Annex A > Chapter 9 - The Split Service > Comments by those outside the Bristol service
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Comments by those outside the Bristol service
7 Professor Peter Fleming, Head of the Division of Child Health, Department of Clinical Medicine, University of Bristol, was Chairman of the multidisciplinary working party on paediatric intensive care convened by the British Paediatric Association (BPA) which produced a report in 1993, `Care of Critically Ill Children'. The report, based on data for 1991 and a smaller data set for 1993, included information from the South West and specifically from the ICU at the BRI and the BRHSC. Returns were received from 80% of the hospitals in the UK. The report showed that 20.5% of children received intensive care in adult intensive care units and, of these children, 23% were under 1 year of age.
8 Professor Fleming in his written evidence to the Inquiry stated:
`Overall, the quality of care offered in the Paediatric Intensive Care Unit at the Bristol Children's Hospital was, and remains, of a very high standard.' [4]
9 Children were also cared for in the ICU at the BRI together with adults. Professor Fleming went on:
`It is, however, important to say that one of the major conclusions of the working party was that, in general, throughout the country, the quality of care in terms of availability of appropriately qualified staff, awareness of the special needs of children and physical organisation of the units to deal with children's special needs in adult intensive care units was deemed quite unsatisfactory. The working party concluded that it was inappropriate that children should be admitted to adult intensive care units and that, in general, intensive care for children should be provided and properly staffed and equipped with paediatric intensive care units.' [5]
10 Dr Jane Ratcliffe, Honorary Secretary of the Paediatric Intensive Care Society (PICS), was asked by Counsel to the Inquiry how common it was in the 1980s and early 1990s for the cardiologists to be on one site and the surgeons on another:
`I cannot think of another unit where the cardiologist and cardiothoracic work were in a different site. I can think of several units, that there were separate cardiothoracic sites, but they were together, in effect, so I am not able to think of one.
`I find it very worrying, because you need somebody to consult very rapidly. I know that the geography of the Royal Infirmary and the Bristol Children's Hospital is not across town, but even so, I think I would find it very difficult in working practice to try and work and do justice to both sites.' [6]
11 Dr Susan Jones, President of the Association of Paediatric Anaesthetists of Great Britain and Northern Ireland (APA), discussed the Confidential Enquiry into Peri-Operative Deaths (CEPOD) report in the following exchange:
`Q. When it [the CEPOD report] concluded paediatric anaesthesia should not be undertaken by those who had only occasional experience in the field, what was the reaction of the APA, or, indeed professional anaesthetists, to that conclusion?
`A. I think the APA certainly supported that conclusion. I think the majority of sensible anaesthetists supported that conclusion, and indeed, since that time, I think for a lot of anaesthetists, it has acted as a catalyst, the CEPOD report, and an awful lot of anaesthetists have flatly refused to anaesthetise small children and infants if they felt it was outside their competence. They have insisted the children are moved to a more appropriate centre.
`Q. CEPOD had recommended that you should not undertake paediatric anaesthesia if you only had occasional experience in the field. Are you able to help us, then, on the implementation of that recommendation, because it was not, I understand, an immediate event after CEPOD had reported?
`A. No, I think that they were recommendations; they were not totally enforceable. I think it just gave people, any sensible thinking people, a document to which they could refer and say, "I think we should move these children. I think we should plan to move these children. I do not think we should be doing these in our hospital any more".' [7]
12 Dr Jones continued in the following exchange:
`Certainly we would not recommend admitting children to an adult ward ... I think surgeons, generally, and those treating children and adults do not want the children moved to another site. That is a generalisation. Things are often historical. One starts with a unit that is basically an adult one, and then children have been taken on board, as it were, the whole thing is blown up, and it becomes very difficult to dismantle the mixed unit. You actually have to put the children into another hospital, or into another children's hospital. It is actually very expensive to move - setting up, the capital needs are high, the infrastructure, the actual staff costs of moving a unit and everybody looks twice at the costs these days.
`Q. When you say that a surgeon might get in the way of such a move, is that a comment on the organisation of hospitals to reflect surgical specialties, or is that a comment on personalities?
`A. A bit of both really. I think that when people do children and adults, the children often come out second best, I think. They are often smaller in number anyway.' [8]
13 Dr Jones told the Inquiry that it was fairly common in 1993 for children to be admitted to a part of an adult ICU ward. She went on:
`I think that it has been changing gradually, anyway, as big paediatric tertiary referral centres, mainly at children's hospitals, have actually expanded their intensive care unit and, indeed, provided retrieval teams so that they can actually go to a DGH [District General Hospital], or wherever, to actually pick up these children and transfer them back.' [9]
14 Sir Terence English, President of the Royal College of Surgeons of England (RCSE) from 1989 to 1992, commented in the following exchange:
`Q. ... the split site that existed at Bristol was ... an additional black mark ... against Bristol continuing to be a designated centre ... ?
`A. I think it may have been an inhibition to the proper development of the service, yes, and in that respect, may have been seen as an undesirable feature, but not necessarily a black mark.' [10]
15 Professor Gareth Crompton, Chief Medical Officer for Wales 1978-1989, told the Inquiry:
`I remember that this was a matter of considerable anxiety. It was clearly an arrangement, the split site; it was not conducive to best standards of patient care.' [11]
16 Professor David Baum, then President of the Royal College of Paediatrics and Child Health (RCPCH) and Professor of Child Health, University of Bristol, was asked about the approach of healthcare professionals in 1984 to nursing children on mixed adult and paediatric wards:
`At that time, if one were looking at or were preparing a policy document, I have no doubt that the conclusion would have been very firmly, these should be separate entities. That would apply if one was talking about the mix from adolescence and adult, let alone younger children and babies, let alone if they were profoundly ill.
`In the ten to 15 years since the time that you are addressing, we have progressed somewhat, but it has only been in the last two or three years that under the heading of paediatric intensive care services, as you know, the Government has come down on the side of not only having a policy, but actually implementing a policy, so that in all parts of the land we are still at the implementation phase, there should be a separate fully equipped, fully staffed paediatric intensive care unit. That has still not been totally achieved for the nation in May 1999.' [12]
`I spent many of my formative years running to another hospital across a car park and through a tennis court with a sick baby in my arms to go from the delivery ward to the neonatal intensive care unit. It was becoming apparent that this was a bad arrangement. It took several years to have the budget and the will to rearrange that so that they were cheek by jowl. It was very difficult to get it right in the historical context.' [13]
18 Miss Sue Burr, Paediatric Nurse Advisor to the Royal College of Nurses (RCN), commented:
`I do not have access to the staffing levels of paediatric intensive care. I would not have thought that that was uncommon, and in fact we do have situations, and you have the evidence, I am sure, in relation to the number of children who are nursed even now in adult intensive care units that I think one of the quite recent reports showed that there was a large number of these units which did not employ any registered children's nurses at all. So I do not think that the situation at the BRI was that uncommon.' [14]
19 Asked by Counsel to the Inquiry about the process of transferring a patient from one site to another, Dr Duncan Macrae, Director of Paediatric Intensive Care at the Royal Brompton Hospital, London, told the Inquiry:
`I think the process is the same, there needs to be just as much preparation to undertake a ten-minute transfer as there needs to be to transfer a child hundreds of miles. The preparation, the stabilisation, packaging, loading safely into the vehicle, is exactly the same whether or not the distance is one hundred yards or one hundred miles.' [15]
`The risks of long transfers are mainly down to inadequate preparation ... These [inadequate oxygen supply or battery life] are avoidable factors, as is a child cooling down because it is not adequately protected from cold, by being wrapped up. As are things like secretions building up in the tracheal tube because there has been inadequate humidification. These are all things that in the present age transport teams are trained to address, but I think it is fair to say that across the country ten or more years ago, many of these issues received scant attention and I am certainly aware of transport over relatively short distances that was conducted very poorly because of those failures. But, as I say, there were very limited facilities for the specialist types of transfer that we can undertake today.' [16]
21 Mr Leslie Hamilton, consultant cardiac surgeon, also told the Inquiry about the transfer of patients in the following exchange:
`Q. This chimes with views given to us yesterday by Professor de Leval and Mr Stark, the children coming from Bergen in Norway to Great Ormond Street might often arrive in a much better condition than children coming up the road from Luton, simply because of the quality of care they had had during the transfer process.
`A. I think the experience in Perth in Australia at the moment, where they do not currently have a paediatric cardiac surgeon, they transfer patients 4, 000 miles, something in that order, to Melbourne and they have no problems. I do not think distance is an issue.' [17]
22 Mr Hamilton commented on the effect of the split site and the split service on the communication within a care team such as the one at Bristol, where the cardiologists were on a different site from the surgeons:
`I think it is more philosophical than physical. I think communication is an attitude within a group, rather than being physically there to talk in person. I think if you have the environment that people get on and have the same long-term view and the same aims, then communication should not be a problem.' [18]
23 Mr Martin Elliott, consultant cardiothoracic surgeon, was invited to apply for the Chair of Cardiac Surgery at the University of Bristol in late 1991. He was approached initially by Mr Wisheart and then by Professor John Farndon. Mr Elliott stated in his written evidence to the Inquiry that he `was interested in the opportunity and visited Bristol on a number of occasions to discuss the position and to review facilities, organisation and potential for change.' [19]
24 After `much thought' Mr Elliott stated that he decided not to apply. [20] He wrote to Mr Wisheart on 3 January 1992 to inform him of his decision. [21] In response to Mr Wisheart's request Mr Elliott prepared a more detailed report of the reasons not to apply. [22]
25 Mr Elliott stated in his written evidence to the Inquiry:
`... the arrangements then in place in Bristol for surgery for children with congenital heart defects were unsatisfactory, indeed I was of the opinion that it was inefficient and potentially dangerous.' [23]
26 Mr Elliott referred to the split service and went on:
`Perhaps the simplest way to explain why this arrangement was unsatisfactory is to consider an imaginary case managed under the two regimes, Bristol and the Ideal Unit. The imaginary patient I propose is a new-born baby admitted in extremis to the Bristol Children's Hospital with a provisional diagnosis of coarctation of the aorta. The child would need to be admitted to either a high dependency unit or a neonatal ICU and need urgent resuscitation by paediatrically trained staff. Ventilation might be required and an immediate examination by a paediatric cardiologist would be undertaken. An echocardiogram would be done and a treatment plan defined. If the diagnosis was indeed coarctation of the aorta then surgery could be undertaken in the Children's hospital on the next available list, (hopefully the next day although the logistics of this in Bristol might have made this difficult). If, however, the echocardiogram was to reveal a VSD and an interrupted aortic arch, then repair would require open-heart surgery. In Bristol the patient would have had to be transferred to the BRI, to the adult ICU in preparation for open-heart surgical repair. Contact with paediatricians would have been lost and the level of the support would have fallen. An urgent space would have had to be found on the operating list, almost certainly at the expense of adult patients, and the surgery undertaken.
`Post-operatively, our imaginary patient is likely to have been sick. Skilled treatment would be required. If we further imagine an acute deterioration a day or two later, the surgeons may have been operating at the BRI or the Children's, there was no paediatric intensivist, and ECHO would have to be done by the radiologists, and the cardiologists would be at the Children's or outlying clinics. The risks were obvious.
`In the Ideal Unit the change in diagnosis would have only limited impact. There would be no need for patient transfer, there would always be a list available to children and there would be no need to displace an adult patient (or more than one since these patients need prolonged ICU care). The consequences for the adult programme would also be considerable. ...
`Thus, to me, the split site issue was one of the major reasons not to apply for the post. I thought it inefficient, archaic, inhibitory to progress and potentially dangerous.' [24]
`Clearly all senior people at the BRI and Children's Hospital carry some responsibility for this issue. There was a conventional, if complex, matrix of responsibility in place at Bristol which should have been able to make appropriate changes. However, the very existence of the split site, the complexity of the management structure and the politics surrounding the, then, new Trust arrangements, inhibited change and obfuscated forward thinking.' [25]
`... it was clear to me that one of the people most wanting to make change was James Wisheart ... Almost all the clinicians I met were in favour of transferring all paediatric heart surgery services to the Children's.' [26]
29 Mr Elliott had a meeting with Mr Peter Durie, Chairman of the UBHT, to discuss, amongst other things, his concerns about the split site. Mr Elliott stated that he found Mr Durie's suggestions as to how to deal with this issue `totally unacceptable'. [27]
`Mr Durie outlined the structure of the new Trust organisation, and the financial arrangements. He stated that there was no way that resources could be made available to correct the split site issue in the short or medium term ... I had said that there might be a possibility of getting new business (more patients) from neighbouring regions (Wales, the South West) if we were able to develop a high quality service, but that it would be impossible without the children's services being centralised away from the BRI. I also pointed out that this would free up resources to increase throughput of, and potentially income derived from, adult practice.' [28]
`Mr Durie made it quite clear that in his view it would be up to me, as the new incumbent, to generate the income to pay for the changes required. I thought that this was not going to be possible. Making the changes was the only rational way to improve both service and income, and the only way to generate the basis for safe, modern neonatal cardiac surgery. I thought it was wrong to place the burden of income generation from clinical practice on the new Chairholder. The changes had to be made BEFORE any income could be generated.' [29]
32 Mr Durie was asked by Counsel to the Inquiry about the split site in the following exchange:
`Q. One of the three reasons given ... by Mr Elliott for not taking the job is the split site. How big an issue was the split site for you in 1991/92?
`A. It was not a big issue for me because it was not unique. In Bristol quite a lot of the specialties for paediatrics were not happening in the Children's Hospital. Just to name a few, within the UBHT there was ENT happening in a general hospital; ophthalmology happened in the Eye Hospital. Trauma in fact still happens in the BRI. So from our point of view, not everything being in one site was not surprising, and just in Bristol alone, you then had Southmead dealing with all the paediatric nephrology and Frenchay dealing with all paediatric neurosurgery and medicine, so it did not come to me as a very high worry or high priority.
`Q. You say in your statement it has never been suggested that the split site was having an adverse effect on surgical outcomes, so far as you were aware.
`A. That is correct.' [30]
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Footnotes
[4] WIT 0505 0002 Professor Fleming
[5] WIT 0505 0002 Professor Fleming
[10] T17 p.109 Sir Terence English
[11] T21 p.53 Professor Crompton
[12] T18 p.40-1 Professor Baum
[19] WIT 0467 0003 Mr Elliott
[20] WIT 0467 0003 Mr Elliott
[21] JDW 0003 0102; letter from Mr Elliott to Mr Wisheart dated 3 January 1992
[22] WIT 0467 0011 - 0027 ; Mr Elliott's paper `The Chair of Cardiac Surgery in Bristol'
[23] WIT 0467 0003 Mr Elliott
[24] WIT 0467 0004 - 0005 Mr Elliott
[25] WIT 0467 0006 Mr Elliott
[26] WIT 0467 0006 Mr Elliott
[27] WIT 0467 0007 Mr Elliott
[28] WIT 0467 0007 Mr Elliott
[29] WIT 0467 0007 Mr Elliott (emphasis in original)