Why did no one stop these doctors killing so many of our children?

Surgeons failed to heed warnings from colleagues

THEY WERE dedicated and methodical heart surgeons applying their skills for the benefit of their patients. The tragedy was that their results were disastrous and they failed to heed warnings from colleagues.

That was the essence of the General Medical Council's case against James Wisheart, 60, and Janardan Dhasmana, 58. The doctors were not abusing their position, as are most who appear before the council's professional conduct committee.

They were hardworking, conscientious individuals doing their best - but their best was not good enough. Out of 53 babies operated on by the two doctors between 1988 and 1995, 29 died and four suffered brain damage. Many of the babies had Down's syndrome, which carries a high risk of heart defects.

The Bristol Heart Children Group, representing the parents, says it has identified 78 children who died and 13 who were brain damaged following operations by the two surgeons over a 10-year period from 1985. They claim 1,000 children may have been put at risk in what they call the "Bristol cardiac disaster".

Why were their results so poor? Why did they not heed the warnings from colleagues? Why, most importantly, did no one stop them when it became clear so many babies were dying? As Sandy Rundle - mother of Matthew, who died, aged 10 months, in April 1994 - said: "Someone must have the power to stop a surgeon. I find it hard to believe no one did."

Consultant anaesthetist Dr Stephen Bolsin, who first drew attention to the high death rate, noticed as soon as he arrived at the infirmary in 1988 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.

Dr Bolsin alerted Dr John Roylance, chief executive of the infirmary, to his concerns. Over the next six years these concerns were reiterated by other anaesthetists in the department, by the Royal College of Surgeons, by the professor of adult cardiac surgery at Bristol, Gianni Angelini, and eventually by the Department of Health itself. Yet the operations continued and babies continued to die.

Open-heart surgery requires a high level of skill, and in babies, especially, speed is of the essence. Both Mr Wisheart and Mr Dhasmana were in their fifties when they carried out the fateful operations and some say such surgery, with its enormous mental and physical demands, is a young man's game (although there are notable exceptions such as the heart transplant pioneer Sir Magdi Yacoub who is still operating at 60-plus).

One reason why they did not stop operating was because they believed they would get better. Mr Wisheart explained to the inquiry that there is a "learning curve" when a surgeon takes up a new procedure and it was common knowledge that other centres had experienced high fatality rates in the early stages.

A central issue to emerge from the case is that there were no benchmarks by which surgeons could judge whether their performance was acceptable and no guidance on training in new procedures.

Between 1990 and 1993, Mr Wisheart carried out 11 hole-in-the-heart operations on babies and five died - a mortality rate of 45 per cent. Over the next 18 months, he carried out a further four operations on young babies and they all died, raising his mortality rate to 60 per cent. At that point he stopped carrying out those operations.

A later review of 2,500 adult heart operations, which are not part of the GMC inquiry, revealed that here, too, Mr Wisheart's mortality rate was worse than that of his colleagues. Published in March 1997, it disclosed that four times as many of his coronary bypass patients died as did those who were operated on by the other surgeons - 12.2 per cent compared with 2.6 per cent.

Mr Wisheart, who had voluntarily stopped operating the previous December, announced his retirement from the NHS 24 hours before the review was published.

One of the many disturbing features of the case is that despite his apparently poor skills, Mr Wisheart rose to become one of the most distinguished surgeons in Bristol. He was made medical director of the United Bristol Hospital Trust - which had taken over the running of the infirmary from 1991 - and, in 1995, he was given an A merit award, worth about pounds 40,000 a year on top of his NHS salary for worldwide services to cardiac surgery. Merit awards are made on the recommendation of other senior consultants. What this reveals about the medical establishment will be a key question for the government inquiry that is to follow the GMC case.

Mr Dhasmana was a more able surgeon than Mr Wisheart, despite being his junior. His mortality rate for hole-in-the-heart operations was 10 per cent, better than the national average and far better than Mr Wisheart's. However, his skills were tested to their limit and beyond when, encouraged by Mr Wisheart, he began trying a new kind of heart surgery involving switching the main arteries in babies who are born with them reversed. Of the 13 new-born babies on whom he operated, nine died and one was left with severe brain damage. Nationally, the average survival rate was nine out of ten.

In their defence, the two surgeons argued that patients did not come with single problems, but with a mix of complications that made comparisons difficult. As the senior surgeon, Mr Wisheart would have been expected to take the riskiest cases. It was impossible to draw meaningful statistical conclusions from those included in the inquiry, they said.

Dr John Roylance, chief executive of the trust, took this argument a stage further. He accepted that Bristol's record was not as good as it should have been. That was why he pressed for a specialist paediatric cardiac surgeon, appointed in May 1995, and for resources to be concentrated in the children's hospital rather than the infirmary - demonstrating that he had taken steps to improve it. He pointed out that if there is a range of performance, someone has to be at the bottom. The question was when that became unacceptable. Once again the case exposed the absence of benchmarks or guidance.

The surgeons' poor results were only a part of the case against them. In addition to ignoring warnings from colleagues Mr Wisheart was also found to have misled the parents of his patients by quoting national survival rates instead of his own personal survival rate which was considerably worse.

Matthew Rundle's mother was told by Mr Wisheart that there was a 90 per cent chance that his hole-in-the-heart operation would be a success. But of the 13 previous children Mr Wisheart had operated on, seven had died - giving him a success rate of less than 50 per cent.

Did these claims amount to lies? Quoting success rates in the early stages of a new procedure is tricky for surgeons. If the first patient dies, do you tell the next that the fatality rate is 100 per cent? Faced with worried parents do you worry them more by quoting cold figures or try to reassure them? Mr Wisheart claimed that the number of patients involved was too small for talk about his personal success rate to be meaningful.

Dr Roylance, charged with failing to heed the warnings about the performance of the two surgeons, claimed that he had to rely on the clinical advice he was receiving - and Mr Wisheart was the medical director of the trust whose role included deputising for the chief executive. Although Dr Roylance happened to be a doctor, as hospital manager it was not his business to meddle in clinical matters.

One of the greatest puzzles of the case is the role of the other specialists at the Bristol Royal Infirmary. Despite the apparently poor record of the two surgeons, they continued to be sent patients for surgery. Why did the cardiologists continue to refer?

Success depends on the whole clinical team, not only on the surgeon who takes lead responsibility. It emerged during the case that, for some of the children, there was inadequate diagnostic information before the operations and, for others, poor post-operative care. Other consultants at the hospital who have not featured in the inquiry received warning letters from the GMC. A picture emerged of an institution in trouble.

Rudolf Klein, professor of social policy at Bath University, who has made a close study of the case, said: "This wasn't just about two incompetent doctors. There were problems with the whole set-up. The impression that emerges is of an enclosed culture run by people who had known and worked with each other for 20 years. I think what we are looking at is the pathology of an institution."

CASE PROVEN

James Wisheart

Witnesses who gave evidence to the GMC attested to Mr Wisheart's kindness, decency and honesty. He was described as dedicated by colleagues, open and sympathetic by patients. But it became clear during the hearing that he was not a man given to self examination and self- criticism - like many of his calling.

Mr Wisheart, who qualified in Belfast in 1962, arrived at the Bristol Royal Infirmary as consultant cardiothoracic surgeon in 1975.

He became chairman of the Hospital Medical Committee, and medical director of the United Bristol Healthcare NHS Trust in 1992.

CASE PROVEN

Janardan Dhasmana

In contrast to the assurance of his senior colleague, Mr Dhasmana was so concerned about his poor performance at the complex switch operations that he went twice to Birmingham, an acknowledged centre of excellence, to try to improve his technique. When that failed he stopped doing the operations.

Mr Dhasmana qualified in Lucknow, India, in 1964. He was appointed consultant cardiothoracic surgeon at Bristol Royal Infirmary in January 1986, and is the only one of the three who is still employed by the United Bristol Healthcare NHS Trust. He now works as an adult cardiac surgeon.

CASE PROVEN

Dr John Roylance

Most NHS managers are not doctors and therefore fall outside the remit of the GMC. It was Dr Roylance's misfortune that he happened to be medically qualified and therefore found himself charged with his colleagues.

Dr Roylance, a consultant radiologist who qualified in Bristol in 1954, was an NHS manager for the last 10 years of his professional life until he retired in October 1995. He was a supporter of the Tory NHS reforms and became the first chief executive of the United Bristol Healthcare NHS Trust in April 1991. He inherited problems and colleagues say he worked hard to pull it round.

Suggested Topics
Life and Style
tech
Sport
Farah returns to the track with something to prove
Commonwealth games
News
John Barrowman kisses his male “bride” at a mock Gretna Green during the Commonwealth Games opening ceremony
peopleBarrowman's opening ceremony message to Commonwealth countries where he would be sent to prison for being gay
Voices
voicesGood for Lana Del Rey for helping kill that myth, writes Grace Dent
PROMOTED VIDEO
Have you tried new the Independent Digital Edition apps?
News
ebookA unique anthology of reporting and analysis of a crucial period of history
Sport
Shinji Kagawa and Reece James celebrate after the latter scores in Manchester United's 7-0 victory over LA Galaxy
football
Arts and Entertainment
The Tour de France peloton rides over a bridge on the Grinton Moor, Yorkshire, earlier this month
film
Life and Style
fashion Designs are part of feminist art project by a British student
News
Very tasty: Vladimir Putin dining alone, perhaps sensibly
news
Life and Style
Listen here: Apple EarPods offer an alternative
techAre custom, 3D printed earbuds the solution?
Arts and Entertainment
Top guns: Cole advised the makers of Second World War film Fury, starring Brad Pitt
filmLt-Col Steven Cole is the man Hollywood calls when it wants to borrow a tank or check a uniform
News
Snoop Dogg pictured at The Hollywood Reporter Nominees' Night in February, 2013
people... says Snoop Dogg
News
The University of California study monitored the reaction of 36 dogs
sciencePets' range of emotions revealed
Arts and Entertainment
A scene from Shakespeare in Love at the Noel Coward Theatre
theatreReview: Shakespeare in Love has moments of sheer stage poetry mixed with effervescent fun
News
Joining forces: young British men feature in an Isis video in which they urge Islamists in the West to join them in Iraq and Syria
newsWill the young Britons fighting in Syria be allowed to return home and resume their lives?
Arts and Entertainment
The nomination of 'The Wake' by Paul Kingsnorth has caused a stir
books
Independent
Travel Shop
the manor
Up to 70% off luxury travel
on city breaks Find out more
santorini
Up to 70% off luxury travel
on chic beach resorts Find out more
sardina foodie
Up to 70% off luxury travel
on country retreats Find out more
Latest stories from i100
Have you tried new the Independent Digital Edition apps?
Independent Dating
and  

By clicking 'Search' you
are agreeing to our
Terms of Use.

iJobs Job Widget
iJobs General

IT Transition Manager - Stirling - Banking - £400

£400 - £420 per day: Orgtel: IT Transition Manager - Banking - Scotland - £400...

General Cover Teacher

£100 - £105 per day: Randstad Education Cardiff: Secondary Teachers of all sub...

Associate Recruitment Consultant

£18000 - £23000 per annum + OTE: SThree: SThree are a global FTSE 250 busines...

English Teacher

£110 - £130 per day + Pay between ?110 - ?130 Day: Randstad Education Cardiff:...

Day In a Page

Screwing your way to the top? Good for Lana Del Rey for helping kill that myth

Screwing your way to the top?

Good for Lana Del Rey for helping kill that myth, says Grace Dent
Will the young Britons fighting in Syria be allowed to return home and resume their lives?

Will Britons fighting in Syria be able to resume their lives?

Tony Blair's Terrorism Act 2006 has made it an offence to take part in military action abroad with a "political, ideological, religious or racial motive"
Beyoncé poses as Rosie the Riveter, the wartime poster girl who became a feminist pin-up

Beyoncé poses as Rosie the Riveter

The wartime poster girl became the ultimate American symbol of female empowerment
The quest to find the perfect pair of earphones: Are custom, 3D printed earbuds the solution?

The quest to find the perfect pair of earphones

Earphones don't fit properly, offer mediocre audio quality and can even be painful. So the quest to design the perfect pair is music to Seth Stevenson's ears
US Army's shooting star: Lt-Col Steven Cole is the man Hollywood calls when it wants to borrow a tank or check a military uniform

Meet the US Army's shooting star

Lt-Col Steven Cole is the man Hollywood calls when it wants to borrow a tank or check a military uniform
Climate change threatens to make the antarctic fur seal extinct

Take a good look while you can

How climate change could wipe out this seal
Should emergency hospital weddings be made easier for the terminally ill?

Farewell, my lovely

Should emergency hospital weddings be made easier?
Man Booker Prize 2014 longlist: Crowdfunded novel nominated for first time

Crowdfunded novel nominated for Booker Prize

Paul Kingsnorth's 'The Wake' is in contention for the prestigious award
Vladimir Putin employs a full-time food taster to ensure his meals aren't poisoned

Vladimir Putin employs a full-time food taster

John Walsh salutes those brave souls who have, throughout history, put their knives on the line
Tour de France effect brings Hollywood blockbusters to Yorkshire

Tour de France effect brings Hollywood blockbusters to Yorkshire

A $25m thriller starring Sam Worthington to be made in God's Own Country
Will The Minerva Project - the first 'elite' American university to be launched in a century - change the face of higher learning?

Will The Minerva Project change the face of higher learning?

The university has no lecture halls, no debating societies, no sports teams and no fraternities. Instead, the 33 students who have made the cut at Minerva, will travel the world and change the face of higher learning
The 10 best pedicure products

Feet treat: 10 best pedicure products

Bags packed and all prepped for holidays, but feet in a state? Get them flip-flop-ready with our pick of the items for a DIY treatment
Commonwealth Games 2014: Great Scots! Planes and pipers welcome in Glasgow's Games

Commonwealth Games 2014

Great Scots! Planes and pipers welcome in Glasgow's Games
Jack Pitt-Brooke: Manchester City and Patrick Vieira make the right stand on racism

Jack Pitt-Brooke

Manchester City and Patrick Vieira make the right stand on racism
How Terry Newton tragedy made iron men seek help to tackle their psychological demons

How Newton tragedy made iron men seek help to tackle their psychological demons

Over a hundred rugby league players have contacted clinic to deal with mental challenges of game