Annex A > Chapter 9 - The Split Service > Comments by clinicians in Bristol
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Comments by clinicians in Bristol
90 Mr Wisheart told the Inquiry that the problem of the split site was known in 1984, but that it took until October 1995 to resolve. [90]
91 He explained in his written evidence to the Inquiry:
`Although the need for this development had been recognised as a theoretical proposition for a very long time there were at least two reasons why it did not become a practical one until after the late 80s. The first was that before 1987 there were no catheter facilities within the Children's Hospital, so the children had to be transferred to the BRI for diagnosis, and back again to the BRHSC. The second was that at the time the whole cardiac surgical enterprise was so small that to divide it into two would have weakened it seriously, even if it had been actually possible from the financial and personnel standpoint.' [91]
`... it is wrong to describe the operating theatre and intensive care unit as adult facilities into which children were placed. It is correct to say that they were facilities which were created both for children and adults.' [92]
93 Mr Wisheart was asked by Counsel to the Inquiry about the concerns expressed by parents about transport between the BRI and the BRHSC:
`I think the shape of the problem is little different for catheterisation of children and open heart surgery, and I think that they are really talking of the problems associated with the transport of very sick children backwards and forwards on the same day before and after the investigation.
`The issue of transport occurred or persisted, if you like, with a relatively small number of children who needed to be transferred for urgent surgery to the Infirmary, but of course the other problems were that the children were being cared for at a site which was some distance from the Children's Hospital.' [93]
94 Mr Wisheart indicated that there were organisational problems arising from the split site: the difficulty in recruiting and retaining paediatric nurses; the failure to attract Mr Martin Elliott to the Chair of Surgery; and the rejection by the Joint Committee on Higher Medical Training Visitor, Dr Elliott Shinebourne, in 1992, of the proposal to create a Senior Registrar post in paediatric cardiology at the BRHSC.
95 Asked by Counsel to the Inquiry whether the decision to move the paediatric surgical workload to the BRHSC was eventually taken so as to increase further the number of adult patients who could be treated at the BRI, Mr Wisheart replied: `I would not put it that way'. [94]
96 The issue was explored in the following exchange:
`A. It is absolutely right to say the increase in adult work was the occasion or opportunity which permitted the children's work to be moved, but there was a clear and independent motivation and desire to do that.
`Q. Would you go this far: that it was the proposed expansion in adult surgery which was the impetus for the move to the Children's Hospital?
`A. I think I would still stick to "occasion".' [95]
97 Mr Wisheart was asked about the funding application made by Dr Joffe in June 1992 to help resolve the split site issue. He was asked if he played a part in the formulation of the application:
`I think I asked him to do that - or we agreed that he should do it, would be better, I am sorry.' [96]
98 He went on, in the following exchange:
`A. I think it would be fair to say that the technical details of funding are something that clinicians have a vague awareness of but it is not their prime interest. So that for funding opportunities or potential, I mean, we would be looking for advice to the financial experts within the Trust or at Region, or whoever.
`The question that I have asked myself, on seeing this, is, when we prepared our proposals in 1990, why did we not knock on this door then? In a sense, all I can say is that the proposals were prepared and they went to all the appropriate authorities at District as it then was and Region, and nobody prompted us to think that this was an avenue to go down.
`Q. So the plain truth is that, notwithstanding experience of having made an application for capital funding earlier, and having had to live daily with the effect of lack of resources generally, no-one actually thought of it?
`A. I think Mr Nix [the then Assistant Treasurer/Financial Manager (Acute) of B&WDHA] has said somewhere that he and his colleagues at Region nearly privately created the application in 1987, and I think our awareness of it was really very limited. It was merely a financial device operated by the financial people, and it did not work, but there we are.' [97]
99 Dr Joffe told the Inquiry that he did not attempt to obtain funding under the Supra Regional Service (SRS) system to deal with the split service [98] before 1992, as he was not aware `of the opportunity to request capital sums from the Supra Regional Services Group until 1992/93'. [99]
100 Mr Wisheart told the Inquiry that the appointment of a specialist paediatric cardiac surgeon and the resolution of the split site issue were both proposed and decided upon before the allegations in respect of paediatric cardiac surgery became public. He went on:
`This was the unit making what it thought was best plans for the future, at that time, with the assistance of the Trust, of course, as a whole.' [100]
101 Mr Dhasmana stated in his written evidence to the Inquiry that he was involved in 1988 in discussions with Dr Pitman, consultant in public health medicine at SWRHA, regarding a cardiac services strategy for the Region. He stated that he indicated his agreement to the transfer of the children's services to the BRHSC:
`I believe that it would be a step in the right direction if we did aim to achieve this goal as children would then be looked after in one place for all their cardiac problems. ... I personally would support the move to split children's services from here and hope that the staffing level would be raised in a few years` time.' [101]
`The problem with the BRI, because it is a place in the hospital where it is mainly an adult service, so whenever we wanted to recruit a paediatric trained nurse in the cardiac surgery, we were not very successful because nurses who were trained in children's care, they are in high demand everywhere and there is a shortage in almost all hospitals so obviously they get absorbed there quickly.' [102]
103 Dr Jordan, referring to the visit in 1991 by Dr Elliott Shinebourne which resulted in a decision not to approve the appointment of a Senior Registrar, told the Inquiry:
`My recollection is that they had no problems with the investigational side but they did not like the fact that there was no open-heart surgery on the same site.' [103]
104 Dr Jordan's views are indirectly referred to by a draft report [104] of March 1984, which urged that the transportation of critically ill infants should be avoided.
105 Dr Martin told the Inquiry that transfer from the BRHSC to the BRI `might be a factor that could potentially increase the risk of surgery in some of these patients and that was of concern'. [105]
106 Dr Martin's evidence included this exchange:
`Q. You have already said that in the course of transfer a couple of children were less stable than you would have wished. No doubt that is a reflection of the fact that there is a split site?
`A. ... This is also obviously talking about parents' experience and patients' experience rather than necessarily talking about clinical care. So as I understand it that is referring to the overall environment and change of environment.' [106]
`With regard to patients having open-heart surgery, with our busy commitments at the Children's Hospital it was often very difficult for me to get to the Royal Infirmary on an absolutely regular and fixed basis. Not everyone may know the geography of the area, they are separated by about a five minute walk downhill but it is a very steep hill coming back so it does involve some effort, if you like, going up and down, it does involve some time going up and down ... but your commitments at the Children's Hospital often made it very difficult to get down there at set times ... That made it very difficult to be actively involved in the day-to-day management of these patients, or minute-to-minute management of those patients.' [107]
108 Dr Martin then explained the interaction with the surgical team in the following exchange:
`A. ... I personally found it difficult to get actively involved in the care of the patients down there [at the BRI]. Patients were under the care of surgeons, the surgical team were looking after the patients in conjunction with the anaesthetic team. It was very difficult to arrange a time when you could be there when other people were there to discuss the individual case, so usually when I went down I would find there was no one else actually physically there that I could talk to about the case and -
`Q. The communication between yourself and the surgeon would necessarily have particular difficulties because of that?
`A. It would be difficult, yes. There would be occasions when surgeons or anaesthetists might specifically ask for an opinion about this or that and of course we would give that opinion and there would be some discussion. But just in the day-to-day management it was very difficult to get very actively involved.
`That was not due to not wanting to, it was very difficult. You felt a little bit of an outsider when you went down there to visit patients; that was not my primary base; you felt as though people did not know you quite as well. You were not primarily directing their care so any advice you might give, whilst I am sure people would say it would be listened to, it may not have been acted upon.' [108]
`... we thought that by perhaps incorporating a unified site it was more likely we would be able to improve the care of the younger children, particularly neonates and infants, because on the site based at the Children's Hospital we would have had a full range of paediatrics specialists, a greater input from paediatric nurses and we felt that might impact particularly in the younger age group. We did not know for sure but that was an impression we had.' [109]
110 Dr Burton, a consultant anaesthetist, who had worked at the UBH/T from 1959 to 1991, stated in his written evidence to the Inquiry:
`There were several disadvantages of working in a split site. Probably the most significant disadvantage was the problems caused by the simultaneous arising of difficult situations in both places. It was, of course, impossible to solve these problems personally and one had to rely on telephone contact with the other hospital. When dealing with the children, the disadvantages of not working in a paediatric teaching hospital were very obvious.'
He also notes in his statement the problems of lack of medical cover. [110]
111 Dr Joffe told the Inquiry:
`One of the factors that we struggled with throughout this period was the split site and the question of whether that was a factor in producing worse results than there should have been and while it was very difficult to identify specific issues, I think there was an overall feeling that if the unit was centralised and under one roof ... and if the staffing was at its optimum levels, that we might be able to get or we should get better results. But that was the situation that there was at the time and although the request or the recommendation was made for unification of paediatric cardiac surgery from as far back as 1981, certainly when I arrived after 1980, there was no progress at that stage for a variety of reasons. Probably the major one being the fact that the unit at the BRI was needing to increase its adult throughput ...' [111]
112 Dr Joffe also told the Inquiry:
`I forgot to mention in terms of the question about the availability of paediatric cardiologists at the BRI that Dr Jordan specifically made a point of going to the BRI every day and often twice a day, so it was not as if there was no presence whatsoever at the BRI. He found it slightly easier than I could because earlier on he was still involved in adult cardiology, had an office at the BRI, and needed to be there anyway, and indeed, he and later Dr Martin were running an outpatient clinic for adolescents and adults who had grown from the childhood period, usually post surgery, at the BRI. Therefore, they had some time when they had to go. So, apart from the weekends, I would say that on a daily basis there was at least one call by a paediatric cardiologist who would look at all the patients, not only his or her own, but all paediatric cardiac cases, and make recommendations about management, if necessary.' [112]
113 Dr Joffe added, in the following exchange:
`Q. To what extent was it the physical separation of the two buildings, one being up the hill, one down the hill, that made it difficult for you? You mentioned that Dr Jordan had an office down at the BRI which meant that he did go to the BRI?
`A. Yes, for a time. That stopped in the late 1980s, I think.
`Q. You did not have such an office?
`A. Well, I did initially, when we first started -
`Q. Was it the physical separation that made a difficulty?
`A. Yes, the physical separation was real, although of course not insurmountable. The distance between the two hospitals was really quite small: 150, 200 metres, maybe. But the hill, when you were walking up it, felt as if it was almost half a mile, rather than 200 metres. It was extremely steep, so it was difficult coming back up; it was easy going down. This may sound trite, but it does make a difference, and it also makes a difference in terms of the ordinary communication that exists in a unit where consultants and various doctors can meet with each other and bump into each other in a corridor, and so on, which facilitates overall management.' [113]
114 In addition to evidence from clinicians involved in the care of children in the relevant period, the Inquiry also received evidence about the split site and service from other clinicians in Bristol.
115 Professor John Vann Jones, consultant cardiologist, and Clinical Director of Cardiac Services from 1993 to 1996, told the Inquiry:
`I must say, my own feeling was that this was the wrong environment for children. As I have already said in my statement, when I did paediatric cardiology, having been an adult cardiologist and thrown into this unusual circumstance, I felt very uncomfortable with it because these youngsters have many metabolic problems that develop extremely quickly. They are tiny little things. They become acidotic very easily; they have their ventilation suppressed very easily. If you do not actually have general paediatricians in the building and you do not have a paediatric cardiologist in the building all the time, and you do not have dedicated paediatric anaesthetists you are going to have more morbidity. That problem needed to be resolved.' [114]
`... if I am in the clinic and someone asks me to go to the ITU two storeys away I can be there in 15 seconds. Obviously you cannot do that in a building the best part of half a mile away. So these sorts of children can go dramatically wrong dramatically quickly. Any cardiac patient can. So there is no way it can have anything other than a negative impact, but I do not think it is quantifiable.' [115]
116 Dr David Hughes, consultant paediatric anaesthetist, referred in his written evidence to the Inquiry to efforts made to transfer the paediatric cardiac service to the BRHSC:
`I believe the first proposal was raised in the late eighties and a working party was set up to look at the implications including costings of the service. A new operating theatre and an extension to PICU was required. This proposal, supported by the National Heart Foundation did not come to fruition and nothing materialised until the issue was raised once again in the early nineties when, I believe, a proposal was put forward to develop adult cardiac services at the BRI. I think it was clear from the implications of this adult expansion that it would require extra beds and it would be necessary to transfer children's cardiac services to the BRHSC.' [116]
117 Dr Robert Johnson, a consultant anaesthetist, stated in his written evidence to the Inquiry:
`I did not personally provide any anaesthetic services at the BCH after 1978 but from about 1971, when I was a trainee at the BRI and worked in both the BRI and BCH, I had always believed and understood that the split site working, between the BRI and the BCH, for cardiac surgery was unsatisfactory.' [117]
118 Mr Eamonn Nicholson, a clinical perfusionist at the BRI since 1988, stated that when he was working at Guy's Hospital in the 1980s there was `a walled-off unit within the ICU for children, with specially trained nurses allocated to that unit'. [118] He stated that when he joined the BRI in 1988 he noticed that there was no separate paediatric intensive care unit. He stated that he also noted that the ICU was on the sixth floor while the operating theatres were on the fourth floor: `This meant that we had to transport patients and this was difficult.' [119]
119 He stated further that when he joined the BRI in 1988 he `was puzzled that there was no back-up service provided at the Bristol Children's Hospital. Perfusionists were located only at the BRI.' [120]
120 Mr Nicholson stated that, although there was a designated children's area within the ICU:
`70-year-olds would sometimes have to be placed there and it was generally recognised by all staff that it was not ideal to have mixed nursing.' [121]
`Since the move to the Children's Hospital in 1995 we have followed practice in Australia, with pre-operative meetings between cardiologists, surgeons, perfusionists and anaesthetists. I have found these meetings interesting. They assist in giving me insight into potential difficulties of a particular operative procedure, or a particular patient's needs ...' [122]
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Footnotes
[91] WIT 0120 0051 Mr Wisheart
[92] WIT 0120 0094 Mr Wisheart (Mr Wisheart's emphasis)
[98] JDW 0003 0142 - 0144 Dr Joffe
[101] UBHT 0163 0003; letter from Mr Dhasmana to Dr Pitman dated 12 September 1988
[104] UBHT 0295 0240; draft report dated March 1984
[110] WIT 0555 0005 Dr Burton
[114] T59 p.164 Professor Vann Jones
[115] T59 p.165 Professor Vann Jones
[116] WIT 0511 0015 Dr Hughes
[117] WIT 0403 0011 Dr Johnson
[118] WIT 0489 0015 Mr Nicholson
[119] WIT 0489 0015 Mr Nicholson
[120] WIT 0489 0015 Mr Nicholson
[121] WIT 0489 0016 Mr Nicholson
[122] WIT 0489 0016 Mr Nicholson