The Wisheart affair: paediatric cardiological services in Bristol, 1990-5BMJ 1998; 317 doi: https://doi.org/10.1136/bmj.317.7166.1144 (Published 24 October 1998) Cite this as: BMJ 1998;317:1144
- Peter M Dunn, emeritus professor of perinatal medicine and child health
Many colleagues, patients, and friends of James Wisheart, Janardin Dhasmana, and John Roylance will have been deeply shocked by the unjust way in which the three men have been treated. Every sympathy is due to those who have lost loved ones. However, whereas doctors will readily understand the aggressive grief that some parents have shown, their anger should surely be reserved for the news media (and their informants) that have misdirected this grief against the Bristol surgeons using a sustained stream of biased, misleading, and often inaccurate information. And the defendants' explanations remained almost entirely unreported after they presented their case.
The Wisheart affair has had an immense impact on the public's confidence in doctors and on the morale of the medical profession in the United Kingdom
Several very senior colleagues of the three defendants, who are close to the Bristol scene, share a grave concern at the way in which the surgeons were tried by the media and found guilty by the General Medical Council's professional conduct committeeacting as prosecutor, judge,and jury
While it is essential that the GMC should continue to regulate the medical profession, its disciplinary process requires urgent modification
Hopefully, next year's public inquiry will resolve these concerns
Finding the charges proved
In June 1998 the professional conduct committee of the General Medical Council announced that it had found the charges proved. But what charges? Few appreciate that many of the original charges against the surgeons, including those of clinical and technical incompetence, had either been quietly dropped or were found not proved. The disputed charges that remained were diminished in substance, some to the point of being tenuous or capable of being levied at any practising doctor.
The legal assessor to the committee advised it to be sure that the facts were true, that no other registered medical practitioner observing proper standards current at the time would have acted similarly, and that any falling short from proper standards had been serious. It was emphasised that the word serious applied to the falling short and not to any consequences such as death or brain damage.
Why then did the professional conduct committee under the chairmanship of the president of the GMC, Sir Donald Irvine, make what, in the light of the advice of the legal assessor, many would regard as a perverse judgment? This committee of seven members (two of them lay people)contained no one with experience of cardiac surgery. Only a simple majority was required to find the charges proved. The GMC was known to be keen to show to politicians and the public that it could be safely trusted to regulate and discipline the medical profession. In addition, the council had been repeatedly accused by the media of being overprotective of doctors. Huge sums were invested by the GMC on this high profile “trial” lasting nine months. The members of the committee, like everyone else, had already been exposed to the trial by media. The pressure to find the defendants guilty must have been almost irresistible.
Questions that need answers
Many questions about the conduct of the inquiry require explanation, of which the following are but a few.
Why were the surgeons judged only on a small selected fraction (4%) of their paediatric surgical workload during 1990-5? Was this because the outcome of 96% of their work did not differ significantly from that of other paediatric surgeons in the United Kingdom?
How was the professional conduct committee able to disregard the fact that Stephen Bolsin made serious errors in his secret audit and never discussed his concerns about the atrioventricular septal defect or switch operations with Wisheart, Dhasmana, or the three paediatric cardiologists before the scheduling of the Loveday operation early in 1995?
Why were two of the three cardiologists and the anaesthetist who knew most about the true facts of the case not called by the GMC to give evidence? Such evidence on who told what to whom and when was absolutely crucial to the judgment as to where the truth lay in this disputed area. Indeed, the GMC actually went further and issued the cardiologists and anaesthetist with warning letters, which made it very difficult for the defendants to call them as witnesses, especially as lawyers acting for the cardiologists andthe anaesthetist had strongly advised them to keep a low profile.
Why did the professional conduct committee ignore the request that risk stratification should be taken into account when judging Wisheart's mortality figures and his advice to parents? Eleven of his 15 patients with atrioventricular septal defects had additional complications, not all of which were known preoperatively; three of the patients had complications that were regarded, in retrospect, as virtually inoperable. In the light of this information, how was the committee able to conclude that Wisheart should have stopped performing operations three patients earlier than he did, as originally charged?
Why was Dhasmana found guilty of failing to seek sufficient retraining for the switch operation when he had twice sought help and advice in Birmingham from one of the country's leading paediatric cardiac surgeons, who in the event gave expert evidence to the committee?
Why were the surgeons alone held responsible for any deaths that took placewhen cardiac surgery—perhaps more than any other surgical discipline—is a well recognised team effort in which anaesthetists, cardiologists, radiologists, technicians, and nurses have a crucial role before, during, and after surgery?
How could the charge of failing to conduct a proper audit of their work, and even of an attempted cover up of poor results, be found proved against the cardiac surgeons when it was shown that their standard of audit (which included regular audit meetings, open discussions of necropsy findings, and the reporting of results to a central registry) was far superior to that of almost all other medical disciplines at that time?
Why was the manager, Roylance, charged at the same time as the surgeons when the charges against him had no substance unless and until the surgeons had been found guilty? Was this not suggestive that the GMC had prejudged the issue?
Why was Roylance found guilty of failing to stop the operation on Baby Loveday in 1995 when a meeting of nine members of the paediatric cardiological team had unanimously advised on clinical grounds that the operation should go ahead? Bolsin alone disagreed, but for medicopolitical reasons.
Why did Sir Donald Irvine not step down from chairmanship of the committee when the barristers for the defence requested this after confronting him with evidence from the transcripts of his repeatedly showing bias against the defendants?
Why did the committee not comply with its normal practice of giving its verdict (determination) shortly after announcing the finding of facts? As might be and was anticipated, the two week delay provided the news media and others with the opportunity of giving vent to their own views and judgments, entirely to the detriment of the defendants.
Why wasn't the responsibility of the hospital administration recognised? For many years (and in particular from 1989 to 1990) Wisheart had been trying to have paediatric cardiac surgery moved from the adult to the children's hospital in Bristol, where all the supportive paediatric staff worked. He was told that there was no spare money and that the move must wait until the new children's hospital was completed (in 2000). Yet the decision to make this move was taken and the necessary funds were eventually found in mid-1994 and the move was made in October 1995. Similarly, Wisheart had been actively seeking for many years the appointment of a full time paediatric cardiac surgeon to whom he would hand over all his work on infants and children. Because of lack of finance and poor operating facilities, this appointment also was achieved only in September 1994 (first incumbent appointed in May 1995).
Why was the failure of the government to provide the financing necessary for such a high tech service never mentioned? Not only was the hospital's healthcare budget being cut in real terms year after year but after 1989 the normal process of providing health care was distorted by the introduction of the internal market.
Acting in patients' interests
Wisheart is a courteous, compassionate, and hardworking doctor of the highest integrity who, since he came to Bristol in 1975, has succeeded in building up the cardiac surgical services for both adults and children in the south west. The professional conduct committee stated in its judgment: “We have considered very carefully the extensive evidence of the care and dedication you have shown to many patients. We accept that, over many years, you have worked hard in their service. We also accept that there is no evidence that you ever had any intention of acting other than in your patients' interests.” Yet in spite of this he was still found guilty by the committee of serious professional misconduct and struck from the medical register, since when he and his colleagues have faced public calumny. After many years of faithful service to his patients and to the health service, this dedicated and caring man has been hounded in public as a murderer.
Similar remarks could be made about Dhasmana, who has also given his best endeavour to the Bristol service and to his patients over many years. Roylance, too, has devoted his whole medical career to Bristol, first as a consultant radiologist and then as chief executive to the trust.
Few doctors would disagree with the view that the GMC is best placed to regulate the medical profession, provided that in highly specialised areas, such as cardiac surgery, peers from the same specialty are always included on the professional conduct committee. However, the quasi-legal process of the committee needs to be overhauled. It is an offence to justice that the committee should act simultaneously as prosecutor, judge, and jury. Inquiries into the performance of doctors should aim at getting at the facts and should not be conducted as an adversarial criminal trial. Without the protection of the contempt constraints normal to legal courts, the activities of the GMC are open to abuse from the news media. This too needs to be changed. Then the terms of any appeal made against the GMC's judgment also requires review.
The confidence of the public in the medical profession has been badly damaged by this affair and by its handling by the GMC. So, too, has the morale of doctors. If justice is to be done, confidence restored, and doctors are not to act defensively in the future the forthcoming public inquiry must set the record straight.
I thank the many senior medical colleagues in Bristol who have given me their advice and support.