Final Report > Chapter 16: The Organisation of the Paediatric Cardiac Surgical Service in Bristol > The split site and the split service
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The split site and the split service
8 As has been explained, until October 1995 the PCS services were provided on two sites. The cardiologists were based at the BRHSC, where closed-heart surgery and investigations were carried out. Open-heart surgery was performed at the BRI, where post-operative care was also provided. The ICU cared for both adults and children. Until 1987, when a new catheter laboratory opened at the BRHSC, cardiac catheterisation was also carried out at the BRI.
9 The service was not only divided physically, by a ten minute walk including a steep hill, but also in its organisation. There was, in other words, not merely a split site, but, much more significantly, a split service. After the creation of the Trust, the organisation of the PCS service was divided. Paediatric cardiology lay within the Directorate of Children's Services, based at the Children's Hospital, under the direction of Dr Joffe, consultant paediatric cardiologist. Paediatric open-heart surgery lay within the Directorate of Surgery. Although all cardiac services were brought together under the clinical direction of Professor John Vann Jones, consultant cardiologist, in 1994, paediatric cardiology remained part of the Directorate of Children's Services at the BRHSC. It was only in October 1995 that paediatric open-heart surgery and paediatric cardiology were brought under the same Directorate, the Directorate of Children's Services at the BRHSC. These divisions in responsibility for what was a small specialist service within a large Trust clearly militated against a clear focus on what was needed for the children being treated and on the standards of care to be and being achieved.
10 Crucially, the organisation reflected the buildings where the children were treated and where the healthcare professionals were based. It did not reflect the needs or interests of the children. Thus, there were both physical and organisational impediments to the adequacy of the service provided. As regards the split site arrangement for the PCS service, Dr Jane Ratcliffe, Honorary Secretary of the Paediatric Intensive Care Society 1991-1998, told us she could not think of another PCS unit in the 1980s and early 1990s where the cardiologists were on one site and the surgeons on another: `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 sides.' [5] As a result of the split, we also heard that for their part, the cardiac surgeons were not readily available on the ward at the BRHSC, although they did visit `sometimes after midnight'. [6]
11 A number of parents described to us their confusion and distress at having to move from one hospital to the other, particularly when they feared that the move was not well planned and prepared. Michelle Cummings [7] told us that on moving her daughter, Charlotte, back to the BRHSC after surgery at the BRI: `... they didn't even know we were coming ... there was no intensive bed for her, no life support machine, and they were still hand ventilating her'.
12 Charlotte's medical notes state that she was: `Transferred from Ward 5. Arrived unannounced as usual.' [8] Joyce Woodcraft, a former nurse and Senior Sister at the BRHSC, told us that she thought that the comment in the record was `harsh', but that such a transfer did happen `occasionally'. [9]
13 We also heard evidence of separate sets of medical notes being prepared and kept on the two sites. On occasions, the notes from the BRHSC would not accompany the child on transfer to the BRI. This clearly was a most unsatisfactory way of caring for very ill children. In fact, the Inquiry has direct experience of the implications of this split service because, for each child who had open-heart surgery, in 1999 (in preparing for the Inquiry) we had to obtain two sets of notes, one for the time spent at the BRHSC and another for the time spent at the BRI. The notes are kept in separate buildings. This is a particularly symbolic demonstration of the way in which the care provided was organised according to the building rather than according to the child.
14 The care provided at the BRHSC, where results were good for closed-heart procedures, was in the main commented on favourably by parents. The dominant theme was of appreciation for the family-centred atmosphere and the specialist paediatric nursing skills provided. John McLorinan, father of Joe, [10] told the Inquiry that: `... in the children's ward one feels cushioned and cradled ... BRI was not really geared for children and families'. There were some dissenting voices. For example, Penelope Plackett, whose daughter Sophie was disabled after undergoing surgery, was distressed to find her with nappy rash after leaving her for the weekend at the BRHSC at Mr Dhasmana's suggestion to take a much-needed break. As regards the BRI, however, although many parents told us how much they appreciated the dedication of the staff, a number also spoke of their distress on finding their child being cared for at the BRI in an intensive care unit which looked after both adults and children. Helen Johnson, mother of Jessica, called it `limbo land'. [11] For mothers of newborns it was particularly difficult to be without the care of trained maternity nurses at this time of great stress. Kathleen Tilley, mother of Lauren, indicated that she was:
`... back and forth between the Bristol Royal Infirmary and the Childrens Hospital all night because I was breast feeding Lauren. I have to say that the two sites were extremely inconvenient. Although I was able to walk, it did mean that I had virtually no sleep that night and when I returned in the morning I was expecting to be met and told when the operation on Lauren was to proceed.' [12]
15 Susan Francombe, mother of Rebecca, stated that: `Rebecca came through the operation [at the BRI] but in the time it took us to reach her from the Bristol Maternity Hospital she had deteriorated considerably.' [13]
16 The process of transferring children between the BRHSC and the BRI had been recognised by the South West Regional Health Authority (SWRHA) to be dangerous as long ago as 1984: `... at the present time, patient's lives are frequently being put at risk by the need to transfer very young children between the Bristol Children's Hospital and Bristol Royal Infirmary every time a catheter investigation is needed' [14] and `The transportation of critically ill infants must be avoided. This current practice has given considerable concern to the Paediatric Cardiologists for some time.' [15] We heard evidence from one of the Experts to the Inquiry, Dr Duncan Macrae, [16] that the process of preparing and stabilising a child is as demanding and important for a ten minute journey as for one of hundreds of miles. He also described how poorly specialist transfer was conducted in the early 1990s. This being so, the need to transfer patients between the two sites was a persistent underlying factor giving rise to a risk of adversely affecting the care of the child.
17 On arrival at the BRI, further problems arose because of the lack of a permanent cardiological presence there. The Bristol surgeons were without cardiological support in the operating theatre, and to a large extent in the ICU. This dislocation of essential cardiological services from the surgical and other services at the BRI was, in our view, one of the most significant adverse factors affecting the adequacy of the PCS services overall. At the same time, the cardiologists were also without full surgical support at the BRHSC. [17]
18 Mr Martin Elliot, consultant cardiothoracic surgeon, Great Ormond Street Hospital, decided not to proceed with an application for appointment as a paediatric cardiac surgeon at the UBHT in 1991 largely because of his concerns about the split service. In his written evidence to the Inquiry he stated: `I thought it inefficient, archaic, inhibitory to progress and potentially dangerous. I made this clear in verbal and written communication to the team in Bristol.' [18]
19 Dr Elliott Shinebourne, acting on behalf of the Specialist Advisory Committee on Cardiovascular Medicine of the Royal College of Physicians, was sufficiently concerned about the split site to advise in 1992 against the BRHSC being designated as suitable for a training post in paediatric cardiology.
20 We acknowledge that throughout the period of our Terms of Reference the clinicians in Bristol wished to consolidate all aspects of the PCS service onto one site. But this was not achieved until 1995. Until then, we have no doubt that the PCS service was adversely affected by being a split service and that, as a consequence, the adequacy of the care provided was constantly compromised. Indeed, of all the factors affecting the adequacy of the PCS service, this was perhaps the most serious. Mr Elliot, as we have seen, described the split service as `... potentially dangerous'. It was in fact actually dangerous.
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Footnotes
[6] WIT 0532 0041 Ms Chinnick
[7] T3 p.149 Michelle Cummings
[8] MR 0722 0063
[12] WIT 0230 0004 Kathleen Tilley
[13] WIT 0349 0005 Susan Francombe
[14] UBHT 0295 0418
[15] UBHT 0295 0420
[17] WIT 0532 0041 Ms Chinnick
[18] WIT 0467 0005 Mr Elliott