Stephen Bolsin is a British anaesthetist, patient safety expert and medical ethicist whose actions as a whistleblower exposed and finally ended incompetent paediatric cardiac surgery at the Bristol Royal Infirmary in 1995. His actions lead to the implementation of clinical governance reforms in the NHS. To mark a decade since the Public Inquiry reported, he tells his story, in his own words….
My first indication that something was badly wrong with the technical skill of James Wisheart was the incredibly long time he took to complete cardiac operations in children and adults. This involved long cross clamp times, which is when the heart is starved of oxygen, leading to death, serious heart failure and other major complications after surgery. But the clearest early example of technical incompetence occurred when he placed a wound drain about a centimeter wide through the liver of an early experimental ‘switch’ operation on a 6 year-old boy. I had never seen or heard of such a clumsy consequence of cardiac surgery. We had to open the child’s abdomen in the middle of the night and remove half his blood volume before sending him back to ICU where he died the same day. I had been in my consultant post 2 months. What could I do?
What I didn’t know was that when Bristol had been designated as a supra regional cardiac surgery unit in 1983 there had been serious doubts about the ability of the unit to expand the service for children under 1 year. The medical secretary of the group proposing Bristol, Dr Norman Halliday, had been reassured by a phone call from Terence English expressing support for Bristol from the Royal College of Surgeons. But then in 1986 Dr Norman Halliday had a visit from the Chief Medical Officer for Wales (Professor Crompton), who wanted to tell him about the serious concerns that senior Welsh cardiac specialists were expressing about the quality of the Bristol paediatric cardiac unit. Dr Halliday’s problem was he had opinions but no hard data. When in 1989 a report with graphs of Bristol’s mortality in infants at twice that of the other centres he had data but no opinion critical of Bristol. It was not until July 1992, after a series of disclosures in Private Eye, that a Confidential Report from a Working Party of the Royal College of Surgeons and the Royal College of Physicians (Sir Terence English, Sir Keith Ross, Professor David Hamilton and Dr Stewart Hunter) showed that the Bristol mortality for infants and neonates was twice the other centres in the UK. This led Sir Terence, who had recently been the President of the Royal College of Surgeons and a supra regional services advisor, to tell Dr Halliday that he believed that Bristol should no longer be a designated center for paediatric cardiac surgery. But Dr Halliday took no action, partly because the Working Party members changed Sir Terence’s plan of while he was on holiday and partly because it would have been ‘unacceptable’ to withdraw the RCS report. Unacceptable to them, but probably not to the parents of the 35 children, who are claimed to have subsequently died in Bristol.
The consequences for me personally were not quite so disastrous but still extreme. Having raised the likelihood of high mortality rates in Bristol with the Director of Anaesthesia, the Chief Executive and the Professor of Anaesthesia in 1990, following very worrying figures presented at audit meetings in that year and in 1989, there was little more I could do. The continued deaths of children led me to consider leaving Bristol with my young family, despite our love for the city and the roots we had begun to put down. This caused huge tensions at home because understandably Maggie my wife did not want to be forced out of Bristol and was very angry that although I was right about the high death rates no other clinicians appeared to be prepared to do anything to stop the children dying. Before I applied for the post I struck a deal with the Professor that he would provide me with a reference and if I was unsuccessful I would collect data on the paediatric mortality and prove the case one way or the other. I was not successful in July 1992 and so started to collect data with Dr Andy Black an anaesthetist with exceptional skills in the analysis of audit data. By 1993 the results were clear and proved that Bristol was much worse than the rest of the country for cardiac surgery on young babies and also many operations. The Professor of Cardiac Surgery, Gianni Angelini, accepted the results and did his best to obtain the review of the service the anaesthetists and he wanted, but the difficulties were mounting as James Wisheart assumed more powerful and influential positions within the Trust. First he became the Chairman of the Hospital Medical Committee and then he also became Medical Director of the Trust holding both positions for some time. He appeared to be in an unchallengeable position.
I contemplated reporting the surgeons to the General Medical Council (GMC) to stop the deadly operations but a solicitor for the Medical Protection Society, which was James’s indemnity provider, advised me that the chances of success were remote. The reasons were complex. Poor results were not, at that stage seen as grounds for serious professional misconduct. The GMC could only investigate poor practice from three causes, which were addiction to alcohol, addiction to narcotic drugs or florid psychosis; it was likely that my case would not get passed the first, screening, stage. Additionally the process for investigating such an allegation by the GMC was to set up a review by what were known as “the three wise men”. These consisted invariably of the Chairman of the Hospital Medical Committee (James Wisheart), the Medical Director of the Trust (James Wisheart) and a Consultant psychiatrist. This trio would investigate and adjudicate the allegation of serious professional misconduct causing excessive deaths in James Wisheart’s own unit. I was told that the chances of a successful complaint were very close to zero. But even worse, the solicitor advised me that if the complaint was unsuccessful the chances of being sued for defamation, or a counter charge of serious professional misconduct, for criticizing a colleague, was extremely likely. This could lead to me being struck off the medical register. The threat to my career meant I did not proceed with this complaint.
In 1994 six anaesthetists wrote to Janardan Dhasmana, the other paediatric cardiac surgeon, urging him to stop doing arterial switch operations in older children. Janardan had previously stopped the operation in one-month-old babies because his mortality was 9 deaths in 13 operations. Cardiac surgeon Bill Brawn, in Birmingham 79 miles away, had performed the same operation on over 200 babies with one death and Janardan had been to Birmingham to try to re-learn the procedure. In December 1994 Janardan listed a switch operation on a cheerful and lively 18-month-old, Joshua Loveday, for 12thJanuary 1995. To me it was utterly inconceivable and immoral that he would risk the life of a toddler to try to prove he could still do an operation that could be done safely in Birmingham or London. I contacted Bill Brawn by telephone and asked for his opinion and help. He told me that his observations of Janardan’s technique, when he had been in Birmingham, led him to believe that Janardan should not do this operation. Later Bill told me he had discussed my concerns at home with his wife and she felt strongly that he must stop the operation. He asked me if I knew anyone who could help get the operation in Bristol deferred or transferred. I gave him the phone number of Peter Doyle, a Senior Medical Officer at the Department of Health. Bill asked me to keep these conversations confidential, which I have done until now. Despite Gianni’s and my best efforts the operation remained scheduled, although a meeting of most of the consultants involved in the paediatric cardiac service the night before was arranged. Peter Doyle contacted me during the meeting and told me that he had spoken to John Roylance, the hospital Chief Executive, and believed that the operation would not proceed. I told him that the meeting had just decided to proceed with the operation and he promised to speak to John Roylance again that evening. Only after the meeting had agreed to proceed with a minority of one (me) against was consent obtained from the parents. They were, of course, not told about the unprecedented meeting hours before.
That evening my wife Maggie and I considered telling the parents to take Joshua to Birmingham, but considered the consequences to our careers (being struck off the medical or nursing registers) were too serious. It was the worse night of our lives and we often wish we had acted on our impulses to inform the parents. The consequences for Joshua were even more serious, he died in an operating theatre at the Bristol Royal Infirmary the following day.
The pace of change in Bristol now increased. Peter Doyle insisted on an independent inquiry. A surgeon, Marc de Leval, from Great Ormond Street Hospital and a child cardiologist Stewart Hunter, from Newcastle, were recruited by James Wisheart, who was put in charge of the investigation by John Roylance, before he went on holiday. This was a mistake. The investigators arrived the night before their 1-day visit and met two of the paediatric cardiologists. Stewart Hunter asked if their inquiry was linked to the Private Eye articles and events of 1992 but was told that it was about the loyalty of an anaesthetist, Steve Bolsin. This was reflected in my reception by the investigators the following day when the response of the Belgian surgeon to the data I presented was almost intolerably hostile. Fortunately his most poisonous criticism was directed at the figures of high mortality rates that had been produced by the surgeons, which I was passing on for information. When he had realized his error he calmed down, but did not apologize, and the ‘independent’ investigators decided to take my own figures seriously. They too became aware of a significant problem. Their first report, which was dissected and agreed by all the cardiac consultants in the hospital as well as the Chairman of the Trust Board, Mr. Bob McKinley, noted Mr Wisheart was “a higher risk surgeon”, and that Mr Wisheart should stop operating on children and Mr Dhasmana should cease the arterial switch operation. But the accepted report was not ‘acceptable’ to the Trust. When John Roylance returned from holiday changes were made, which the ‘independent’ investigators agreed. Their final ‘whitewash’ blamed tensions between the anaesthetists and the surgeons for the high mortality rate. Another whistleblower was marginalized.
Somehow, the national press had followed up Private Eye’s lead and the Daily Telegraph asked me to confirm figures that were now becoming more widely known. A non-committal “You seem to have got most of the story.” From me permitted them to publish figures naming me as the source, but fortunately spelling my name incorrectly. Understandably public scrutiny was the last thing that the Trust wanted and their response was to threaten me with possible constructive dismissal and remove cardiac sessions from my job roster although I had been the National Audit Coordinator for Cardiac Anaesthetists for several years. This is another well-documented response of health care organizations to whistleblowers. This was a very unpleasant time both at home and at work. I became withdrawn and dominated by the deaths and complications in children’s heart surgery. Most of my colleagues shunned my company and I relied on a few close friends both medical and non-medical for support and reassurance. I applied for other jobs in the UK but learned that I was considered ‘unappointable’; the common response of alternative employers to whistleblowers. The hospital tried to establish a conciliation process through the Department of Psychiatry but this smacked too much of the worst excesses of ‘psychiatric care’ for dissidents in the old Soviet Union. When I had obtained a position setting up a new adult cardiac surgery centre in Geelong, Australia I withdrew from the process, which was being reported back to the Trust Board.
The contrast in attitudes to whistleblowing between the BRI and the Geelong hospital could not have been greater. I decided to inform the interview panel in Geelong of my reasons for leaving a UK teaching hospital for a regional hospital in Victoria. I briefly explained everything, including the difficulties I had encountered, before any questions had been asked. The response of Patricia Heath, the Chair of the Hospital Board almost reduced me to tears. “What you have told us sound like excellent qualifications for the position we have advertised Dr Bolsin.” This response in 1995 amazed me and was the first positive affirmation of my actions from a senior healthcare manager.
Leaving the UK with my wife and family was an incredibly sad and disappointing time but I am sure now that there could never have been ‘Clinical Governance’ or a change in medical attitudes while I remained in the UK. Only when I had a contract in a new hospital, in a new country did I feel secure enough to report the mortality rate in the Bristol paediatric cardiac surgery unit to the GMC. Sadly despite the Presidents and Council Members of 2 Royal Colleges, the Dean of the Medical School, numerous Professors, some members of the Trust Board, members of the Department of Health and many local clinicians all knowing about Bristol, no other doctors in the UK reported these events to the GMC. I believe that this is a serious and permanent indictment of the attitudes of the profession that prevailed at that time and persist in some quarters in the UK. At least 12 sets of parents had reported deaths to the GMC, but their complaints would not have been investigated without a complaint from a doctor. However after a prolonged inquiry and hearing of the Disciplinary Committee of the GMC the Chief Executive, John Roylance and the Senior Cardiac Surgeon, James Wisheart, and Janardan Dhasmana, the other child cardiac surgeon were found guilty of serious professional misconduct. James Wisheart and John Roylance were ‘struck off’ the medical register. At this stage a colleague, who was attending a European Cardiac surgeons meeting, told me that I was “the most hated cardiac anaesthetist in the world”. And this was for doing the right thing in saving children’s lives. That common and ignorant opinion hurt me deeply at the time, although I realized that it was only reflective of a group that was very uncomfortable with having been forced to rethink their attitudes to patients. Shortly after the GMC verdict the first article to champion ‘Clinical Governance’ as the guiding principle of health professional management was published, co-authored by Gabriel Skally (the Regional Medical Officer who had seen Bristol develop in his region and whose desk had been a stone’s throw from the BRI) and the new Chief Medical Officer, Liam Donaldson.
The parents had been able to persuade the new Health Secretary Mr Frank Dobson of the need for a full Public Inquiry. This was given access to all the confidential documents held by the Department of Health, the Regional Health Authority, the Hospital and the individuals involved. The ‘dirty washing’ was given a public airing but the ‘no blame culture’ prevailed. The result was an in depth analysis that criticized many of the participants from Sir Terence English, Dr Norman Halliday, Dr Peter Doyle, Dr John Roylance, James Wisheart, Janardan Dhasmana and Margaret Maisey, the hospital matron but also tried to be more constructive. The report also made 198 recommendations for the NHS many of which have yet to be introduced. The statisticians confirmed that 30-35 babies under one had died unnecessarily in Bristol; sacrificial offerings on the altar of professional pride and institutional indifference.
My life, along with that of my family, was changed irrevocably by the events of Bristol. I am now a dual citizen of Great Britain and Australia and I have brought up two adorable Australian children in an enjoyable exile from the NHS. No one in the UK has ever offered me alternative employment and I suspect I remain ‘unappointable’ as I was in 1995. The only person brave enough to acknowledge my role was Professor Terence Kealey, Vice Chancellor of Buckingham University, whose institution awarded me an Honorary Degree in 2004 and I remain grateful for his recognition.
I have developed my career in Anaesthesia, Patient Safety and Medical Ethics with numerous publications and chapters in textbooks. In Geelong I led a team that successfully allowed junior doctors to measure their competence in medicine as part of an ongoing, lifelong commitment to assessing quality in healthcare. The same group also published the world’s highest incident reporting rate in medicine using the same mobile computers in a supportive environment. This was 10 years before the iPhone but sadly the project has now been shelved.
Barely a day goes by when I do not think of some aspect of the events of Bristol and I have often been asked if I would do anything differently. The simple answer is ‘No’. But, knowing what I know now, the real answer is I would never have taken the position in Bristol.
Stephen Bolsin July 27, 2011