Final Report > Chapter 16: The Organisation of the Paediatric Cardiac Surgical Service in Bristol > The operating theatre
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The operating theatre
25 We heard critical comments from staff about the organisation of work in the operating theatre at the BRI. In particular, Mr Wisheart was criticised for his tendency to arrive late, having to be called even after the patient had been made ready to go on to bypass. [25] We heard of Mr Dhasmana's impatience with staff in the theatre, itself an indication of poor training and teamwork. [26] Criticism was also made of the absence of anaesthetists during surgery, who would leave to make their ward rounds. [27] Dr Pryn, consultant anaesthetist, told us: `I found it difficult to look after sick patients on the CICU [Cardiac ICU]. When I was at the same time anaesthetising for cardiac operations. Often I would have to leave my patient in theatre with a trainee anaesthetist while I went to the CICU to assess patients'. [28] Difficulties with equipment were also mentioned, such as the fact that use of the diathermy machine interfered with monitors. [29] Echocardiography was not available in operating theatres or in the ICU. Dr Jordan stated that the Heart Circle provided funds for the purchase of an echocardiograph machine, which could be kept on the ward. [30] Mrs Pratten, founder of The Bristol & South West Heart Circle, confirmed that in 1992 the Heart Circle was approached by Dr Jordan and asked to provide £25,000 towards the cost of a Doppler/echocardiograph.
26 Perhaps the most significant deficiency was the lack of availability of cardiological advice and assistance to the surgeons in the operating theatre. We heard from our Experts about the problems which can arise as a consequence.
27 We were told of the case of Marc Stevens, who, having had a shunt operation in May 1986, was admitted to the BRI in April 1991 for a corrective operation. We heard that during the course of the operation the surgeon, Mr Wisheart, encountered a further complication and took the decision to put in a second shunt. One of our Experts, Mr Philip Deverall, a retired consultant paediatric cardiothoracic surgeon, commenting on this decision, told us:
`It is not easy to think on your feet under those pressures on bypass and under considerable stress, and under optimal circumstances, it is nice under those circumstances to be able to ask your paediatric cardiologist, your fellow surgical consultant, your anaesthetist, to stand back, if necessary, in my experience, to actually leave the operating room and cool down and decide what to do.' [31]
28 Acknowledging the difficulties in contacting the cardiologists in such a situation due to the split site and their other commitments, Dr Jordan told us: `I would have liked to think if I had been there in theatre, discussing this, I would have ... said "The last thing you want to do, I am afraid, is to do another shunt".' [32]
29 Once again, there emerges a picture of less than adequate care, with the principal factor being the split site, and the consequently split service and a lack of the presence of the cardiologists.
30 Ultimately, teamwork and collaboration among the healthcare professionals working in the operating theatre was put under particular strain by the growing sense among some that the results in surgery on the under-1s were poor. The anaesthetists sought a veto over the performance by Mr Dhasmana of neonatal Switch operations and two of the theatre sisters, Ms Kay Armstrong and Mrs Mona Herborn, refused to scrub for such work.
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Footnotes
[25] T59 p.63 Sister Armstrong
[26] See exchange between Mr Dhasmana and Leading Counsel to the Inquiry T85 p.14 Mr Dhasmana. T59 p.31 Sister Armstrong
[27] As early as 1987, Mr Keen had complained in a letter that there was not always `consultant anaesthetic cover' in the operating theatre. UBHT 0138 0022
[28] WIT 0341 0030 Dr Pryn
[30] WIT 0099 0041 Dr Jordan