The Bristol Story

All £14 Million worth of it!

Delivered by Dr Russell D. LutchmanConsultant Forensic Psychiatrist

The Bristol Story

What’s the Bristol Story?

• It is a story that cost £14 million!• The lessons are lost, forgotten or

still being learnt – at a rather slow pace.

• It was a public inquiry into events at Bristol Royal Infirmary between 1991-95.

• 30-35 children who underwent heart surgery died over those years.

The Bristol Story

So?

• This story rocked the medical establishment

• It was to change the way the NHS and related organisations would function thereafter

• The inquiry report was published in July 2001 – 540 pages.

• Annex A of the report – 1538 pages.• Who’s got the time to read this kind of

stuff? – Me!

The Bristol Story

Why Public inquiries?

• Matters of greatest public outcry.• The demands of public interest.• Political anxiety.• No clear criteria.

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Purpose of public inquiries• Lord Justice Clarke at Thames Safety

Inquiry– to restore public confidence by carrying out 'a

full, fair and fearless investigation into the relevant events'.

– identify lessons to be learned. • Bristol

– identifying 'the truth'. …– “it may be rare for there to be 'one truth'.

There are often a number of 'truths', all held with sincere conviction by those advancing them.”

The Bristol Story

Who’s who at Bristol

The late Shipman. was a GP in Manchester.

The late Ledward was in Kent. Struck off in 1998.

These two had nothing to do with Bristol

WisheartRoylance

DhasmanaBolsin Walmsley

The Bristol Story

Who are the main players?

• Dr John Roylance – Chief Executive• James Wisheart - Surgeon• Janardan Dhasmana – Surgeon• Stephen Bolsin – Anaesthetist• Private Eye!• Royal College of Surgeons• GMC• Dept. of Health

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Learning the lessons..

In this historic interview, Dobson committed to going after those who did wrong.

The Bristol Story

Recap - the main players.

• Dr John Roylance – Chief Executive• James Wisheart - Surgeon• Janardan Dhasmana – Surgeon• Stephen Bolsin – Anaesthetist• Private Eye!• Royal College of Surgeons• GMC• Dept. of Health

The Bristol Story

History of the Bristol affair• 1975 – James Wisheart began work at

BRI• At that time it was small centre doing only

108 paediatric cardiac operations per yr. • 1984 the BMJ said Bristol had the worst

capacity for heart surgery• 1984 - Government decided to develop

the PCU into a specialist centre.• Avon Health Authority began pumping

money in• By 1985 they were doing 435 ops/yr

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BRI – 1988 to 1990

Dhasmana joined BRI in 1988

Bolsin joined same year– He noticed operations taking

longer at BRI than other hospitals

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BRI: 88 – 90 cont’d• Bolsin wrote to Roylance in 1990 expressing

concern about increased mortality among Wisheart’s patients.

• Shortly after Bolsin said that Wisheart approached him in fury (denied by Wisheart).

• Martin Elliott a specialist paediatric cardiac surgeon, declined an opportunity to work at BRI, citing poor facilities.

• Wisheart elected chairman of the Hospital Medical Committee, and made Assistant Director of Cardiac Surgery - both prestigious positions.

The Bristol Story

BRI 1991 - 1992• Wisheart promoted again, this time to

Medical Director of the BRI.• Dhasmana moved from operating on

toddlers to newborn babies. • Private Eye publishes its first article

critical of the PCU. • Bolsin speaks to DOH official.• Dr Zorab (Frenchay Hosp) contacts Sir

Terence English of RCS to express concern about quality of surgery.

• RCS considers removing the units specialist status but delays in doing so.

The Bristol Story

Doing his best…• James Wisheart said in evidence

and to BBC Radio 4's Today programme: "I have never claimed to be perfect. But I have done my best. I believe I have produced acceptable results. I believe in time the record will show that. ”

• Not really.• Lesson – doing one’s best may not

be sufficient.

The Bristol Story

Private Eye..huh?• Dr Phil Hammond, GP, Lecturer in

Communication Skills, University of Bristol, ‘MD’ from the magazine Private Eye and Daily Express columnist (not employed at BRI).– Was perceived as a ‘Whistleblower’s advocate’ or ‘go-

between’– Became concerned about deaths at BRI in 1992– did not hide factual associations with Private Eye– Received information from Bolsin – Spoke of emphasis placed numbers of patients treated

rather than treatment outcomes – Surprised about lack of action from the DOH and Royal

College of Surgeons following the publication of his 1992 articles.

– With hindsight wished he had personally drawn them to the attention of key figures within the NHS

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What happened next?April 5 1995 - Bristol Royal infirmary (BRI) halted a

pioneering kind of open heart surgery for infants, after 9 of 13 babies operated on, died over an 18-month period prior to 1993.

March 19 1997 - Health Secretary Stephen Dorrell, announced an inquiry into cardiac surgery at the hospital after an independent review showed that James Wisheart's patients were 4 times more likely to die than those treated by his colleagues.

October 1997 – – GMC investigation - cost of £2.2 M– 67 witnesses– Mr Wishart and Mr Roylance struck off – Mr Dhasmana banned from children's heart operations

for three years.

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Rewind - how did it happen?• Open-heart surgery on very young kids was split

between two sites, without dedicated paediatric intensive care beds, no full-time paediatric cardiac surgeon and too few paediatrically trained nurses.

• No agreed means of assessing the quality of care.

• No standards for evaluating performance. • A poorly organised system of hospital care beset

with uncertainty as to how to get things done.• When concerns were raised, it took years for

them to be taken seriously.

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So who spilled the beans?

1. Stephen Bolsin – anaesthetist - unofficially the biggest ‘rat’ amongst UK doctors.

2. Carried out an audit of survival after surgery.

3. Unable to get work in the UK after shopping his colleagues. Not surprising.

4. Scurried off to Australia to earn a living...but now happy as a professor in his field.

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Finally..

• September 10 1998 - United Bristol Healthcare trust finally sacked Mr Dhasmana.

• Oct 5 1998 - Dept of Health offered families £20K each.

• Some families refused the money.• March 18, 1999 -

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Culture in the NHS

• A sense of collective solidarity among the various groups of professionals in the face of what is seen as considerable adversity has been a cultural strength which has served the NHS well.

• A type of ‘Dunkirk spirit’, during the evidence in Phase One and Phase Two

• The General Medical Council (GMC) referred to ‘a national "make do and mend" culture’

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Culture

• “To a very great extent, the flaws and failures of Bristol were within the hospital, its organisation and culture, and within the wider NHS as it was at the time. That said, there were individuals who could and should have acted differently."

• There was a club culture at BRI.

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Culture bound

• The senior management was close to the "old guard" of clinicians and supported them. There was a "club culture," with insiders and outsiders.

• Management style had a punitive element, and the environment did not make speaking out or openness safe or acceptable.

The Bristol Story

Culture…and patients

• ..built-in traditional attitudes of some healthcare professionals ...'.

• Such attitudes discourage patients from asking questions, and lead to their being given only limited access to information, thereby preventing patients from participating fully in their care.

The Bristol Story

Culture and doctors• Subservience or deference to a perceived superior

can be a particular barrier when issues arise among healthcare professionals about a colleague's performance.

• Although there is now a duty on doctors and nurses to protect patients from risk and not to suppress concerns about a colleague's performance, very many in practice today were educated and trained in a culture in which there was a reluctance to criticise or comment upon the conduct of colleagues, particularly those who were more senior or practised in the same team or specialty.

• Not only does it make it difficult for an individual to summon up the courage not to conform, but this sense of hierarchy also influences who gets listened to within the organisation when questions are raised.

The Bristol Story

Culture..more• Members of separate professions …may not

always act in the interests of patients as a whole. • Their particular culture may even work against

these wider interests…• …not because the professionals involved, be

they managers, doctors, nurses or others, are bad people. It is merely that they have come to view the world in a particular way and, as a consequence, are unable to see the wider interests of patients as a whole (rather than the patient before them) and the wider picture of the NHS.

The Bristol Story

Culture and the risks• As a recipe for the future, it is useless. What

needs to be cultivated is a new sense of collective effort based on opportunity, rather than frustration.

• adverse circumstances seem to tap a particular quality in the national psyche

• such an approach is ultimately hopeless. It exploits the preparedness of the professionals to sacrifice themselves, while exhausting them.

• This is the negative side of the tradition of group loyalty which has been a strength in times of relative adversity.

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Cultural change?• Changing a culture takes time; • Change depends on a recognition of the need to

change.• It takes a sense of direction and;• It takes determination and patience • No short cuts. • Requires understanding and commitment • First stage must be an open and honest

appraisal of the culture in which healthcare is practised and an acceptance that it must develop.

• A process not free from pain

The Bristol Story

YAPI? [Yet Another Public Inquiry]• NO• It was one of the most detailed

investigations into the NHS ever undertaken, addressing fundamental issues of clinical safety and accountability, professional culture in the health service, and the rights of patients.

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But…• It was not an account “about bad people”.• It was an account of “..people who cared

greatly about human suffering, and were dedicated and well-motivated”.

• It was about healthcare professionals “..who were victims of a combination of circumstances which owed as much to general failings in the NHS at the time than to any individual failing.

• Despite their manifest good intentions and long hours of dedicated work, there were failures on occasion in the care provided to very sick children.

The Bristol Story

Bristol – Core terms of reference• the management of the care of children receiving

complex cardiac surgical services at the Bristol Royal Infirmary between 1984 and 1995 and relevant related issues;

• adequacy of the services provided;• what action was taken both within and outside

the hospital to deal with concerns raised• to identify any failure to take appropriate action

promptly;• draw conclusions and make recommendations

which could help to secure high quality care across the NHS.

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Practical difficulties

• Events took place over 12 yrs.• ..and 3 years before the start of inquiry.• Making proposals for improving the

quality of care in the NHS: to engage, in other words, in an analysis of how the lessons of Bristol might be applied to the NHS in the future.

• Digesting evidence from carers and expert witnesses – and making sense of it.

The Bristol Story

Tell more..

• The report painted a picture of a flawed system of care with poor teamwork between professionals, "too much power in too few hands," and surgeons who lacked the insight to see that they were failing and to stop operating.

The Bristol Story

Failings…

• the failings were not those of the surgeons alone.

• inadequacies were found at every point, from referral to diagnosis, surgery, and intensive care.

• The surgeons cared but "some lacked insight and their behaviour was flawed."

The Bristol Story

Complacency

The report said: • “The NHS is still failing to learn from the

things that go wrong and has no system to put this right. This must change. Even today, it is not possible to say, categorically, that events similar to those which happened at Bristol could not happen again in the UK or indeed, are not happening at this moment."

• The double negative means that they thought that it was still happening.

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The End…

May the force be with you