Final Report > Chapter 12: Responses to Concerns and Actions Taken, and Whether Such Actions were Appropriate and Prompt > Responses within the UBH/T > Other clinical staff
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Other clinical staff
The anaesthetists and intensivists
50 In addition to the long-standing efforts of Dr Bolsin, which we have referred to already, the other anaesthetists discussed and shared his concerns. A number of attempts were made to bring those concerns to the attention of Dr Roylance and Mr Wisheart by the anaesthetists' Clinical Director, Dr Monk, who acted with care and forethought. He spoke to the surgeons concerned, Mr Wisheart and Mr Dhasmana, in the autumn of 1993 (albeit that he did not show them any data), to the Chair of the Division of Surgery, Professor Farndon, in 1993, and in March 1994 saw Professor Angelini and Dr Roylance. With Professor Angelini, he invited Mr Wisheart and Dr Bolsin to an informal dinner at Bistro 21, intending to facilitate an informal and open discussion of the PCS results. Sadly, the dinner represents in microcosm the inability of these colleagues to communicate on the questions at issue, and the conversation turned to football. Dr Monk's handling of the anaesthetists' joint letter, his asking junior staff to collect data for discussion, and his determined attempt to involve Dr Roylance, by redefining the issue as managerial rather than clinical, was a well-thought-out attempt to get a response, which Dr Roylance failed to provide. It is difficult to see what more Dr Monk could have achieved within the existing power structure and management culture.
51 Dr Pryn had put together some figures at short notice to present to the special meeting of cardiologists, surgeons and anaesthetists in January 1994. But, through no fault of his own, he was not sufficiently prepared to make a formal presentation. Mr Wisheart presented his own data and Dr Pryn's figures were rejected. [49] As a result of his own concerns about the organisation of the Intensive Care Unit (ICU), Dr Pryn had tried to get `single form' recording in the ICU, in order to improve the co-ordination of care. Unfortunately, he had to abandon the attempt when clinical colleagues did not
co-operate. Dr Pryn, supported by Dr Masey, was also asked to prepare data for the meeting to discuss the operation on Joshua Loveday. It is difficult to see what more Dr Pryn could have done.
The surgeons
52 Professor Angelini took action on his own initiative to remedy the problem of the lack of a resident anaesthetist to be on call for the ICU. He succeeded in securing an appointment within a month of his arrival in 1992. He approached Dr Roylance and Dr Martin about the concerns expressed to him by Dr Bolsin, which he came to share, and went to Great Ormond Street Hospital to seek expert advice from Mr Stark who worked there as a Consultant Cardiothoracic Surgeon. Finally, he corresponded with Dr Doyle at the DoH, and was instrumental in bringing the DoH's awareness of the concerns to the attention of Dr Roylance. It is unfortunate that he did not feel able to discuss Dr Bolsin's concerns when he went to dinner with Mr Wisheart at Bistro 21, but, as has been said, this was not so much a failure to act properly as a symbol of how difficult communication had become by then.
53 Professor Farndon, by 1994, offered to act as honest broker, saw Mr Wisheart, but, despite his efforts, could not take things forward.
54 Mr Wisheart, throughout the period, in his role as a clinician, kept records, encouraged audit meetings, and presented data. In response to queries, he continually repeated his arguments that poor results were due to the particular condition of the patients he treated. The Clinical Case Note Review carried out by the Inquiry as a retrospective exercise in 1999, did not, in fact, reveal major problems in surgical technique, but rather with the overall organisation of care, particularly in the ICU. But we take the view that Mr Wisheart should have realised that the poor results that were being discussed could have their origin in the overall organisation of care, particularly in the ICU. We do not have evidence of a prompt or effective response to the concerns identified to him by individuals (by Mr Elliott in 1991, and by colleagues at the BRI, for example, Professor Angelini and Professor Farndon, in December 1993, Ms Maher in April 1994, Dr Monk and Professor Farndon, again, in November 1994, and Dr Monk in 1993 and 1994). We do have evidence (for example, from Dr Bolsin, Mr Bryan and Mrs Ferris) that Mr Wisheart was not an easy man with whom to raise concerns, particularly about his own work.
55 Mr Dhasmana, by contrast, was acutely aware of the difficulties he was encountering with the neonatal Switch. He made efforts to undergo retraining for himself and his team (although the cardiologists did not go with him to Birmingham when invited) and he stopped operating when his results failed to improve. He took part in collecting and presenting data and was open to discussion. Indeed, on occasions, he was strongly self-critical. But he could not see the impact of stress on himself or the surgical team before Joshua Loveday's operation. This was a product of his over-concentration on his responsibilities as surgeon and a less than complete awareness of the importance of the whole team.
56 By way of conclusion, we take the view that the other surgeons either felt dominated by Mr Wisheart, or were unable to find a way around his insistence that matters were under control.
The paediatric cardiologists
57 The Inquiry heard no evidence of action taken by the cardiologists in response to the concerns about the PCS service after their rebuttal of the questions raised in Wales. We heard evidence instead about their isolation from the surgery being undertaken at the BRI, the impact of the split site on cardiological input in both the operating theatre and the ICU, and their heavy programme of work both in Bristol and in a number of outlying and distant clinics. Their workload was further exacerbated by the fact that the refusal of accreditation for training posts meant that they had no junior doctors in training who could support them. They might have been expected to have picked up any concerns about referral to the BRI, but we have no evidence that such concerns were expressed to them. [50] They took part in audit meetings with their surgical colleagues, and in the `paediatric club', but found no reason to question the data or comments on it made by their surgical colleagues. They regularly pressed for a long-term solution to the problems posed by the split site by suggesting that care be united on a single site. In all of these respects, therefore, we make no adverse comment on the conduct of the cardiologists, even though we recognise that Dr Joffe's ambitions for the cardiac unit at the UBH/T were somewhat out of line with the reality of the actual situation.
58 We do, however, make one adverse comment as regards Dr Joffe. We find it regrettable that, in his position as a manager, namely the Director of Children's Services from 1990 to 1994, he failed to enquire more diligently into the quality of care received by the children undergoing open-heart surgery at the BRI, when concerns began to be raised more widely in 1994.
Nurses
59 We regard it as significant that we did not hear concerns being brought to senior figures at the UBH/T by the nursing staff. We do not infer from this any lack of concern on the part of nurses. Rather, we see it as illustrating a larger truth. The hierarchical system common at the time (and regrettably still too prevalent now) made it difficult for the nursing staff to voice concerns and to be heard. It is revealing that only when independent experts from outside the UBHT, Professor de Leval and Dr Hunter, came to carry out their Review, did Fiona Thomas feel able to express her concerns about the lack of proper organisation in the ICU. It is also indicative of the state of affairs that the only way which Kay Armstrong and Mona Herborn felt was open to them to make known their dissatisfaction with aspects of PCS was to withdraw their services from the operating theatre when a Switch operation was to be performed. [51] Nursing staff were let down by a culture that excluded them.
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Footnotes
[51] Ms Armstrong, for example, said she `dreaded' the scheduling of complex cardiac surgery (T59 p.37) and `could no longer bring myself to go and scrub for those cases' (T59 p.40)