Final Report > Chapter 12: Responses to Concerns and Actions Taken, and Whether Such Actions were Appropriate and Prompt > Responses within the UBH/T
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Responses within the UBH/T
Dr Bolsin's actions
16 By the late 1980s concerns about outcomes in PCS began to develop within the BRI. They arose initially from Dr Bolsin's observations. These were gradually supported by his collection of data that was shown to some colleagues, but not to Mr Wisheart or Mr Dhasmana. It may be helpful to set out step by step the actions taken by Dr Bolsin.
- In 1988 he approached the issue as a clinical problem through his own division, seeing first the Professor of Anaesthesia, Professor Cedric Prys-Roberts, and then the Chairman of the Division of Anaesthesia, Dr Brian Williams.
- In 1990, after consulting the Chair of the Medical Audit Committee (MAC), [15] he approached the senior management of UBH and raised the question of the results in PCS in a letter to the Chief Executive-designate, Dr Roylance. He told the Inquiry that, as a consequence, he was rebuffed by both Dr Roylance and Mr Wisheart. Dr Williams confirmed that Mr Wisheart was annoyed by the content of the letter to Dr Roylance. [16]
- In 1991 Dr Bolsin raised his concerns in a meeting of cardiac anaesthetists. His colleagues and the Clinical Director, Dr Monk, were supportive of his concerns, though critical of the manner of his approach. In 1991 he referred to matters having been thought to have reached crisis proportion in the preceding year. This was in writing, in the form of minutes of a meeting made available openly to paediatric surgeons and cardiologists.
- Late in 1991 it seems that his views became known to colleagues in anaesthesia outside the UBHT (in Southampton and in Frenchay Hospital in Bristol).
- In Spring 1992 Dr Bolsin again approached the management at the BRI, but this time at the level closest to the service, the General Manager of the Directorate of Surgery.
- In April 1992 he took his concerns outside the hospital and spoke to Dr Phillip Hammond.
- In 1993 he spoke to surgeons other than those whose work gave rise to the concerns: Professor Farndon, Mr Bryan, and Professor Angelini, to Dr Willatts, the intensivist, and to the cardiologist Professor Vann Jones, head of the new Directorate of Cardiac Services.
- In late 1993 Dr Bolsin approached the DoH through Dr Ashwell and in July 1994 and January 1995 through Dr Doyle.
17 Throughout this period Dr Bolsin's raising of concerns was coupled with his involvement in audit, first within the practice of anaesthesia and intensive care (in relation to intubation and inotropics in 1989), and later with Dr Black, working across the boundaries of specialties, looking also at the work of perfusionists and surgeons.
18 Dr Bolsin's role has been lionised by those critical of the PCS service, and attacked by those who support the Bristol surgeons. The path he followed in raising concerns did not follow the route advised by the DoH, known as the `Three Wise Men' procedure. This is not surprising, however, as this procedure was perceived as dealing primarily with individual clinicians whose performance was affected by problems, such as ill health. Furthermore, his concerns involved the work of Mr Wisheart, who at one time occupied two of the three positions from which the `Wise Men' were selected, in his roles as Chair of the Hospital Medical Committee (HMC) and Medical Director of the Trust. In addition to the contacts Dr Bolsin made, there was no other obvious route for raising questions about quality of care, other than by discussing results with colleagues at audit meetings and making comparisons with available national data. In our view, the possibility of such open discussion was barred by the firmly held view of Mr Wisheart, in particular, that the explanation for their poor results in complex procedures lay in the condition of the patients treated rather than the care provided. Mr Bryan described in the BRI:
`a culture ... of explaining or justifying ... mediocre or poor results on the basis of case severity rather than directing attention to producing better results'. [17]
`... if you are confronted with a result which is not very good, then there are two responses ... either ... "the results are not very good and they should be better, we must be doing something wrong, we have to get this right and improve things", or ... "actually the results are not very good but it is because they are bad patients ... and we are doing our best".' [18]
19 This avoidance of open discussion was compounded by what we regard as the uneasy relationship between anaesthetists and surgeons, [19] which made it difficult for any anaesthetist to appear critical of a surgeon and particularly of a surgeon such as Mr Wisheart who was a senior figure in the hospital and worked closely with the Chief Executive. The path followed by Dr Bolsin in seeking acknowledgement of, and support in raising, his concerns was, therefore, understandable. His initial, rather oblique, approach to Dr Roylance in his letter of 1990 was rebuffed by both Dr Roylance and Mr Wisheart. Thereafter, he spoke to colleagues within his specialty, moving on to anaesthetic colleagues outside the hospital, to his hospital peer group among the newly appointed consultants in a number of specialties including surgery, and finally to the management of the UBHT and the DoH. The difficulties he encountered reveal both the territorial loyalties and boundaries within the culture of medicine and of the NHS, and also the realities of power and influence. After all, as we have said, his concerns related to one of the most senior and long-serving surgeons in the BRI, Mr Wisheart, and had to be addressed by Dr Roylance, who was a long-standing colleague of Mr Wisheart. The manner of Dr Bolsin's approach was criticised by his colleagues, and he seems to have antagonised both senior management and senior medical figures at an early stage. Thereafter, he felt that he had to take a more circuitous route to arouse awareness of what was troubling him. It is also clear that he was not alone in having difficulty in approaching the senior figures, Dr Roylance and Mr Wisheart. For example, Mr Bryan described Professor Angelini's telling him that when he (Professor Angelini) and Professor Farndon tried to raise concerns with Mr Wisheart in December 1993, the latter spoke to them `like a couple of schoolboys'. [20]
20 It is worth noting here that the Public Interest Disclosure Act, passed in 1998 to give protection to `whistleblowers', would not have protected Dr Bolsin, had it been in force, if he had sought to make his views known publicly. This is because the Act, as currently drafted, would only have protected Dr Bolsin if, in good faith, he had made a `qualifying disclosure' to his employer, or his legal adviser or the Minister of State or a prescribed official. The disclosure which Dr Bolsin made would not have qualified in this way. [21]
21 Collecting and validating data is not a simple task (Mr Bryan told us that retrospective clinical data is very difficult to collect [22]). Definitions varied depending on whether classification by diagnosis or procedure was used, records were incomplete or the numbers of procedures were small, and to achieve any sophistication in statistical analysis required that categories be collapsed to a point at which the validity of the clinical information could be challenged or even compromised. Risk stratification [23] in PCS is still problematic today. That said, Dr Bolsin's data was broadly accurate. He made a significant error in the misclassification of four VSD deaths, an error he later accepted. The Inquiry is mindful of the fact that Dr Bolsin was not preparing data for publication, but to raise questions for discussion and review. Professor de Leval told us that if queries of this kind had arisen at Great Ormond Street Hospital, he would not so much have relied on particular figures but would have initiated an open discussion. [24] It is one of the greatest matters of regret that, for a number of complex and interlocking reasons, such discussion did not take place at the BRI.
22 Dr Bolsin was advised and encouraged by a number of colleagues to share the information which he collected with Mr Wisheart and Mr Dhasmana, and to be open about collecting information about clinical work outside his specialty of anaesthesia. We accept his difficulty about approaching Mr Wisheart, a senior figure of whom he was in some awe, and perhaps even in fear. It is less clear why he did not approach Mr Dhasmana, who was willing to acknowledge and seek to correct his imperfections. We are aware that traditionally anaesthetists see themselves as providing a service and working across disciplines and are thus comfortable with looking at the work of others. But this view was not shared by surgeons. At this time cross-disciplinary audit was not common. Mr Dhasmana could have regarded an approach from Dr Bolsin as acceptable, in which case things might have been different. It is unfortunate that Dr Bolsin did not approach him.
23 In summary, while Dr Bolsin's actions may not always have been the wisest, and sometimes he gave mixed signals, such as his assurance to Dr Ashwell that all was well, [25] he persisted and he was right to do so.
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Footnotes
[15] Dr Trevor Thomas
[16] WIT 0352 0027 Dr Williams
[19] Dr Bolsin, for example, said: `... there is a particular rivalry between surgery and anaesthesia because probably they work so closely together. Surgeons do not like to be told what to do by anaesthetists and anaesthetists do not like to be told what to do by surgeons and it is legendary and it exists.' T82 p.132
[21] It is for this reason we propose, in Section Two, that the Act be amended
[23] The Inquiry's Experts advised that `risk stratification' can refer to two distinct types of risk: that arising from case mix and that arising from the operation itself in the light of the patient's `age, previous medical history and current clinical condition at the time of operation'. See Annex B (4a), `Overview of statistical evidence presented to the Bristol Royal Infirmary Inquiry concerning the nature and outcomes of paediatric cardiac surgical services at Bristol relative to other specialist centres during the period 1984 to 1995', September 2000, Dr Spiegelhalter et al. See also Annex A Chapter 19
[24] T60 p.43 Professor de Leval
[25] UBHT 0061 0270; letter dated 10 February 1994