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.