Medical Ethics: Routine operations brought tragic results

Heart surgery on children at Bristol Royal Infirmary now has one of the best outcomes in the country. But, as Elisabeth Winkler reports, just five years ago it had one of the worst, according to a report by the then President of the Royal College of Surgeons.

In 1988, when Dr Steve Bolsin became consultant anaesthetist at Bristol Royal Infirmary (BRI) he soon noticed that major heart operations on children were lasting up to three times longer than similar operations he had attended at the Royal Brompton in London - the longer the operation, the higher the risks - and that children undergoing relatively routine operations were dying. Statistics for 1988-89 appeared to suggest that the mortality of Bristol children's heart surgery was twice the national average.

Dr Bolsin was asked by the hospital's Professor of Anaesthesia, Professor Cedric Prys-Roberts, to produce a detailed audit of children's heart surgery over the next two years. The results, made available in 1993, showed the disturbingly high mortality rate for surgery to correct heart defects (A-V Canal procedure). In 1991, Helen Rickard and her partner, Andy, handed over their 11-month-old daughter Samantha to the care of James Wisheart, the hospital's most senior paediatric cardiac surgeon. He was also medical director of one of the NHS's largest trusts and chairman of the hospital management committee - in other words, his own boss.

Samantha was about to become the first of six A-V Canal operations (out of a series of seven) to end fatally. "Mr Wisheart drew us a diagram explaining the operation," said Ms Rickard, now 30. He was very quietly spoken and non-threatening. I felt drawn in by him - I thought he was wonderful."

Samantha went down to the operating theatre at 8am on 3 February 1991. At 2pm, her parents were told by a liaison nurse that they were having difficulty getting her off the by-pass machine and that the patches (used to repair the holes in her heart) needed to be removed and put back on again.

"At 4.00pm we were told that the surgeon couldn't get Samantha's heart to beat by itself. I said, `how long will they keep trying? When will they know when to stop?' The liaison nurse answered, `oh, the surgeons are very good, they know what to do'. I replied, `they might as well take her off the by-pass machine - she's gone.' I knew instinctively that she had died. Samantha died at 6.10pm. In the meantime Andy and I were going frantic. Wisheart came up and began talking but I broke in saying `she's dead', and he nodded. I screamed `no, no'. Even as I was screaming there was a voice in my head saying, `Helen, be quiet, this poor guy is trying to speak to you'. But I couldn't stop.

"The next two years were a nightmare and my relationship with Andy was destroyed. We were both leaning on someone bent double with their own pain. We had another child, Ben, but Andy never came to terms with Samantha's death. Just before the second anniversary of her death, Andy committed suicide. If I knew then what I know now both my daughter and husband might still be alive."

In 1992, Mr Janardan Dhasmana started doing switch operations, a procedure for unscrambling the major arteries. Of the 13 babies having switch operations, nine died. The mortality rates at Bristol for switch was 67 per cent. The GMC is investigating Mr Dhasmana's switch operations.

In July 1993, six cardiac anaesthetists wrote to ask for a formal review of the switch programme to be undertaken in view of the recent deaths of children undergoing the operation. This never took place.

In 1993, the Department of Health was informed of the situation in Bristol both by Dr Bolsin and Professor John Farndon, the professor of surgery. The department had funded the United Bristol Healthcare Trust pounds 2m for paediatric cardiac surgery in 1992. Dr Peter Doyle, senior medical officer at the Department of Health, asked the cardiac surgery department in Bristol to prepare a report. The report recommended the cessation of the switch programme and the appointment of a new children's heart surgeon.

In December 1994, a switch operation was listed for 18-month-old Joshua Loveday, to be performed by Mr Dhasmana. As late as the evening of the operation, there was a meeting to decide whether the operation should go ahead. It decided that it should. The operation took place the next day. Joshua died on the operating table.

In response, an external report was commissioned into Bristol paediatric cardiac services and at a meeting to discuss the report Mr Wisheart was described as a "higher risk surgeon". He carried out one more operation which ended in a fatality. On 1 May 1995, the day that the new surgeon, Mr Ash Pawade, took up his post in Bristol, Mr Wisheart undertook a non- emergency operation on an 18-month-old boy. During the operation the boy suffered severe brain damage and died a month later.

Ms Rickard, who is part of a parents' pressure group, Informed Consent, said: "NHS consumers have a right to know about a surgeon's operating record."

Later that year in November 1995, Mr Wisheart received the A Merit Award for services to cardiac surgery. This NHS incentive bonus is worth about pounds 35,000 each year. In the same year Dr Bolsin left the country with his family and now works in Australia. Mr Wisheart then turned to adult cardiac surgery. An independent inquiry, published in March 1997, found his adult mortality rate was four times higher than other surgeons in the unit. Shortly before the report was published, Mr Wisheart stepped down as medical director and retired from operating. Mr Wisheart describes himself as a man devoted to his work. He has said: "I've served the patients of the West Country for 22 years, literally body and soul."

As it prepares to start proceedings on Monday, questions are being asked as to whether the General Medical Council, the doctors' own watchdog, is the best place to investigate what William Waldegrave, the former Bristol MP, called, in a letter: "The BRI cardiac disaster."

Laurence Vick, of Tozers solicitors in Exeter, Devon, is representing 21 of the families in law suits against the United Bristol Healthcare Trust; seven of the cases are children who survived but were brain damaged. Mr Vick has sought leave to apply for a judicial review to have the GMC's powers reviewed in the High Court. "We have been very concerned about the lack of information and secrecy surrounding the GMC process," he said.

In a preliminary hearing this week, it was made clear that the GMC will not be looking at cases where children survived operations but with serious brain damage, regardless of the quality of life afterwards. "The way things stand at the moment," said the father of one of these children, now a four-year-old boy who now cannot hear, see or speak, "My son is counted as a success."