Final Report > Chapter 16: The Organisation of the Paediatric Cardiac Surgical Service in Bristol > Post-operative care
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Post-operative care
31 We heard from our Experts that the transfer from the operating theatre to the intensive care unit is one of the most difficult stages in the care of a child. The principal reason is that the child passes through the care of three distinct groups. The levels of skills available to monitor the patient go from those of the consultant surgeon and anaesthetist in the operating theatre, to those of the porter, the nurse and the anaesthetic assistant who move the child, and then to those of the nursing staff and the surgical senior house officer who receive the child in the ICU.
32 At the BRI the stress, and the opportunity for things to go wrong at this critical stage, were exacerbated by the need to travel in a small lift between two floors from the operating theatre up to the ICU. We heard from one of our Experts, Dr Barry Keeton, consultant paediatric cardiologist, that Southampton General Hospital also faced this problem in the 1980s. But, in contrast to Bristol, he told us that at Southampton they commandeered one of the hospital lifts and made it into a dedicated lift for the purpose of transfer between the operating theatres and ICU. The lift itself was equipped with resuscitation and monitoring equipment in order to reduce the risk to the child. [33] No such arrangements were in place in Bristol. As we have said, not only was the lift very cramped when it had to accommodate a bed, a nurse and an anaesthetic assistant, but it had no emergency equipment installed, and, most remarkably, was at risk of being summoned and stopped or sent to another floor, if the lift button was pressed while in transit. If ever there were an environment conducive to error and danger this was it. Yet when the BRI was twice inspected as a centre suitable for training surgeons by representatives of the Royal College of Surgeons of England, [34] no adverse comment was made. Indeed, on both occasions, the visiting team appear from their report to have thought that the operating theatre and the ICU were on the same floor! This is an extremely worrying comment on the rigour and reliability of the process of inspection, as a precursor to approval of a hospital for training purposes.
33 It was a particular feature of the ICU, as we have seen, that there were no dedicated beds for children. They were nursed with adults. Professor John Vann Jones told us:
`... when I did paediatric cardiology, having been an adult cardiologist and thrown into these unusual circumstances, I felt very uncomfortable with it because these youngsters have many metabolic problems that develop very quickly. They are tiny little things. They become acidotic very easily: they have their ventilation suppressed very easily. If you do not actually have general paediatricians in the building and you do not have a paediatric cardiologist in the building all the time, and you do not have dedicated paediatric anaesthetists you are going to have more morbidity. That problem needed to be resolved.' [35]
34 Post-operative management at the BRI was criticised by Dr Hunter and Professor de Leval in the first draft of their report as `highly disorganised with conflicting decisions'. [36] The fundamental problem, which was unresolved throughout the period of our Terms of Reference, was the stark question: who was in charge? Anaesthetists and surgeons carried out separate ward rounds. Mr Wisheart told us that he did not regard conducting ward rounds at different times as posing a particular difficulty. [37] We heard that, as a consequence, nursing staff felt that they received conflicting instructions. [38] A course of action indicated by one clinician might be changed by another on a later ward round. For example, Dr Pryn told us that `relatively frequently' [39] complex decisions had been taken at the earlier ward round by registrars with which he, as the intensivist, disagreed. Mr Wisheart expressed the view that this only occurred `occasionally' when `a difficulty might arise if one party instituted a course of action, for whatever reason, without discussing it with the other party and the second party then comes along and may not agree with what has been done'. [40]
35 There was no clear line of command to indicate who could take decisions about changes in treatment with the urgency required in the case of very young babies, whose condition changes far more rapidly than that of adult patients. The doctors physically present in the ICU for most of the time were junior doctors training in general surgery. They were not authorised to make decisions without consulting the senior surgeons, but the latter were often either in the operating theatre or in a clinic. Moreover, the junior doctors, while knowing something about surgery, might well have no expertise in cardiac care, paediatrics, or intensive care. Yet they were the medical presence in the ICU, caring for seriously ill children. Dr Pryn told us that: `it was a unit run by trainees ... quite familiar with the cardio-vascular system ... but relatively poor at integrating that with other systems, for instance the respiratory system'. [41] Even when two intensivists at consultant level were appointed in 1993, they were only present for part of the week on a rota system, such that the difficulty of who was in charge remained unresolved. When Dr Pryn took it upon himself to try to resolve the matter by introducing a single clinical report form, others did not co-operate. Professor Baum referred to the need for paediatric input because the `physiological needs of children ... might be very different from an adult approach to fluids, to electrolytes, [and] to drugs'. [42]
36 We pause to notice that it was at two key points in particular in the care of a child that there was a degree of confusion, or lack of agreement, as to who was ultimately in charge of care, and considerable shortcomings in the practical arrangements. These were when the cardiologist handed over care to the surgeon, and later when the surgeon handed over care to the ICU. In neither of these situations were the arrangements clear and smooth. It is not surprising that difficulties at these two crucial points significantly contributed to making the care of the child on occasions less than adequate. Simply put, the system for maintaining continuity of care was flawed.
37 The situation was made worse by the fact that, until 1992, when a registrar in anaesthesia was appointed, there was no resident anaesthetist in the BRI on call for the ICU. This meant that at night and on weekends, if an anaesthetist was needed in the ICU, he or she would have to be contacted and drive in from home. It was only on Professor Angelini's insistence, shortly after he arrived, that a room was found so that an anaesthetist could be accommodated and be on call for the ICU at the BRI. We were also told of the recurring shortages of trained nursing staff. Over and above the national shortage, there were difficulties in recruiting trained paediatric intensive care nurses, because at the BRI they had to care for adults as well as children. This was not a good career move for them. Sister Fiona Thomas told us of her continuing concern about staffing levels. [43] The ratio in the ICU at the BRI from 1992 was 5.4 whole-time equivalent nurses per patient. The national standard in 1992, to which Sister Fiona Thomas referred us, was 5.1 to 7.8 qualified nurses per patient to provide 24-hour cover per bed. The standard published by the Paediatric Intensive Care Society in 1992, however, recommended 6.4 [44] because the nurse must not only nurse the patient, but also support and care for the family.
38 The evidence is compelling that the care provided in the ICU to the children who had just undergone open-heart surgery was less than adequate in a variety of ways. Fundamentally, these failings led back to one principal flaw: a lack of effective leadership.
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Footnotes
[34] UBHT 0038 0187
[35] T59 p.165 Professor Vann Jones
[36] This was subsequently changed in the second draft to `less organised with multiple decision making process'; see Annex A Chapter 30
[39] WIT 0341 0011 Dr Pryn and T72 p.50 Dr Pryn
[43] WIT 0114 0010, 0019 Fiona Thomas
[44] WIT 0060 0011 Dr Ratcliffe