Final Report > Summary > The adequacy of the paediatric cardiac surgical service in Bristol > Particular elements of the PCS service which were less than adequate

Particular elements of the PCS service which were less than adequate

The system and culture of management in Bristol

26 Bristol was not unusual in having problems. It was, after all, managing the transition from the known (the old NHS) to the unknown (Trust status). Problems arise in all institutions. But it is incumbent on senior management to devise systems which respond quickly and effectively to these problems. What was unusual about Bristol was that the systems and culture in place were such as to make open discussion and review more difficult. Staff were not encouraged to share their problems or to speak openly. Those who tried to raise concerns found it hard to have their voice heard.

27 We accept that Dr Roylance, the Chief Executive of the Trust, was both thoughtful and principled in his development of a management system for what was one of the newest and largest trusts in England. He also succeeded in meeting the principal obligation of balancing the books. Sadly, a system of separate and virtually independent clinical directorates, combined with a message that problems were not to be brought to the Chief Executive for discussion and resolution, meant that there was power but no leadership. The environment was one in which problems were neither adequately identified nor addressed.

28 Nor were there effective measures outside Bristol to monitor the approach adopted by Dr Roylance. This was a feature of the NHS reforms in 1989-1991. Senior managers were invited to take control, but little or no system existed to monitor what they did in the exercise of that control. Indeed, it did not really exist inside the Trust either. The Chairman and the Trust Board were either part of the `club' or treated as outsiders. Referring to information about the outcome of care, Mr McKinlay, the Chairman of the United Bristol Hospital Trust (UBHT) from 1994 onwards, told us that:

`... there was no tradition or culture in UBHT that the Board or the committees of the Board should be involved ... I thought that was something that was wrong. I thought the Board should have some knowledge of statistical outcome, but there was a tightrope to be trod to find a way of easing it into place.'

The PCS service

29 The adequacy of the PCS service in Bristol was undermined by the fact that it was divided between two sites, with cardiologists in one hospital and surgeons in another. The cardiologists, who were well regarded throughout the South West, were understaffed. There was a national shortage of specialists in paediatric cardiology. Among other things this meant that the cardiologists at Bristol could not effectively participate in surgery or intensive care. In addition, the prevailing national shortage in nurses trained in caring for children was reflected in Bristol. The surgeons operated on adults as well as children; and the children were nursed alongside adults in a mixed Intensive Care Unit (ICU). While there was an effective child-centred approach to care at the Children's Hospital, this was not so in the BRI where open-heart surgery was carried out and where the management of care in the ICU was described as `highly disorganised with conflicting decisions'. It was never really clear who was in charge.

Monitoring the quality of care

30 At a national level there was confusion as to who was responsible for monitoring quality of care. The confusion was not, however, just some administrative game of `pass the parcel'. What was at stake was the health, welfare, and indeed the lives of children. What was lacking was any real system whereby any organisation took responsibility for what a lay person would describe as `keeping an eye on things'. The Supra Regional Services Advisory Group (SRSAG) thought that the health authorities or the Royal College of Surgeons was doing it; the Royal College of Surgeons thought the SRSAG or the Trust was doing it, and so it went on. No one was doing it. We cannot say that the external system for assuring and monitoring the quality of care was inadequate. There was, in truth, no such system.

31 At a local level, although information arising from reviews of PCS emerged only rarely in the formal structures for audit within the Trust, or in the Trust's dealings with the District Health Authority, a good deal of activity did, in fact, take place. Moreover, it pre-dated the introduction of the formal system of medical audit in 1990. The clinicians involved in providing the PCS service collected, recorded and analysed data on procedures and deaths, set up and maintained computerised information systems, produced and circulated figures and reports, made annual returns to the national UK Cardiac Surgical Register (UKCSR) and received back aggregated data about national performance. They also held regular meetings to discuss the results of audit, and reviewed individual cases and series of cases.

The views of parents

32 The evidence of parents was mixed. To some, the staff, doctors, nurses and others were dedicated and caring and could not have done more. To others, some staff were helpful while others were not. To others again, the staff, largely the doctors and particularly the surgeons, were uncaring and they misled parents.

33 While the evidence is polarised, there is a strong sense that on many occasions communication between parents and some staff was poor. There does not appear to have been any deep thinking about how to communicate information to parents in advance of surgery, nor any systematised approach to doing so. While some parents felt that they had been significantly helped to understand what the surgery and subsequent intensive care involved, we were also told of doctors and nurses drawing diagrams on scraps of paper, or even a paper towel. The sense is gained that informing parents and gaining their consent to treatment was regarded as something of a chore by the surgeons.

34 As regards the process of gaining consent to surgery, it is difficult to imagine a more stressful time for parents whose children were about to undergo surgery. Their child was facing a major operation with an uncertain outcome and, to add to their great anxiety, they had the burden of responsibility of saying `yes' or `no' to that operation. That being so, the sharing of information should be a process. There must be time to take in what has been said by the clinicians, to reflect on it and to raise questions. This does not seem to have been the practice at Bristol, but neither would it have been regarded as poor practice elsewhere during the relevant period. With the benefit of hindsight it is clear that much distress and unhappiness will result if parents are not sympathetically allowed to find out what they wish to know about what is facing their child. It should not be a question of the healthcare professional judging what the parent needs to know: it is the parent who should make that decision. At the time, however, the prevailing view was that parents should be protected from too much information.

35 Some parents told us that they were given support and counselling, and commented favourably on it. When, sadly, their child died, many parents were critical about the way in which the news was broken. Some said that they received no counselling. The United Bristol Healthcare Trust (UBHT) conceded in its evidence that the service it provided was insufficient to meet the needs of some parents. We were impressed, however, by the sensitivity and support shown by the nursing staff.