Annex A > Chapter 30 - Concerns 1995 and after > Concerns 1996 and later > Review of adult cardiac surgery
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Review of adult cardiac surgery
272 The performance of the paediatric cardiac surgical service inevitably gave rise as to questions as to the performance of the adult cardiac surgical service. Accordingly, the Trust decided to have an expert external review of adult cardiac surgery. The president of the Royal College of Surgeons suggested Professor Tom Treasure of St George's Hospital and Professor Ken Taylor of the Hammersmith Hospital. They accepted this appointment, and were subsequently joined by Professor Nick Black of the London School of Hygiene and Tropical Medicine.
273 Their report [337] set out preliminary results from their analysis of all adult cases operated on by the five cardiac surgeons from 1 January 1993 until 30 September 1995, following an examination of 2, 577 case records. The report compared the mortality rates of one surgeon (designated `consultant 1231' for the purposes of the report) with the combined mortality rates of his four colleagues, in respect of any operation which consultants conducted. [338] The overall mortality rate of consultant 1231 was 13.6% compared with 5.9% for his colleagues. The mortality rate of consultant 1231 for all coronary artery bypass grafts (CABGs) was 13.4% compared with 4.1% for his colleagues, and his mortality rate for CABGs in risk categories one to ten was 12.2% compared with 2.6% for his colleagues.
274 The assessors reported that the results for consultant 1231 were `significantly poorer' than the results for his colleagues. [339]
275 The number `1231' had been used to anonymise the surgeon, with a view to ensuring that knowledge of individual surgeons did not influence the results.
276 When the data were presented to the UBHT, the UBHT asked to know the identity of consultant 1231. It was Mr Wisheart.
`1. that the overall performance of adult cardiac surgery in UBHT is satisfactory and is in line with published average figures for UK cardiac surgical units as a whole.
`2. that the individual performance of consultant 1231 is significantly poorer than the rest of the UBHT consultants. Furthermore, in absolute terms, the assessors consider that consultant 1231's operative mortality figures are too high. The data indicated a particular problem in the area of coronary surgery.
`The assessors recommend to UBHT that consultant 1231 should not resume operating.' [340]
278 In the course of his evidence, the questioning of Mr Wisheart went as follows:
`Q. The purpose of this question is not to embarrass you but to lay the groundwork for what will follow in respect of paediatric cardiac surgery. Was [surgeon 1231] you?
`Q. Can we go to page 71? The second recommendation: "... in absolute terms, the assessors consider that [the] operative mortality figures are too high. The data indicate a particular problem in the area of coronary surgery." You accepted their recommendation?
`A. I accepted their recommendation.
`Q. The adult surgical report had, had it, approached the analysis of one surgeon in respect of another by looking at risk stratification?
`Q. So the results which you purported to show were results which as far as possible, gave a level playing-field for comparison?
`A. Yes, they did that, a number of - well they did it - in the actual report they used what one might call a conventional method of risk stratification and they used it to a limited degree.
`Q. When did you, if you did, first realise that your personal performance by this period of time, despite attempting to do your best, was not in line with the other adult surgical performances of your colleagues?
`A. In the proceeding November [341] when the provisional results that you referred to a moment ago were drawn to our attention and that is when I stopped operating.
`Q. But before then, despite your interest in and to an extent the retention of some of the figures relating to cardiac surgery, you had no idea?
`A. I was surprised, that is correct, but it is not only because of my own personal views. The period we are referring to here is 1997 and over a period of approximately two and a half years, just a little less than that, questions had been asked, that is, prior to Professors Treasure, Taylor and Black holding their investigation.
`At each point when those questions were asked, the figures of all the surgeons and my figures were examined by a whole range of different people who I can tell you about if you wish to know, but the point I wish to make was that it was not only my own assessment of the figures that had given me a measure of confidence up until that time, it was the advice I had received from leading people, both inside and outside the specialty, both inside and outside the hospital, so the figures had been shared, as we knew them, fully and openly, and the judgement of those to whom I had looked for advice during that two and a half year period was entirely supportive. So that is why I was surprised, not just my own judgement.' [342]
279 Mr Wisheart said that if he had had an indication of the results earlier he would have stopped operating then, rather than later.
280 On 17 November 1994 Professor Farndon had raised with him the fact that some were questioning the adult figures for cardiac surgery. He had responded that the figures for adults had been examined especially in detail in 1992 and 1993, and that if stratified for risk category, there was little difference between consultants. [343] At that time he had been noted by Professor Farndon as saying that:
`... [the]adverse results must in part be due to (1) weighted patient population re adverse factors, and (2) natural history of AO and valves is that they will, by now, be ready for revisional surgery - : difficult? results.' [344]
He accepted that he was explaining the apparent poor results on the grounds of case mix and the fact that the surgery was revision surgery.
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Footnotes
[337] External Assessors' Report `Independent Review of Adult Cardiac Surgery - United Bristol Healthcare Trust (UBHT)
[338] As opposed to operations where the consultant was in charge whilst a junior surgeon operated
[339] UBHT 0053 0066; External Assessors' Report
[340] UBHT 0053 0071; External Assessors' Report (emphasis in original)
[341] In 1996
[344] WIT 0087 0025; Professor Farndon's note