Appendix A
Still Nobody Told the Parents
Bristol remains a charming city in an idyllic setting, and I was delighted to be appointed as a consultant anaesthetist for adult and paediatric cardiac surgery in 1988. Maggie and I planned to bring up our family there. The job content of adult and paediatric cardiac anaesthesia included some of the most challenging work in the specialty available at the time, with a mixture of intensive care medicine thrown in for good measure. I was excited by the prospects and opportunities. I had no idea that Bristol would become the graveyard of my dreams at the same time as it became the graveyard of 171 children who could have survived if they had been operated on anywhere other than Bristol. From the deaths of these children emerged the concept of clinical governance, which has saved thousands more lives in the UK and worldwide. Sadly the change in attitudes of the profession came too late for these small sacrificial lambs.
The surgeon I worked with was Mr James Wisheart. He was soon to become the senior cardiac surgeon in the South West region, and head of the department in Bristol. At the time, I had no idea how good or bad the results in paediatric cardiac surgery were anywhere in the UK. Nobody except the surgeons did. However, what I did know was that, in Bristol, the operations were taking a long, long time. That, by itself may not have been a bad thing, but two other factors worried me even more. Firstly, the long times on the cardiac-bypass pump led to much more postoperative organ damage than in London hospitals. Secondly, the length of time the heart was starved of oxygen during the operations in Bristol was also much longer than London, and this led to severe heart damage and children dying in much greater numbers.
A few months after I had started in Bristol, an audit meeting of the paediatric cardiac surgical specialists confirmed my suspicions that the death rates in Bristol were abnormally high. The meeting was held specifically to discuss the operation of repair of ventricular septal defect (or VSD: a hole in the heart). The mortality rate for this operation at the Royal Brompton Hospital in London and around the world was very low, at around 1 per cent. Figures were presented that indicated the mortality in Bristol for this simple operation was incredibly high, as much as 30 per cent. The problem in Bristol was not that surgeons and cardiologists were unaware of the high mortality rates; the problem was that they were not prepared to do anything to get the death rates down. In those days, holding audit meetings was revolutionary, forward-thinking, and probably ahead of many other centres with better results. However, failing to act on the evidence of these audit meetings and annual reports was typical of the attitudes in Bristol.
The paediatric unit in Bristol had been under a cloud for many years. An expert paper produced for the Department of Health in 1980 had insisted that paediatric cardiac surgeons needed to do at least 50 operations each year on children less than one year of age (infants) to maintain their skills. Units doing more than 50 operations in young children had lower mortality rates than those that did fewer than 50. Bristol had never achieved that number of operations, and had not been considered in the first list of centres to be given the prestigious ‘Supra-Regional Paediatric Cardiac Surgery Centre’ status by the Supra-Regional Services Advisory Group (SRSAG), chaired by Dr Norman Halliday. The description by the Committee of the Bristol unit at that time was that it ‘did not shine like a star’ and was ‘not one of the leading lights’. Bristol was designated to fail, but was added to the list of Supra-Regional centres in 1983, as an afterthought, in response to its geographical location in the west of England. There was no consideration of high mortality rates at this stage.
The city of Cardiff, in Wales, is 44 miles from Bristol. In 1986, the senior cardiologist in Cardiff, Professor Andrew Henderson, negotiated a special arrangement with the paediatric cardiac centre in Southampton (138 miles away) to assess and treat children from Cardiff and Wales. In doing so, he was replicating a deal that the paediatricians in Plymouth (120 miles from Bristol) had negotiated with Southampton (152 miles away), also in 1986, to assess and treat their children as well. Both arrangements were specifically made to ensure that children were not treated in the ‘high-mortality’ Bristol centre. Nobody told the parents in Plymouth, Cardiff, or Bristol. At that time, the criticisms of Bristol were so strident the Chief Medical Officer for Wales, Professor Gareth Crompton, discussed the matter with the Chief Medical Officer for England Sir Donald Acheson. Professor Crompton was advised to speak to Dr Norman Halliday.
Also in 1986, a report co-authored by Mr Terence English had confirmed that Bristol did not have the number of operations necessary to achieve low mortality rates, but Dr Halliday’s SRSAG continued its designation of Bristol as a Supra-Regional centre. By 1987, the criticism was so loud that the broadcaster BBC Wales aired a scathing documentary about the survival of children from south Wales in the Bristol centre.
My problem from 1989 was that operations on tiny babies less than one month old were the highest risk in Bristol. After consulting a senior colleague, in June 1990, I decided to express my concerns, and wrote to Dr John Roylance, who was about to become the chief executive of the Bristol Royal Infirmary. The response to my letter was swift. First, a phone call from the chief executive dismissed the concerns. Second, a meeting with the chairman of the Hospital Consultants Committee concluded that I had been manipulated by a senior colleague. Later, I attended a meeting that was much more sinister. An obviously infuriated Mr Wisheart explained that writing to the chief executive was not the way to behave in cardiac surgery, and he delivered a potent threat: ‘If you wish to remain in Bristol you should not disclose the results of paediatric cardiac surgery to people outside the unit ever again.’ The venomous and intense manner of the delivery of the message added to its sombre content. This was reinforced at an anaesthetic audit meeting held to discuss paediatric heart surgery some weeks later. The president of the Association of Anaesthetists of Great Britain and Ireland, himself a cardiac anaesthetist, advised caution in dealing with the issue, because, as he put it, ‘Steve had already put his head above the parapet and had a “pot shot” taken at him’. This was colourful language from a colourful character, but very sobering feedback for a junior anaesthetist like me who desperately wanted to do the best for his patients.
Later that year, the annual report for the Bristol unit, which was produced by the surgeons, confirmed that the mortality for ‘complex’ and ‘moderately complex’ paediatric heart surgery was twice as high as the national average. This report confirmed that the surgeons and the cardiologists themselves knew how badly they were performing. However, their combined lack of action to improve the mortality rates indicated that they had no intention of regulating their referrals or their surgery to reduce the risk of death and serious injury to the patients they served. There was no evidence they were prepared to do anything about the high death rates, and they certainly did not warn the parents of their tiny patients.
I continued to collect audit data on my patients, including the vital outcome of whether they survived the operation to leave hospital. My figures only served to increase my anxieties about the dangerous nature of the service of which I was an integral part. I was now so convinced of the deadly nature of the operations that I decided to apply for a position outside Bristol. I approached the Professor of Anaesthesia for a reference. I explained about the paediatric heart surgery results, and he confided that he had known about the long operations since his appointment to Bristol in the 1970s. His first task in Bristol had been to adjudicate a disagreement between the cardiac surgeons and the cardiac anaesthetists about how long the cardiac surgery was taking. Now he struck a deal with me; I would collect robust mortality data on all paediatric heart surgery patients, and he would provide his senior lecturer to help in the analysis of the data if my application was unsuccessful. Andy Black and I started the data collection in August 1991.
By the summer of 1992, two audits had been conducted by Professor David Hamilton with members of the Royal College of Surgeons and the Royal College of Physicians for Dr Halliday’s SRSAG in the Department of Health. The audits had confirmed that Bristol had twice the mortality rate for open-heart surgery than every other centre in the UK bar one. A letter to Sir Terence English, who was the president of the Royal College of Surgeons, from Bristol anaesthetist John Zorab, had raised the problem of high mortality at the Bristol Royal Infirmary. Sir Terence had discussed the issue with Professor David Hamilton after reviewing the professor’s recent report to the SRSAG. Professor Hamilton had admitted that he and his working party had paid ‘insufficient attention’ to the figures in Table 1 of the report. These showed Bristol had more than twice the mortality of other centres for many conditions.
Sir Terence and Professor Hamilton then agreed to take executive action on this important issue. Sir Terence informed Dr Halliday of their recommendation that the SRSAG should de-designate Bristol as a specialist paediatric cardiac surgical centre. However, Sir Keith Ross and Professor Hamilton reviewed this decision while Sir Terence was abroad, and, in consultation with the other members of the working party, Sir Keith advised Dr Halliday that Bristol should not be de-designated because of its high mortality. The reason given by Professor Hamilton in his letter to Sir Terence was that he was concerned about ‘a possible specific source of “breach of confidentiality” which could arise’ and ‘a further feeling that the de-designation of one of the Units would probably leak out in the course of time’. The SRSAG instead decided to de-designate all centres at their July meeting. This decision cost scores of children their lives.
Still nobody thought they should warn the parents.
By late 1992, Andy Black and I had produced preliminary results that painted an alarming picture. Compared to the national-average data from several years before, there was not a single operation for which Bristol had lower death rates, and, for several operations, Bristol had much higher death rates. The argument that Andy and I developed was that Bristol should concentrate only on the operations for which there was evidence the Bristol results were similar to the ‘national average’, and we should only start the more dangerous operations when there was reason to believe we could do them safely. The message was not well received at any level in the organisation. With the results verified by a paediatric cardiologist, we took them to the new Bristol Professor of Cardiac Surgery, Gianni Angelini. The results were no surprise to him because the appallingly high death rates in Bristol were the ‘open secret’ of British cardiac surgery.
Andy’s and my audit results confirmed the worst, but no one wanted to question Mr Wisheart, who by now was the senior cardiac surgeon, head of the cardiac surgery unit, chair of the hospital medical committee (representing all the hospital senior doctors), and also medical director of the entire hospital. The situation continued to deteriorate, with many more children and babies dying unnecessarily. I made plans to give up my paediatric cardiac surgery practice.
One of the cardiac procedures for which the Bristol surgeons had an exceptionally poor record was the relatively new ‘arterial-switch’ operation. This is an intricate, dangerous, and technically challenging operation. In babies under one month of age, the record at Bristol was an unenviable nine deaths in 13 cases. In Birmingham, which is only 90 miles away, Bill Brawn had operated on more than 200 babies for this condition, with only one death. Nevertheless, in December 1994, Bristol surgeon Janardan Dhasmana listed an 18-month-old toddler, Joshua Loveday, for an arterial-switch operation. Gianni, Andy, and I were horrified, and set about agitating the organisation for a review of this decision. I contacted Bill Brawn, the excellent surgeon in Birmingham, who had offered to retrain Janardan after his initial dismal failure at the operation. Bill’s view, from what he had seen of Janardan’s capability when he had visited him in Birmingham for retraining, was that he could not, and therefore should not, do the operation. However, he forbade me from communicating his opinion to Janardan, or anyone else, as this would ruin his mentoring programme for paediatric cardiac surgeons. We both agreed to contact a Department of Health official (Dr Peter Doyle) to try to get the operation stopped. Unfortunately, the surgeons remained completely unmoved, until the night before the operation, when Mr Wisheart called a meeting to discuss the operation.
Gianni and Andy were specifically excluded, but I attended. The meeting was told that Joshua’s operation was necessary and urgent. The figures for the arterial-switch operation in Bristol were compared to ‘national average’ figures. The sub-division of the figures into small numbers made statistical comparison with the national figures meaningless, and thus the poor record was obscured. Mr Wisheart proposed that the operation should proceed. Seeing that there were no dissenters, I took a deep breath, and said ‘No’.
My argument was that the record in Bristol for this operation was poor, and had not improved since Janardan had ‘retrained’ in Birmingham. I included the low Birmingham death rate, adding that I had been concerned enough to raise the results with the Department of Health. This horrified the consultants, who were obviously petrified of external scrutiny. I believed that Joshua should be referred to another unit, and that operating unsuccessfully on him in Bristol would have serious repercussions. Despite fierce criticism, a vote was finally taken, and I asked my single minority view to be minuted. I did not know that Peter Doyle had contacted Dr Roylance (Bristol Royal Infirmary chief executive) regularly to get the decision to operate reviewed. Peter had also insisted that Mr Wisheart arrange the last-minute meeting. What neither Peter nor Dr Roylance expected was the agreement to proceed with Joshua’s operation.
And still nobody warned the parents.
That night was the worst in the whole of my medical life. Far, far worse than the exhaustion of a ‘five-day continuous on-call weekend duty’ was the heartache and genuine anguish of the certainty that a child’s life was being placed at risk just for surgical pride. Maggie, my wife, and I discussed the options of telling Joshua’s parents to take him to Birmingham, but decided that the near certainty of having our concerns dismissed by the parents and of being de-registered or ‘struck off’ the nursing and medical registers made the whole mission a disaster from the start. I am still haunted by the knowledge that Joshua’s parents wished we had tried to tell them the truth. In another world, I would have done so. I was not brave enough then.
The switch operation proceeded the next day, 12 January 1995. I rang the operating theatre to find out how the operation had proceeded that evening. I heard from a nervous theatre sister that Joshua was still in the operating theatre after nearly 12 hours of continuous operating. I knew then that he would not survive, and, an hour later, Gianni Angelini told me that the toddler, Joshua Loveday, had just died, still on the operating table. Maggie and I cried with sorrow and anger. Our anger was directed at an institution that had cold-heartedly sacrificed a child’s life for the sake of surgical pride. This was an unforgiveable act, but who would hold anyone to account?
The Department of Health decided that external investigators should review the Bristol paediatric heart surgery service. The reviewers invited by the hospital were Marc de Leval, a consultant cardiac surgeon from Great Ormond Street Hospital in London, and Dr Stewart Hunter, a paediatric cardiologist from Newcastle, who had co-authored the 1992 report for Dr Halliday’s Committee that had led to Sir Terence English advising de-designation of the Bristol centre. Stewart Hunter arrived in Bristol and met paediatric cardiologists the night before the inquiry.
On the day of the inquiry, I faced a relatively hostile inquiry team to whom I presented my information in the form of annual reports, tables, sequences of operations, and graphs, all packaged in clear plastic envelopes. It was not until I was able to convince them that the information came from multiple sources, including the surgeons themselves, that I was given any credibility.
The first report produced by the ‘independent reviewers’ concluded that Mr Wisheart must be seen as a ‘higher-risk surgeon’ and should cease paediatric cardiac surgery immediately. Mr Dhasmana should retrain in the arterial-switch procedure, and could continue other paediatric cardiac surgery operations. The report was completely unacceptable to the hospital and at least one of the surgeons. When Dr Roylance returned from his holiday, it was ‘rewritten’. Sadly, no one remembers by whom. This decision cost another young child, Andrew Peacock, his life. He was operated on by Mr Wisheart on 1 May, which was the same day that Ash Pawade, the new, safe paediatric cardiac surgeon started. Andrew died of brain damage a month later. His parents were never told of the findings in the first report that Mr Wisheart was ‘a higher-risk surgeon’.
I do not know to this day who ‘rewrote’ what sections of the report. The second version claimed that the concerns of the anaesthetists had so undermined the confidence of the surgeons that they had been unable to operate successfully! In this Orwellian organisation, the source of the problem was redefined as not the surgeons, but the anaesthetists. The ‘revised’ report was released to the BBC in Bristol, and I believed I had a right to defend myself as one of the anaesthetists allegedly responsible for the high mortality. I was advised by senior colleagues not to attend the interview, but I felt strongly enough to complete an interview, on camera, with Matthew Hill for BBC television.
The same week a reporter from The Daily Telegraph newspaper contacted me to discuss some figures for death rates from cardiac surgery operations, and an article was published in the Telegraph the next day. My first task that morning was to explain, in person, to Dr Roylance how the highly damaging results for paediatric cardiac surgery in his hospital had been spread across the front page of an influential daily paper. It was an uncomfortable experience, but I was helped by the fact that the Telegraph had misspelt my name. In the end, I was accused of nothing more than naivety in handling a press inquiry, but, as I left Dr Roylance’s office, he made a very curious comment. ‘You know, Steve, you were right, but you were too young.’ It left me puzzled and frustrated. It meant that he knew that there was a problem in paediatric cardiac surgery, that I was doing the right thing in highlighting the issue, but that he would allow the senior clinicians to hold sway over the children’s best interests. I felt very strongly that it was an immoral and unacceptable attitude. However, my opinion meant very little in the Bristol management structure, and the concerted cover up continued.
Parents were still none the wiser.
As the legal cases against the Bristol Royal Infirmary mounted, investigations revealed that, in at least one case, operated on by Mr Wisheart, crucial evidence had gone missing. The ICU chart, confirming an avoidable, medical cause of permanent brain damage in a child, had disappeared shortly after Mr Wisheart had withdrawn it from the medical records department. My legal report at the time confirmed the facts.
I visited local MPs Dawn Primarolo and Jean Corston (now Baroness Corston), and questions were asked in the House of Commons. Unfortunately, the answers remained evasive, and the true position was not disclosed. However, parents were becoming more involved and more determined to expose the truth. Michaela and Stephen Willis from North Devon, whose son Daniel had died during arterial-switch surgery by Mr Dhasmana, were pursuing answers through their member of parliament, Nick Harvey.
I applied for positions in other English hospitals, but also considered Australia. I secured a position as Director of Anaesthesia in Geelong, Australia, starting a new cardiac surgery service. I was then approached by James Garrett, an investigative journalist working in Bristol. I was now prepared to tell the whole, disgraceful story, but my fear of the medical establishment in England meant the programme was broadcast after I had left the country. ‘Broken Hearts’ went to air in April 1996. The next day, an article entitled ‘Why Did They Allow So Many to Die?’ was published in The Times. The author, Sir William Rees-Mogg, was from Bristol. The article was highly critical of the hospital management, naming and shaming both Mr Wisheart and Dr Roylance.
I also wrote to the General Medical Council (GMC), the official body that regulates doctors in the UK, and reported what had happened in Bristol, suggesting it might constitute ‘serious professional misconduct’. I was subsequently told I was the only doctor to report the events in Bristol to the GMC, and I believe this failure remains an indelible stain on the medical profession in the UK at that time. The GMC were forced to take firm action, and recommended an inquiry. This turned out to be the longest and most expensive inquiry in their 140-year history. The inquiry confirmed that children had died in Bristol who would have survived had they received care in other centres.
The findings of the Disciplinary Committee of the GMC were announced in 1998. Chaired by Sir Donald Irvine, the Committee found that Dr Roylance, Mr Wisheart, and Mr Dhasmana were all guilty of serious professional misconduct. Dr Roylance and Mr Wisheart were ‘struck off’ the medical register, and Mr Dhasmana was to undergo retraining. Dr Roylance appealed the verdict and the sentence of the Committee. The Privy Council upheld both the verdict and the sentence, thereby confirming in law that medical practitioners in roles of medical management had as a primary duty the welfare of the patients in their care. Ignoring that duty could lead to erasure from the medical register.
Later in 1998, the Bristol hospital announced the results of an inquiry into the performance of adult cardiac surgery. Mr Wisheart had always claimed that the excessive examination of his paediatric cardiac surgery results was unfair, because these operations represented only a very small proportion of his total work, the rest of which was excellent. The results of this inquiry showed something very different.
For coronary artery surgery in adults, Mr Wisheart’s mortality was nearly six times that of his colleagues. For other cardiac surgery, his mortality was four times higher. The conclusion was that Mr Wisheart found the delicate surgery involved in adult coronary surgery too difficult to do it well. He should probably never have started paediatric surgery, where structures are smaller, and suturing much more delicate. The figures on mortality had made this clear for many years, but no one, not even the Royal Colleges or the Department of Health, was prepared to tell him to stop the dangerous surgery. I am sure things are different now in the UK.
The response of the cardiac surgical community was unpredictably paradoxical. When the senior cardiac surgeon in Geelong returned from the European Cardiac Surgical Conference in 1998, he smiled as he told me I was ‘the most hated cardiac anaesthetist in Europe’. It was an unexpected and bitter pill to swallow for saving so many lives. Articles in The Lancet and the British Medical Journal documented the appalling death rate in Bristol. From a peak of 30 per cent mortality in the early 1990s, the unit now became one of the safest in Britain, with a mortality rate falling to below 3 per cent only two years after I left.
I could live with the hate if the children survived.
In June 1998, the following Early Day Motion was passed in the House of Commons:
That this House notes the courage of Dr Stephen Bolsin, the consultant anaesthetist who first exposed the high death rate and injury in heart operations on babies at the Bristol Royal Infirmary during the late 1980s and early 1990s; regrets that the tragedies were allowed to occur; notes that many of the improvements in the NHS emerging from these tragic events will be traced back to Dr Bolsin’s decision to speak out knowing it could put his job on the line to do so; believes his behaviour sets an example to others; and commends his judgement in prioritising patient care above professional pressures to conceal bad practice.
The wider response was also constructive. The new Chief Medical Officer, Professor Liam Donaldson, and Dr Gabriel Scally, the Regional Medical Officer, who had watched the scandal develop under his nose, published an article outlining the principle of clinical governance. This became an accepted part of hospital medical practice around the world, and has probably saved hundreds of thousands, if not millions, of lives since its inception. I am immensely proud of this lasting contribution to patient safety, which can trace its roots back to the ‘Bristol Cardiac Disaster’. My contribution to the medical profession was to update the attitude, current in the 1980s and 1990s, that ‘your best was good enough’. The new aphorism was ‘the best is good enough’, and, to know that you were achieving the best, it was important to measure and compare the performance of units and, if necessary, individuals. Only then could patients have the confidence to approach specialists all over the country, knowing that their treatment would be as safe as possible.
The health secretary announced a public inquiry, chaired by Professor Ian Kennedy, into the management and care of children having heart surgery in Bristol between 1984 and 1995. They concluded that, for children less than one year old, from 1991–1995, over 35 children had died who would have survived had they been treated in other UK centres. The inquiry identified a ‘club culture’ in Bristol that had favoured the senior figures in the organisation and had placed ‘too much power in too few hands’. The surgeons had ‘lacked insight’ and ‘their behaviour was flawed’. Avoiding direct praise of individuals, Professor Kennedy highlighted my role in uncovering the problems in Bristol, and concluded: ‘he persisted and he was right to do so’. The Kennedy inquiry produced 200 recommendations for the NHS, and the evidence and transcripts remain a monument to the children who died.
The final death toll for Bristol was 171 children who would have survived if they had been operated on in Birmingham or London. No parent was ever warned.
No one has ever tried to count the excess adult deaths.