The findings of the Public Inquiry into the care of children receiving complex cardiac surgical services at the Bristol Royal Infirmary (BRI) between 1988 and 1995 makes devastating reading.
The largest ever investigation into medical standards of care in Britain’s National Health Service (NHS) concluded with the publication of a 600 page report the week before last. The Inquiry, led by Professor Ian Kennedy, was conducted between October 1998 and July 2001. Thousands of pages of documents were submitted from witnesses and parents, including the medical records of over 1,800 children. Oral evidence was also given, as were papers from the NHS.
The Inquiry found that Bristol had a significantly higher mortality rate for open-heart surgery on children under one than other centres in England. Between 1988 and 1994 the mortality rate was roughly double the national average in five out of seven years. The report states that from 1991 to 1995, between 30 and 35 more children under one years of age died after open-heart surgery in the Bristol paediatric cardiac surgery (PCS) unit than might be expected had the unit been typical of other PCS units in England. Two surgeons, Wisheart and Dhasmana, operated on patients suffering from acquired and congenital heart disease, both adults and children. Open-heart operations were undertaken at the BRI, closed operations at the Bristol Royal Hospital for Children (BRHSC), and were carried out by both surgeons.
The report states that up to 35 children who underwent heart surgery at BRI died unnecessarily as a result of sub-standard care and that flaws in hospital procedure and management meant around one third of all children who underwent open-heart surgery received “less than adequate care”.
Most attention has focussed on the fact that whilst there was enough information from the late 1980s onwards to cause questions about mortality rates to be raised, no intervention was made.
The report highlights a “club culture” within the PCS that refused to address concerns raised by a number of medical professionals working within the department and from outside experts as far back as 1986-1987. Further reports were published and circulated throughout 1989/90 that showed a consistent pattern of poor outcome at Bristol.
In 1992 the satirical journal Private Eye published six articles criticising the PCS services at the BRI, but it took the tragic death of 18 month old Joshua Loveday in January 1995 to finally bring a halt to the dangerous practices that prevailed under the tutelage of Wisheart and Dhasmana.
In all the inquiry made 198 recommendations for improvements in the NHS—focusing on changing the way doctors deal with patients, better access to information about the performance of hospitals and consultant teams, tighter leadership and nationally agreed standards for quality and care. It also calls for the NHS to set up an overarching Council for the Quality of Healthcare, to coordinate different bodies regulating healthcare standards, alongside a Council for the Regulation of Healthcare Professionals to oversee the work of the General Medical Council and other regulatory bodies.
Whilst these may go some way to overcoming the type of bureaucratic indifference and mis-management highlighted by the events in Bristol, it is striking that no substantive recommendations are made on NHS resources. Yet it is impossible to read the report without drawing the conclusion that the lack of resources—and the struggle to acquire new ones in what, due to the introduction of the market into health care, is a highly competitive environment—played an essential role in events at Bristol. It certainly contributed to the creation of a climate in which “passing the buck” and fatally ignoring certain details could occur.
It is worth quoting that section of the report which deals with the physical environment of the hospital in full. The Inquiry team visited the BRI in July 1999, 14 years after initial concerns were raised. The team stated that:
“We were shocked by what we saw at the BRI. There was a sense of dilapidation. The corridors were dirty, with an array of discarded equipment and bric-a-brac pushed against walls and in corners. The ICU was cramped and crowded. Large items of equipment were ‘stored’ in the middle of the room, making the space even more crowded. The area previously allocated for children was small and would have allowed little space for family members. The room set aside for parents to await news was small, cramped and windowless. The main lift used to transport children to and from the operating theatre, two floors below, was cramped and old. The space in the alternative lift was so limited that on occasions staff who should have been accompanying a child had to run up the two flights of stairs to meet it. Our overall, lasting impression was that Wards 5A and 5B were cramped, overcrowded, overheated, dirty and neglected. It was a tribute to the staff that they were prepared to work there.”
The report explains that due to national pressure to reduce heart disease in adults, especially after the introduction of the market into the NHS in 1990 to increase the income generated by the numbers of adult patients, the care of child patients suffered. The cardiac surgical service in Bristol was mainly an adult service, with the PCS unit tacked on to it, rather than being a dedicated service in its own right. The inquiry team found that the unit had no dedicated paediatric intensive care beds, no full-time paediatric cardiac surgeon and too few paediatrically trained nurses. Children were only separated from the adults by using two beds that were between a side wall and the nurse’s station. Due to the pressure on beds, however, this was not always possible.
The supposed existence of a “club culture” within the PCS does not explain why it was that other NHS bodies ignored evidence of problems with the unit. Despite these reports, Sir Terence English, then President of the Royal College of Surgeons, recommended that the unit at Bristol should not only “retain designation but recommended they should be pressed to increase the workload”. Both the Department of Health (DOH) and the Welsh Office were made aware of the situation at Bristol and also took no action. But there existed a national shortage of paediatric cardiologists, which was described by the British Medical Association as “unacceptable” in 1988 and “perilous” in 1992. This shortage was particularly acute in the South West area, due to there being few large hospitals in the area and none in Wales. This may go some way to explaining why it is that no action was taken regarding Bristol’s poor record.
The situation among nursing staff was no better. During the late 1980s and early 1990s there were only two Registered Sick Children’s Nurses (RSCN) at the BRI in Wards 5A and 5B. Nurses were often asked to give conflicting advice to parents due to the consultants doing their rounds at different times. Parents were expected to be involved in the care of their children and one mother even told of how she nursed another mother’s boy, as well as her own daughter.
By any criteria this is a hospital service in a state of collapse. Yet the report states that what went wrong at Bristol could not have been caused by a lack of resources, because other UK hospitals are in a similar position and do not have the same bad record.
This is a truly astonishing submission to make and a devastating indictment of the state of health care generally in the UK.
Professor Kennedy has stated that the scandal at Bristol could be repeated elsewhere and could even be happening now. But having acknowledged the enormous difficulties faced by the health service nationally, his report dismisses this as a significant factor. Despite the gravity of the situation revealed at Bristol, the suffering of those involved and the time and energies of thousands of people expended during the inquiry, the declaration that cuts are no excuse will help to ensure that no fundamental changes will be forthcoming and millions will be left dependent for their lives on wholly inadequate NHS provision.