Letters

More on the Bristol affair

The affair has had several serious negative outcomes

Audit was secret yet not confidential

Audit was not secret

What went wrong and how can we move forward?

Look at this case again

The affair has had several serious negative outcomes

EDITORBolsin's audit of the Bristol surgeons' work in 1990-2 was first seen by them in May 1995 after it had been widely reported in the media. It was then found to be flawed.¹ Bolsin's article also contains several errors,² to some of which I have already responded. ^{1 3} I was surprised, for example, that he still denied that his audit had been secret, for he had referred to it in those terms at the General Medical Council's inquiry (day 7, 23 October, p 102 of transcript). I note too that he now claims that his audit started in 1991²; when asked at the inquiry whether his data could have been used by Private Eye in April 1992,⁴ he categorically denied starting data collection and analysis before the late summer of that year (see the inquiry's transcripts for day 6 (22 October, pp 81-6) and day 7 (pp 16-20, 24).⁵

It is difficult to understand Bolsin's motivation for continuing to attack the Bristol surgeons after the GMC's harsh determination in June 1998. Until May 1995 he was for seven years a vital member of the surgical team. Anaesthetists share responsibility during cardiac bypass operations for keeping patients alive and their brains well perfused. Has Bolsin ever considered whether he may himself have contributed to the disappointing outcome among 4% of the surgeons' cases (see day 7 of inquiry's transcripts, p 42).⁵

Bolsin has been hailed as a "courageous whistleblower." ⁴ But his unilateral approach to the Department of Health in January 1995 had no positive influence on paediatric cardiac surgery in Bristol. The highly effective improvements to the service, first requested by the surgical team in 1989, had been agreed by the trust several months earlier and were already being implemented.¹

There were, however, several serious negative outcomes. Bolsin's kind of whistleblowing has been sanctioned and even encouraged. Morale and trust among colleagues have been damaged. The public's confidence in the profession has been undermined. The willingness of doctors to perform high risk interventions to save life, or to undertake honest and open clinical audit, must have been eroded. Critics have been provided with ammunition to attack the profession and hasten changes in regulation, some of which may not be in the best interests of the service. Worst of all, the breach in confidentiality that resulted has led to the opening of emotional wounds among bereaved and grieving parents. These, then, are some of the legacies of this sorry affair to which Bolsin himself has made such an important contribution.

Peter M Dunn, Emeritus professor of perinatal medicine and child health. 
University of Bristol, Southmead Hospital, Bristol BS10 5NB P.M.Dunn{at}bristol.ac.uk

1. Dunn PM. The Wisheart affair: reply to Dr Bolsin. eBMJ 1998;317. (www.bmj.com/cgi/eletters/317/7166/1144#EL12 [23 December 1998].)
2. Bolsin SN. The Wisheart affair: responses to Dunn. BMJ 1998; 317: 1579-1580[Free Full Text]. (5 December.)
3. Dunn PM. The Bristol affair. BMJ 1998; 317: 1659-1660[Free Full Text]. (12 December.)
4. MD. Doing the rounds. Private Eye 1995 May 4:12.
5. MD. Doing the rounds. Private Eye 1992 May 8:13.

Audit was secret yet not confidential

EDITORGuidelines on clinical audit in surgical practice lay down several important points of principle and good practice.¹ Among the most important is confidentiality, whose rules bind "all members of the clinical team." This confidentiality should apply to data collection, analysis, and the meeting at which the audit is presented. General conclusions should of course be more widely available. The guidelines also state that all members of the clinical team must participate. Thus all parties concerned with the service being audited must know that the audit is being performed. If these basic principles are not respected mutual trust will be lost and the consequences may be disastrous.

The secret audit performed by Bolsin (and on which the General Medical Council's inquiry relied so heavily) fails these fundamental principles.² Prime examples of lack of confidentiality are the articles in Private Eye in May 1992 and 1995. ^{3 4} The first contained confidential audit data and the second claimed that Bolsin's secret audit "was first published in the Eye." ⁴ These data, whatever their state of reliability or completeness, were passed to others outside the team and outside Bristol, but they were not discussed with the paediatric surgeons or cardiologists, who knew nothing of the data collection until 1995.

Clinical audit must be carried out properly, and the data must be accurate and analysed appropriately. Dunn has already commented on the more than fivefold error in death rates in Bolsin's data for ventricular septal defect operations.⁵ Although Bolsin privately acknowledged the error in 1995, this did not become public until the GMC's inquiry in 1997. Since the inaccurate data had previously been leaked to the media, a recognised error was allowed to persist uncorrected in the public perception for at least two years. This emphasises the danger of inaccurate data collection with lack of confidentiality.

The guidelines also state that "audit meetings should be followed by action, when indicated, to improve clinical results." ¹ Bolsin's audit (not shown to the surgeons or chief executive until 1995) did not even achieve this objective. The organisational and structural changes, first proposed by the much maligned paediatric cardiac surgeons and their cardiologist colleagues in 1989, had already been set in train by mid-1994.

So what lessons can we learn? Among the most important is that audit must be governed by principles of good practice. Without them, results cannot be relied on and mutual trust is wantonly destroyed not only between healthcare professionals but also among the public.

Gordon M Stirrat, Professor of obstetrics and gynaecology. 
University of Bristol, St Michael's Hospital, Bristol BS2 8EG g.m.stirrat{at}bristol.ac.uk

1. Royal College of Surgeons of England. Clinical audit in surgical practice. 1st ed. London: RCS , 1989(Revised June 1995.)
2. Bolsin S. The Wisheart affair: responses to Dunn. BMJ 1998; 317: 1579-1580. (5 December.)
3. MD. Doing the rounds. Private Eye 1992 May 8:13.
4. MD. Doing the rounds. Private Eye 1995 May 4:12.
5. Dunn PM. The Wisheart affair: reply to Dr Bolsin. eBMJ 1998;317. (www.bmj.com/cgi/eletters/317/7166/1144#EL12 [23 December 1998].)

Audit was not secret

EDITORIn his letter on the BMJ's website Stirrat emphasises several points from the original document on clinical audit in surgical practice. ^{1 2} As the first national audit coordinator for the Association of Cardiothoracic Surgeons of Great Britain and Ireland I was well aware of the ground rules governing audit in clinical practice. He did not say that all of these points are qualified by the phrase "under normal circumstances." What was occurring in Bristol's paediatric cardiac surgery unit was not normal (in fact it was judged by the General Medical Council to have been serious professional misconduct), and consequently normal considerations did not apply.³

Stirrat should also know that the secret audit he refers to was authorised in 1992 by Professor Cedric Prys-Roberts, head of the university department of anaesthetics at the Bristol Royal Infirmary, and the results were shown to him on completion in early 1993. Professor Prys-Roberts immediately discussed the results with Dr John Roylance, then chief executive of the United Bristol Healthcare Trust (which included the Bristol Royal Infirmary). The results were also shown to Professor Gianni Angelini, head of the university department of cardiac surgery at the infirmary, Dr Chris Monk, director of anaesthesia at the infirmary (and a paediatric cardiac anaesthetist), Dr Sally Masey, senior paediatric cardiac anaesthetist at the infirmary, and Professor John Vann-Jones when he was the clinical director of cardiac services, which included paediatric cardiac surgery.⁴ To describe a survey that was circulated as widely as this at very high levels in the Bristol Royal Infirmary as secret shows a staggering but understandable ignorance on the part of Stirrat, who, of course, did not work at the infirmary. Both Professors Stirrat and Dunn were close friends of Mr Wisheart, and they may have allowed this to colour their appreciation of events. The editors of scientific journals may need to bear this in mind when considering publishing future material from these sources.⁵

I do not deny that the paediatric cardiac surgeons and cardiologists proposed structural changes to the service in 1989 and that they were implemented later. My concern was that the high mortality for some surgeons for several procedures exposed children to the risk of excess mortality from these operations at the Bristol Royal Infirmary after changes were proposed for whatever reason. I would like to think that I can take a small amount of the credit for some of the action that has resulted in the improvement in overall death rates in the new service at the Royal Bristol Children's Hospital compared with the service that existed in 1995 at the Bristol Royal Infirmary.

Stephen Bolsin, Director of perioperative medicine, anaesthesia and pain management. 
Geelong Hospital, Victoria 3220, Australia STEVEB{at}BarwonHealth.org.au

1. Stirrat GM. The Bristol affair: Auditsecret yet not confidential. eBMJ 1998;317. (www.bmj.com/cgi/eletters/7172/1579 [31 December].)
2. Royal College of Surgeons of England. Clinical audit in surgical practice. 1st ed. London: RCS , 1989.
3. Dyer C. Bristol doctors found guilty of serious professional misconduct. BMJ 1998; 316: 1924[Free Full Text]. (27 June.)
4. Bolsin SN. Professional misconduct: the Bristol case. Med J Aust 1998; 169: 369-372[Medline].
5. Dunn PM. The Wisheart affair: paediatric cardiological services in Bristol 1990-5. BMJ 1998; 317: 114-115. (24 October.)

What went wrong and how can we move forward?

EDITORDoctors can make mistakesthis is not the issue. The issue is how mistakes are dealt with. A problem addressed can be rectifieda problem concealed cannot. Our concern is that resistance to acknowledging problems in Bristol Royal Infirmary's cardiac unit blocked improvement. As early as 1983 the unit was seen as unsafe, and in 1989 it was identified as substandard.

How did Mr Wisheart, who was both medical director of the United Bristol Healthcare Trust and chairman of the hospital medical committee (both defendant and judge), react to these findings?

Even if a senior cardiac surgeon ignored his own unit's failings, was there no one in higher authority to bring them to his attention? In July 1992 the Royal College of Surgeons made its concerns known to the Department of Healthto no avail. In January 1995 not even a telephone call from the Department of Health could halt a non-emergencyand fataloperation.

Bristol was an avoidable tragedy and is not unique. Because of its limited remit the General Medical Council took us no nearer to finding out why the entire system failed. Neither does the GMC have powers to bring charges against doctors' competence. In other words, doctors have clinical freedom without clinical accountability.

What is the way forward? One way is through clinical audit. Although the Royal College of Surgeons is promoting league tables for coronary bypass grafting, we suggest that this audit system is open to abuse. For an effective model we need to look at present day Bristol for a transparent and accountable process.

Bristol's cardiac data are published on a website (www.ubht.org.uk). Collected prospectively, they cover a range of operations (not only coronary artery bypass grafting) and give a clear picture of the surgeons' competence. Surprisingly, this model operates in only five out of 40 cardiac centres, although it is not expensive to implement.

We know mistakes happen in spite of doctors trying hard. What we seek is an audit system which identifies problems early. Until audit is driven by patient benefit, not professional loyalties, mistakes will continue to be concealed.

Maria Shortis, Mother of child who had cardiac surgery in Bristol. 
Elisabeth Winkler, Mother of child who had cardiac surgery in Bristol. 
Constructive Dialogue for Clinical Accountability, 54 Alma Vale Road, Bristol BS8 2HS 101636.1720{at}compuserve.com

^a One child died in 1987 and the other, who was operated on in July 1998, recovered fully.

Look at this case again

EDITORCharlotte was born on the 12 March 1987 with multiple congenital heart defects. After the diagnosis was made she was placed into the care of Mr Wisheart. He did not have the arrogance you sometimes find in men of his standing, but he instead displayed dedication, gentleness, and honesty. My husband and I found him to be generous with his time, and he always ensured that Charlotte received the best possible care.

Mr Wisheart was particularly meticulous in planning the operations. Every consideration was taken into account. It was important that it was the best choice for the child. We were informed every step of the way; never were we misled or misinformed. The possibility of brain damage was mentioned, as were possible problems when removing children from the ventilator. There was also the uncertainty that until the heart is viewed directly the surgeon cannot be sure that the tests have shown every abnormality. We were aware of all these possibilities and more. The parents were also kept informed by the cardiologists and supported by the cardiac liaison officer.

In Bristol in 1988 open heart surgery for children was carried out at the Royal Infirmary. Diagnosis and closed surgery was done at Bristol's Children's Hospital. Charlotte's operation was carried out in June 1988, and her recovery was long and difficult. She died in March 1989.

The General Medical Council's findings showed these children did not die because of any lack of surgical skill. Many were desperately ill; it was our responsibility as parents not to rob our children of a second chance of life. It's because of people like Mr Wisheart who have devoted their lives to such matters that these chances are possible at all.

My husband, also born with multiple heart defects, was operated on by Mr Wisheart, when success rates were much lower. Robert is fit and healthy and looks forward to a long life with our children, Lucy and Christian. In all those years Mr Wisheart's dedication to those in his care has been constant, making himself totally accessible to staff, parent, and patient alike. We can argue Mr Wisheart's case because during the 20 years we have known him we've been privileged to see how he thinks, what he believes, and how he works.

Please look at this case again and look at it through open eyes.

Michelle Cummings, Mother of child who was operated on by Mr Wisheart. 
61 New Cheltenham Road, Kingswood, South Gloucester BS15 1UL