`I trusted the hospital and my baby died'

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The Independent Online
THE mother of a baby who died after heart surgery seven years ago will tell a panel of two men and two women today why the experience has destroyed her trust in doctors.

Tracey Clarke, 36, will be the first witness to give evidence to the Bristol Royal Infirmary Inquiry, which is set to be the longest and most emotionally harrowing investigation into a medical disaster.

Graham and Tracey Clarke's daughter Melissa was one of hundreds of children who underwent complex heart surgery at the infirmary between 1984 and 1995, the period under investigation. She was 11 months old when she was operated on in October 1991 and died 10 days later.

Her surgeon was Janardan Dhasmana, one of three doctors found guilty of serious professional misconduct by the General Medical Council last year. It concluded that the three doctors - Mr Dhasmana, James Wisheart and John Roylance, who was the hospital's chief executive - had ignored warnings from colleagues and allowed the operations to continue for too long when they should have known that their death rates were too high.

Mrs Clarke, from Tiverton, Devon, said in an interview last year that the details of her baby's operation had been kept from her, that the success rate had been exaggerated and that Melissa had been brain-stem dead on a ventilator for two or three days before she was told there was no hope for her.

"There are so many questions that we want answered," she said. "This is why we need a public inquiry. It is more than the actions of the three doctors that need looking into. What about the other doctors who saw Melissa and referred us to Dhasmana, despite knowing what was going on? What about the nurses and other staff who said nothing?"

For six years the Clarkes believed that Melissa had had an arterial switch operation, in which the blood vessels supplying the heart - which have been transposed at birth - must be "switched" back again. Last year's GMC inquiry looked at two types of operation, the switch and hole-in- the-heart surgery, and involved 53 babies, of whom 29 died and four were brain damaged. It was only when the Clarkes were told they had been excluded from the GMC inquiry that they learnt their daughter had had a different operation, called a Senning, which, had she lived, would have necessitated further surgery in her teens.

The Clarkes believe that both pre- and post-operative care may have contributed to Melissa's death. They say Mr Dhasmana told them the operation had a 90 per cent chance of success, and that, even after complications had set in, she had a 70 per cent chance. "I put her life in their hands. I put my complete and utter trust in that hospital. I will never trust a hospital or a doctor again," said Mrs Clarke.

The GMC investigation was limited to a narrow range of operations, where the evidence was strongest, and focused on the doctors. The public inquiry will broaden the focus to include the institution in which they worked, other staff, the Royal Medical Colleges and the Department of Health, all of which are accused of failing to act to protect patients.

The inquiry, chaired by Ian Kennedy, professor of health law and ethics at University College London, is expected to hear evidence from about a dozen parents during its first two weeks. Later it will consider evidence from the doctors and other staff. Hearings are expected to continue in Bristol until the end of the year and will be followed by a series of seminars elsewhere.

The inquiry report is likely to be published in mid to late 2000.