Final Report > Chapter 9: The Paediatric Cardiac Surgical Service in Bristol > The organisation of paediatric cardiac surgical services in Bristol > The place of PCS in UBH/T

The place of PCS in UBH/T

2 It is important to stress that the PCS service was only a very small part of the overall service provided by the UBH (a large hospital group), and later by the Trust. Moreover, it was only a small part of the cardiac surgical service. It was always an adjunct to the service provided for adults. [1] Dr Bolsin, consultant anaesthetist at the BRI, said that: `The major throughput of cardiac surgical cases on the BRI site was related to adult cardiac surgery. In 1988 3 paediatric cardiac surgical cases each week would be undertaken compared to twelve adult cases'. [2] Mr Wisheart explained that during the 1980s the number of cardiac operations at the BRI increased, but pointed out that the greater increase was in adult surgery. He stated: `The sessions which Mr Dhasmana and I did devote to children amounted to three operations a week - I do not mean three half days; there were three operations a week of whatever length, which were children ...'

3 The PCS service was a split service provided over two sites until October 1995. [3]

Figure 1: Location of relevant Bristol hospitals during the period of the Inquiry's Terms of Reference

Figure 2: Services provided at the BRHSC and BRI from 1984 until October 1995

4 The two surgeons, Mr Wisheart and Mr Dhasmana operated on patients suffering from both acquired and congenital heart disease, both adults and children. Open-heart operations were undertaken at the BRI, closed operations at the BRHSC, and were carried out by both surgeons. However, there was always pressure to care for the increasing volume of adult patients not least because of national and regional priorities given to reducing heart disease in adults and, after 1991, the income generated by increased numbers of adult patients. Dr Joffe told us that developments in the care of children, such as the transfer of the catheterisation laboratory to the BRHSC in 1987 and ultimately the move of open-heart surgery to the BCH in 1995, were achieved `on the back of adult developments'. [4] As regards paediatric cardiac surgery (PCS), the UBH/T offered children the whole range of operations expected of a centre providing this service, although in the case of the Switch operation, this was offered at Bristol for non-neonates from 1988 and for neonates from January 1992 [5] some years after it became available at other centres.

5 The annual returns made by the cardiac surgical service in Bristol to the UK Cardiac Surgical Register (UKCSR) provide an indication of the volume of paediatric and adult open-heart surgery respectively carried out at the BRI over the period of the Inquiry's Terms of Reference. These annual returns were divided into two parts, the first part relating to open-heart operations for acquired heart disease and the second relating to open-heart operations for congenital heart disease (CHD). To a large extent, adults fell into the first category and children into the category of CHD. The following table based on the figures returned to the UKCSR by Bristol for the years 1987, 1991, and 1994-1995, illustrates the growing volume of adult patients (`open acquired') compared with the smaller and static numbers of child patients (`open congenital').

6 Notwithstanding the provisos as to the quality of the UKCSR data (which are set out in the statistical evidence in Annex B and Chapter 19 of Annex A), these figures seem to illustrate that the total number of open-heart operations carried out on children in Bristol was relatively small in proportion to the total numbers for adults and that the disparity increased with time.

7 To understand this disparity further, it is important to realise that to carry out PCS, not only is a slot required in the timetable for the operating theatre, but also a bed in the Intensive Care Unit (ICU), nursing staff, and theatre technicians. Moreover, the surgeons' three sessions per week dedicated to PCS must be co-ordinated with the availability of the paediatric cardiac anaesthetists. Since adult and child patients used the same facilities and were cared for by the same staff, this state of affairs constantly created a tension between caring for adults and for children. This tension was exacerbated further by the fact that children needed to stay in the ICU for a significantly longer time after surgery than adults.

Footnotes

[1] Table 1 later demonstrates the growing disparity in the proportion of children and adults receiving open-heart surgery

[2] WIT 0080 0002 Dr Bolsin

[3] See Figure 1: Location of relevant Bristol Hospitals during the period of the Inquiry's Terms of Reference

[4] T90 p.32 Dr Joffe

[5] Mr Dhasmana suspended the neonatal Switch programme for several months following a series of deaths. After changes in practice, the Switch programme was resumed briefly in Bristol in July 1993. Following a further death of a child the neonatal Switch programme was ended until the appointment of Mr Pawade, a specialist paediatric cardiac surgeon, in May 1995