Final Report > Chapter 12: Responses to Concerns and Actions Taken, and Whether Such Actions were Appropriate and Prompt > Responses within the UBH/T > The context

The context

24 How do we view the action or inaction of those whom he approached? At no stage, and to us this is important, was he told that he was wrong or mistaken in seeking to gather information. Rather, he was told that he should take great care to verify his information, and that he should seek to discuss it openly with colleagues, including those whose work gave rise to his concern. From senior colleagues, he received assurances that the matter would be raised with Dr Roylance or Mr Wisheart, but none of the attempts to do so succeeded in achieving the open discussion or action desired. Perhaps Professor Farndon came closest after his meeting with Mr Wisheart in November 1994, after which he told us that Mr Wisheart accepted that the results were not good, and agreed that all five cardiac surgeons (i.e. including those who operated only on adults) should tabulate their results and discuss them with the cardiologists and anaesthetists. Professor Farndon offered to chair such a meeting, as `honest broker', [26] but was never approached to do so. The events surrounding Joshua Loveday's operation brought matters to a head shortly afterwards.

25 A number of questions arise at this point: Was this apparent failure to respond to Dr Bolsin's concerns the full story, or was action on the PCS service being taken through other routes as part of wider plans for development at the UBHT? Was there a wider context in which the concerns raised by Dr Bolsin need to be understood?

26 In one sense, the senior clinicians and management of the UBH/T had fundamentally resolved, in their own minds at least, by the early 1980s how to deal with the issues relating to the split site and consequent split service. The aims were to unify, so far as possible, the care of children on one site and, as regards PCS, to recruit a surgeon specialising in PCS (and presumably build up the team associated with PCS accordingly). This is so, notwithstanding the fact that when the UBHT came into being in 1991 formal proposals to implement these aims were not initially put to the Trust Board.

27 These twin aims remained the long-term objective with regard to the PCS service. Despite the rapid and extremely complex changes of the late 1980s and early 1990s, the management in Bristol eventually realised their objective. It took about 14 years. In terms of comparable developments (for instance, the agreement to plan and construct a major hospital) this is by no means a long time. Furthermore, all the elements of the plan were agreed and in place before `the story' of the PCS service in Bristol broke in the national press in 1995; that is to say, the plans were not a response to concerns expressed. They were in response to a recognition that change was needed: a recognition that the problem was identified and a solution settled upon if not formally agreed, which, in time, would come about. But therein lay a danger. Because change had been agreed upon and was on the way, at least in the minds of senior clinicians and managers, the danger existed that the expression of concerns would be interpreted merely as complaints that matters were less than ideal, rather than that they were unacceptably poor. Those raising concerns were of the latter view. The more senior of those with whom the concerns were raised took the former view.

28 Thus, there was a mindset among senior managers that:

• the solution to the care of children, including the PCS service, had been identified and was in train, albeit that things moved slowly in the NHS;
• meanwhile, everyone had to manage within the constraints of limited resources, as was typical in the NHS (and remains so today);
• the clinicians, led by Mr Wisheart, could be trusted to get on with things. Mr Wisheart would let other members of senior management know if there were problems; and
• the PCS service was, in any event, a small part of the UBH/T's overall activity and was not a prominent item in the managerial range of concerns. Professor Vann Jones said in his evidence: `I think the total has been calculated; the whole GMC Inquiry was based on 4 per cent of the paediatric workload, and not only that, but these surgeons were also doing a lot of adult work as well.' [27]

29 At the same time, there was a mindset among those long-serving clinicians who had been at the BCH/BRI for some years that:

• a long-term solution to the PCS service was ultimately going to be achieved. As early as 1981 Dr Joffe and Dr Jordan had advocated `the eventual performance of open-heart surgery in children at the BCH' in their joint paper `The development of Paediatric Cardiology in Bristol'. [28] Mr Wisheart stated that, around 1990-1991, detailed plans were drawn up to transfer open-heart PCS to the BRHSC. But the Trust's proposal to build a new children's hospital took priority and again set back plans to effect the move; [29]
• in the interim, they would seek to do their best and gradually develop their expertise;
• as part of a teaching hospital, they should aspire to be at, and be seen to be at, the leading edge of developments. This was a form of professional hubris. No question could arise of withdrawing from any activity. It was a matter of `onward and upward'. Designation as a supra regional service (SRS) was a feather in Bristol's cap. (Indeed, Dr Joffe's stated goal in 1990 was that the BRI should become a designated centre for heart transplants `within a year or two', [30] a view that Mr Wisheart endorsed); [31]
• they were actively collecting and discussing data. They were quick, however, to deny any adverse inferences drawn from the data, by resort to plausible justifications such as case mix. To some, this could be seen as wilful blindness; to others, a justifiable reaction in the context of difficult procedures with low numbers performed under less than ideal circumstances; and
• the younger consultants in anaesthetics and cardiology (taking up positions in a provincial hospital after training in major international centres) did not always behave in an `appropriate' manner, meaning that they were less deferential and more questioning of existing practice than was expected by the `old guard'.

30 Among the younger clinicians there was a mindset that:

• the older, established consultants had been left behind by recent developments, were slow and reluctant to change and were in something of a backwater;
• there was a degree of resentment and defensiveness among the older consultants if practices were challenged;
• the senior management was close to the `old guard' and supported them. There was a sense of a club, to which one belonged or from which one was excluded. This meant, for instance, that it was difficult to raise what were considered to be legitimate concerns. The style of management had a punitive element to it; and
• there was no properly effective system for dealing with concerns: everything depended on people rather than systems. Also, the environment was not such as to make `speaking out' or `openness' safe or acceptable.

31 Mr Dhasmana does not fit readily into any of these camps. He was deferential to Mr Wisheart. He saw himself as a progressive, modernising surgeon. His surgical skill, except in performing the neonatal Switch operation, was commended by Professor de Leval in the first of the two drafts of the Hunter/de Leval Report. [32] The subsequent statistical analysis carried out for the Inquiry, however, concluded that there was `no evidence to suggest that there was any marked difference in the mortality rates of the two surgeons for similar operations.' [33] He was disengaged from management, even of his own surgical team, despite having had to be a manager. He was, however, self-critical and aware of his shortcomings. He showed himself ready to seek training, and to withdraw from a procedure. The Inquiry takes the view that he was wrong not to inform the parents of Joshua Loveday about the clinical meeting that preceded the operation and seek their views as to whether they wished the surgery to proceed in the light of the meeting. He was, in short, wholly caught up with his surgery. He should have displayed a wider vision and told Joshua's parents about the meeting. This is the particular criticism we make of Mr Dhasmana. However, we acknowledge and appreciate the regret expressed by Mr Dhasmana when he gave evidence to the Inquiry.

32 This is the context within which we can consider the actions taken in the hospital and the Trust in response to concerns raised. We concentrate first on the management of the UBH/T.

Footnotes

[26] T69 p.193 Professor Farndon

[27] T59 p.108 Professor Vann Jones

[28] WIT 0097 0203 Dr Joffe

[29] WIT 0120 0106 Mr Wisheart

[30] WIT 0097 0025 Dr Joffe

[31] Mr Wisheart T94 p.120

[32] UBHT 0052 0263

[33] INQ 0012 0033 Professor Stephen Evans; and Chapter 19