatre in the patient's best interest. Surprisingly it was his wish to revert to his original working programme and work with me, despite the views that he had expressed.' [269]
`It is my belief that the Trust never wished to dismiss Dr Bolsin, either by constructive dismissal or any other way. On the contrary, the Trust set up a process of conciliation to resolve the differences between Dr Bolsin, Mr Dhasmana and myself. This conciliation process was conducted by two consultant psychiatrists and was carried forward actively during the months of June, July and August, 1995. During this time there were a series of meetings when the psychiatrists interviewed us individually and subsequently we all met together. All parties were acting positively until Dr Bolsin withdrew from the process in the autumn of 1995.' [270]
`The fact that the Trust set up this process seems to contradict the suggestions of a threat to his employment.' [271]
`At no stage was there any serious consideration, discussion or proposal to the effect that Dr Bolsin might be sacked. On the contrary there were repeated statements that Whistleblowers would not be victimised, and in the summer of 1995 there was an attempted conciliation. Dr Bolsin appeared to participate actively and positively in this process; he then walked away from it to go to Australia.' [272]
230 Dr Bolsin stated that a diminution in the volume of his private practice also had `some impact' on his decision not to stay in Bristol:
`The number of cardiac surgery cases being referred to me had diminished in the 1990s and I believed that this was related to the fact that I was criticising the paediatric cardiac surgery service at the BRI.' [273]
231 Dr Monk in his written evidence to the Inquiry stated:
`I am unaware of the background to the statements concerning private practice nor am I aware of any reduction in his [Dr Bolsin's] practice.' [274]
232 Dr Bolsin left the Trust's employment in late February 1996, to take up an appointment in Australia. [275] Before doing so, he sought advice from the BMA as to whether he had a claim against the UBHT for constructive dismissal. He was advised that there was `very little evidence' to sustain such a case. Whereas the Trust:
`... may not have supported you as you would have liked, they do not appear to have left you out in the cold and appear to have tried to remain impartial to minimise the arguments between consultants.' [276]
233 Before Dr Bolsin left, Mr Hugh Ross (the newly appointed Chief Executive of the UBHT) wrote to him in the following terms:
`I write further to the series of meetings we have held in recent months. I recognise that your departure to a new career in Australia is imminent. The Chairman and I felt we should put on record our belief that your actions in recent years have been motivated throughout by your concern for the best interests of patient care. The records available to us confirm that you did raise your concerns internally within the Trust in the first instance, and only when you felt they were not being adequately recognised did you raise them outside the Trust.
`Best wishes for the future.' [277]
Andrew Peacock's surgery
234 The protocol agreed following the Hunter/de Leval report envisaged that Mr Wisheart would withdraw from paediatric practice. [278]
235 Sharon Peacock, mother of Andrew, set out in her written statement to the Inquiry that Andrew, who was born on 29 November 1993, suffered from a Coarctation of the Aorta. [279] He was admitted to the BRHSC on 8 December 1993, and operated upon by Mr Wisheart the following day. [280] Andrew was able to return home in the week before Christmas. [281] He was followed up in the outpatient clinic, but subsequently required re-admission for investigation and catheterisation. This was performed, by Dr Martin, on 5 January 1994. [282] Mrs Peacock was soon told that a further operation on the aorta would be required, in order to place a patch on the aorta. [283] This took place on 9 March 1994. Again, the operation was conducted by Mr Wisheart. [284]
236 A second catherisation took place in September 1994. Mrs Peacock was informed that a further operation on the aorta would be needed in 6-12 months' time. [285] She saw Mr Wisheart in November 1994. Mrs Peacock stated in her written evidence to the Inquiry that Mr Wisheart discussed the risks of the procedure with her, giving Andrew's operation a 94% chance of success. [286] She stated that he also explained the risks of paraplegia. [287]
237 Before she received a date for the operation, Mrs Peacock stated that she saw an item on BBC television's local news:
`... which mentioned problems with the paediatric heart surgeons in Bristol. The programme said that there was a problem with the "Switch" operation, and talked far more about Mr Dhasmana than about Mr Wisheart. There was a helpline given out at the end of the bulletin, and I called it immediately, as I felt extremely concerned for Andrew. A man, who identified himself as a cardiologist from Bristol Children's Hospital, answered the telephone. He said that there was not a problem with the type of surgery that Andrew was to undergo, and that the media had blown things out of proportion'. [288]
Mrs Peacock stated that she spoke to Mrs Vegoda, Counsellor in Paediatric Cardiology, who `also said that the media were getting things out of proportion.' [289]
238 At his clinic on 25 April 1995, when a date for the operation had not yet been fixed, Mrs Peacock stated that Dr Martin told her of the new surgeon, and asked her who she wanted to perform surgery on Andrew. Mrs Peacock stated:
`I felt that Dr Martin would know who was best to carry out Andrew's surgery. I told Dr Martin that I could not make this choice, in case I made the wrong decision. He did not offer me an appointment with the new surgeon in order to discuss Andrew's case.' [290]
Andrew therefore remained Mr Wisheart's patient.
239 On the next day, 26 April, Mrs Peacock stated that she telephoned Mr Wisheart's secretary, to inquire about the state of the operating list, and was told to bring in Andrew for surgery the following day (27 April). Andrew was in fact admitted to the BRI on 28 April and surgery took place on 1 May 1995. [291]
240 Andrew did not recover after the surgery, and died on 30 May 1995. The post-mortem results revealed that he had suffered brain damage. [292]
241 Mrs Peacock stated in her written evidence to the Inquiry:
`If I had realised what the true state of paediatric cardiac surgery was at the BRI ... I would never have taken Andrew there for his operation. Neither would I have allowed Mr Wisheart to operate on Andrew. I would have waited for Ash Pawade (who arrived on 1 May, the day of Andrew's third operation) to perform the surgery...' [293]
242 Mr Wisheart, in his written comment on Mrs Peacock's evidence, stated that:
- `Initially (October to November 1994) Andrew's third operation was expected to take place in early 1995 before Mr Pawadi [sic] came, so the question simply did not arise at that time.
- `I had already operated twice on Andrew and felt that there was a good relationship with the Peacock family.
- `I had considerable experience in all forms of surgery for coarctation of the aorta.
- `The events of 1995 and findings of the Hunter and de Leval report did not apply to Andrew or to surgery for coarctation. The reservations expressed were only about open heart surgery and were chiefly in relation to my surgery for complete AVSDs.
- `The agreement of the 15 March 1995 provided for me to continue to operate on children but not on infants and not to correct complete AVSDs during the period until Mr Pawadi [sic] arrived. It further provided that I would do some open heart surgery in the months after Mr Pawadi [sic] arrived, with the agreement of the cardiologist and the parents.
- `I understood that there was such agreement following the consultation between Dr Martin and Mrs Peacock on 25 April 1995.
- `Mr Pawadi's [sic] employment did begin in Bristol on 1 May 1995 which was also the day of Andrew's operation. Mr Pawadi [sic] would hardly have wished to undertake such an unusual or complex operation on his very first day in Bristol before [he] had got to know either the surroundings or his colleagues.' [294]
243 Maria Shortis stated that she, and other members of the public, had been led to believe that Mr Wisheart intended to give up all paediatric cardiac surgery even before Mr Pawade came to the UBHT. [295] She referred to a letter written by Dr Joffe, Dr Martin, Dr Hayes, Mr Wisheart and Mr Dhasmana. [296] Addressed to medical colleagues who would be coping with `questions from anxious and confused parents without the facts being available to you', it discussed the Bristol results and the investigation by Professor de Leval and Dr Hunter, and continued:
`The report concluded that the Unit should continue to perform all forms of congenital heart surgery, including non-neonatal switches; recommended that regular multi-disciplinary audit take place to monitor outcomes and foster teamwork; agreed with the Trust's decision to appoint a cardiac surgeon dedicated to paediatric work to join Mr Dhasmana (Mr Ash Pawade from the Melbourne Unit arrives in May); and supported the transfer of all children's open heart surgery to the Children's Hospital. ... Babies with TGA who are found to be suitable for the arterial switch operation (about 10 per annum) will be referred to another centre until Janardan, Ash and the cardiologists are confident to recommence the programme. James Wisheart has decided to confine his work to adults in the future because of increasing managerial responsibilities within the trust.' [297]
Quoting risks
244 Ms Sheena Disley, Ward Sister, Ward 5, since 1984, told the Inquiry in the following exchange about Mr Wisheart's reference to risks in a conversation with parents:
`Q. Do you ever remember attending one of these discussions and hearing a risk or a benefit quoted to a patient, or a parent of a patient, that you disagreed with?
`A. I do recall such an occasion, but it was actually after the child had had surgery.
`A. It was an occasion where the child was - I cannot even recall the surgery he had. He had made slower than expected progress, and was beginning to fit, if I can recall.
`Q. What was said that you disagreed with?
`A. I cannot recall the details of the discussion, but I felt that it seemed optimistic.
`Q. The chances of survival being quoted? What was being quoted that was optimistic?
`A. The recovery that the child would make.
`Q. What did you do when you heard this being quoted that you thought was optimistic? How did you react?
`A. At the time, I did not do anything - at the time, no, I did not do anything.
`Q. When was this incident that you recall?
`Q. Who was the clinician who was giving what you thought was an optimistic prognosis?
`Q. If you had a similar experience tomorrow at work with a patient and a clinician, would you react differently now?
`A. Yes, I think there are occasions perhaps when we are discussing the care of
long-term patients, and - yes, I would.' [298]
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Footnotes
[224] PAR2 0001 0137 - 0138; `Press Statement: Paediatric cardiac surgery at the United Bristol Healthcare NHS Trust', dated 6 April 1995
[225] PAR2 0001 0137 - 0138; `Press Statement: Paediatric cardiac surgery at the United Bristol Healthcare NHS Trust', dated 6 April 1995
[226] PAR1 0001 0090 - 0091; article in the `Daily Telegraph' dated 5 April 1995
[228] Including an article in the `British Medical Journal' on 15 April 1995 (BMA 0001 0007) and an article published in `Private Eye' on 4 May 1995 (JDW 0003 0150). Dr Joffe responded to the `BMJ' article by letter published on 6 May 1995 (BMA 0001 0008) and a `correction' was also published on 20 May (BMA 0001 0014)
[229] BMA 0001 0004; note of advice
[230] WIT 0120 0467 Mr Wisheart
[231] WIT 0222 0026 Maria Shortis
[232] WIT 0222 0026 Maria Shortis
[233] WIT 0222 0027. Maria Shortis subsequently made arrangements to speak to other clinicians, including Professor Angelini and Dr Joffe. She had a further discussion with Dr Bolsin and Professor Angelini on 19 August 1995 (WIT 0222 0035) and with Dr Bolsin, James Garrett (Head of Current Affairs, HTV) and Michaela Willis on 14 September 1995. `Soon after this meeting Penny Cotter, assistant producer for Channel Four, began the investigation work into the "Dispatches" television programme.'(WIT 0222 0037)
[234] WIT 0108 0029 - 0030 Dr Roylance
[236] T88 p.20 Dr Roylance. Professor Stirrat stated in his written evidence to the Inquiry that: `... there was no policy of exclusion of Dr Bolsin - indeed, it was to the contrary.' WIT 0245 0009
[237] See WIT 0080 0422 for the comments of the UBHT upon this incident; and WIT 0080 0444 for the comments of Mr Hutter (consultant cardiac surgeon), who refers to it and other criticisms of the clinical practice or care offered by Dr Bolsin as a reason why `Dr Bolsin did not have the full respect of many of the consultants within the cardiac surgery unit. For this reason, they may have been less willing to take note of his comments on the basis that he did not appear to be pulling in the same direction as the main body of consultants, whose only aim was to work hard, continuously making improvements to the unit.'(WIT 0080 0444)
[238] WIT 0080 0002 - 0003,0121
[239] WIT 0080 0003 Dr Bolsin
[240] WIT 0080 0019 Dr Roylance
[242] WIT 0080 0017 Dr Roylance's response to a statement prepared by Dr Bolsin
[243] According to Mr Wisheart, the decision not to bring charges was taken by the Crown Prosecution Service in February 1995 (WIT 0080 0336)
[244] See, e.g., UBHT 0007 0088; notes of the meeting of the Executive Committe of the UBHT Board on 14 October 1994, at which the incident was recorded
[245] WIT 0080 0016 - 0017 Dr Roylance's response to a statement prepared by Dr Bolsin
[246] Dr Roylance subsequently told the Inquiry that he agreed that Dr Bolsin was further seeking his assurance that he would say something publicly to exculpate Dr Bolsin from any criticism contained in the report (T89 p.97)
[247] WIT 0080 0018 - 0019 Dr Roylance. Dr Roylance told the Inquiry that the conversation was not `a personal threat to Steve Bolsin. It was not. It was a personal request of mine to Steve Bolsin for help.' (T89 p.94.) Mr Wisheart stated in his written evidence to the Inquiry that he supported Dr Bolsin: `When the Crown Prosecution Service were considering charging him in connection with the blood transfusion error, I advised the Chief Executive that he should not be suspended.' (WIT 0080 0322)
[253] WIT 0080 0130 Dr Bolsin
[254] WIT 0080 0130 Dr Bolsin
[255] WIT 0080 0417 Mr McKinlay
[256] WIT 0105 0029 Dr Monk
[257] WIT 0080 0030 Dr Monk
[258] WIT 0080 0030 Dr Monk
[259] WIT 0105 0029 Dr Monk
[260] WIT 0105 0029 Dr Monk
[261] WIT 0080 0030 Dr Monk
[262] WIT 0080 0303; letter dated 24 April 1995
[263] WIT 0080 0304 - 0305 ; letter dated 26 April 1995
[264] WIT 0080 0304; letter dated 26 April 1995
[265] WIT 0080 0304; letter dated 26 April 1995
[266] WIT 0080 0031 Dr Monk
[267] WIT 0080 0019 Dr Roylance
[268] WIT 0080 0003 Dr Bolsin
[269] WIT 0080 0049 Mr Wisheart (emphasis in original)
[270] WIT 0080 0049 - 0050 Mr Wisheart. See also Mr Wisheart's comments in his `Response to the talk entitled "The Whistleblower in Medicine" given by Dr Stephen Bolsin to the Medical Legal Society of Victoria on Friday 19 March 1999' at WIT 0080 0407- 0408
[271] WIT 0080 0345 Mr Wisheart
[272] WIT 0080 0412 Mr Wisheart
[273] WIT 0080 0132 Dr Bolsin. In his statement Dr Bolsin implied that Mr Wisheart suggested to at least one surgeon that private cases should not be referred to Dr Bolsin. Mr Wisheart commented: `Again this is a matter of which Dr Bolsin has no direct knowledge. I did not ask any surgeon not to refer private patients to Dr Bolsin, or seek to influence any surgeons not to refer private patients to Dr Bolsin.'(WIT 0080 0347). In BMA 0001 0023, Dr Bolsin estimated that the loss of work in private practice had cost him `in excess of £30, 000 this year'[1995]
[274] WIT 0080 0031 Dr Monk
[275] GMC 0004 0112; letter from Mr Ross to Dr Bolsin dated 31 January 1996
[276] BMA 0001 0027; letter from Mr S Cusack, Industrial Relations Officer at the BMA, to Dr Bolsin dated 28 December 1995
[277] GMC 0004 0113; letter dated 20 February 1996
[278] WIT 0106 0127 - 0128 and see above for the text of the protocol
[279] WIT 0011 0002 and WIT 0011 0004 Sharon Peacock; see Chapter 3 for an explanation of this term
[280] WIT 0011 0003 and WIT 0011 0006 Sharon Peacock
[281] WIT 0011 0007 Sharon Peacock
[282] WIT 0011 0009 Sharon Peacock
[283] WIT 0011 0010 Sharon Peacock
[284] WIT 0011 0011 Sharon Peacock
[285] WIT 0011 0014 Sharon Peacock
[286] WIT 0011 0015 Mrs Peacock added, `He did not explain what the 6% chance of failure referred to, or what it consisted of.' Mr Wisheart in his written comment on Mrs Peacock's evidence responded: `As this operation followed two others, which Mrs Peacock knew carried a risk of not surviving, it is hard to imagine that there would not have been a risk of death associated with this operation also. Moreover, in my explanations I always made it absolutely explicit that I was talking of the risk of a certain number of children not surviving the operation or the recovery period afterwards.'(WIT 0011 0041; emphasis in original)
[287] WIT 0011 0015 Sharon Peacock
[288] WIT 0011 0017 Sharon Peacock. On the creation of the helpline, see para 194
[289] WIT 0011 0017 Sharon Peacock. Mrs Vegoda agreed `It is possible I said that the media is known to get things out of proportion. I would certainly have suggested that she speak directly to Dr Martin and may have offered to arrange this ... I may have tried to re-assure her that if Dr Martin and Mr Winspur were advising surgery for Andrew then this was necessary'(WIT 0011 0032). Mrs Peacock acknowledged in her written evidence to the Inquiry the help and support which she received, after Andrew's death, from Mrs Vegoda and Helena Cermakova, a Hospital Chaplain (WIT 0011 0031)
[290] WIT 0011 0017 Sharon Peacock
[291] WIT 0011 0018 Sharon Peacock
[292] WIT 0011 0043 Mr Wisheart; the timing of any such damage was a matter of controversy or uncertainty
[293] WIT 0011 0030 Sharon Peacock
[294] WIT 0011 0042 Mr Wisheart; see Chapter 3 for an explanation of clinical terms
[295] WIT 0222 0038 Maria Shortis
[296] Maria Shortis stated that the letter was dated 21 April 1995, but the letter was written on 16 April 1995
[297] UBHT 0052 0240 - 0241 ; emphasis in original; see Chapter 3 for an explanation of clinical terms