- Thilini Nisansala Egoda Kapuralalage
A public inquiry is a review of an event or events that is conducted by the government body to find out what went wrong. Moreover, “an inquiry is a retrospective examination of events or circumstances, specially established to find out what happened, understand why, and learn from the experiences of all those involved” (Walshe, 2003). Bristol Royal Infirmary (BRI) inquiry is an example of inquiry which
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The inquiry is related to two teaching hospitals; the Bristol Royal Infirmary (BRI) and the Bristol Royal Hospital for Sick Children (BRHSC) and particularly the inquiry is related to congenital heart disease; babies with heart problems. The inquiry was carried out by a panel which was chaired by Professor Ian Kennedy from October 1998 to July 2001.
2. A summary of key information
2.1. Background information
The National Health Service, in 1984, designated the Bristol Royal Infirmary and the Bristol Royal Hospital for Sick Children as a centre to provide paediatric cardiac surgeries to the infants under 1 year old. The Bristol Royal Infirmary performed open-heart surgeries while the Bristol Hospital for Sick Children performed closed-heart surgeries. Compared to other paediatric units in UK, Bristol did not have the required standard to perform the surgery. However, the decision to designate a paediatric unit in Bristol mainly made due to geographic issues that the patients had to undergo (Weick & Sutcliffe).
2.2. Physical setting
Physical setting of the hospital and operation theatre play a pivotal part in the inquiry. The location of BRI is noteworthy and it is located two block away from the BHC. Bristol Royal Infirmary conduct open heart surgeries in their hospital, while Bristol Hospital for Sick Children conduct closed heart operations in their hospital. Although the BRI conduct open heart surgeries, they lack cardiologists and they are in the BHC (Weick & Sutcliffe).
The operation theatre and ICU of BRI are located in two different floors. The ICU can access through an elevator and the elevator is non-dedicated. After conducting the surgery, the children are moved to sixth floor until they are stabilized. Then they are moved to BHC for further care and treatments (Weick & Sutcliffe).
2.3. Administration and staff
The CEO, Dr John Roylance directed the regional health authority and hospital board. Simply, these two parties relied on Dr John Roylance. On the other hand, Dr John Roylance relied on Dr James Wisheart who was “a man of many trades, holding other positions in BRI such as associate director of cardiac surgery and the chairman of the hospital’s medical committee” (Weick & Sutcliffe). Furthermore, his patients were already on bypass before his arrival as he was normally late to his surgeries. In addition, Dr Janardan Dhasmana was another surgeon who was “described as self-critical, disengaged from his surgical team, and unaware of their importance as a “whole team. (Weick & Sutcliffe).
According to the experts, to maintain required expertise in the surgeries in a centre averagely 80-100 open heart surgeries should be conducted per year. But, the average case load of Bristol was lower than the minimal required cases. In addition, the performance of Bristol did not improve, while the performance of the all other centres began to improve. “Between 1988 and 1994, the mortality rate at Bristol for open-heart surgery in children under one was roughly double the rate of any other centre in England in five of the seven years. The mortality rate (defined as deaths within 30 days of surgery) between 1984 and 1989 for open-heart surgery under 1 at Bristol was 32.2% and the average rate for the other centres for the same period was 21.2%” (Weick & Sutcliffe). Furthermore, the mortality rate increased up to 37.5% by the end of 1990. Also, according to the data analysis from 1990 to 1995, Bristol had approximately 30 and 35 excess deaths (Weick & Sutcliffe).
3. Information about the issue
3.1. What happened?
3.2. How it happened?
The series of incidents happened because of several reasons. First is the poor organisation of BRI. Open-heart surgery service had been provided in two sites where they lacked the proper staff to maintain the required care and treatment to the patients. Second is the lack of physical resources. The BRI was doing only the surgery and later they transferred the children into the BCH for further treatment. This cause to another issue of poor team work where the staff was not involved in the surgery and treatments effectively. Also, the BRI was using the same ICU for both adults and children. Third is the lack of information sharing with the parents and they were unaware of the relevant information (Hindle, Braithwaite, Travaglia, & Iedema, 2006).
3.3. Who was involved?
Few key figures were involved in the issue and they were Dr John Roylance, Dr James Wisheart, and Dr Janardan Dhasmana. First, Dr John Roylance was the CEO of the hospital but he had mentioned that he was unable to interfere with the work that were done by the surgeons. Moreover, he “chose to ignore warnings from whistle blower Steve Bolsin about the standard of operations being offered to young children” (BBC, 2003). Second, Dr James Wisheart was the director of the BRI and he claimed in an interview with BBC Radio 4’s that “the babies who died suffered from serious conditions and most had additional complications. He believed he would be vindicated in time” (BBC). Third person who was involved in Bristol was Dr Janardan Dhasmana and he was number two to Dr James Wisheart. He was responsible for over 29 deaths. Also, four babies were left brain damaged after the surgeries (Woods, 1998).
3.4. Reasons to failure
There are several factors that caused the failure of surgeries at BRI. First is the poor team work which affects the performance of the work and final outcome. Effective team work plays a pivotal factor to succeed the surgery but it was absent at BRI. Second reason to failure is lack of openness. The system and culture of BRI was different and they did not encourage their staff to share their issues openly. “Those who tried to raise concerns found it hard to have their voice heard” (Kennedy, 2001). Third is the lack of human resources. There was a significant gap between the resources available at BRI and the required resources in the PCS unit. There were a shortage of staff from operating theatre and ICU. Furthermore, “the complement of cardiologists and surgeons was always below the level deemed appropriate by the relevant professional bodies. The consultant cardiologists lacked junior support” (Kennedy, 2001). Fourth is the lack of physical resources. The BRI and the BCH were located in two different places. The BRI conducted the surgeries and after that, the patients were transferred to the BCH for further treatment and care. In addition, the ICU at BRI was not properly organised and it was a mixed unit that cared for both adults and children (Kennedy, 2001).
3.4. Who discovered the problem?
The performance of pediatric cardiac unit began to concern in early October of 1986 by a professor of the University of Wales. He reported to the Regional Health Authority about the unit’s performance and the authority concluded that the problem was related to the volume of cases. In addition, Dr Stephen Bolsin, a consultant anesthetist who joined the Bristol hospital in 1988, found few issues with the performances. What he noted was that surgeries done in BRI took a long time than usual and the babies were kept under the by-pass machine for a long time (Weick & Sutcliffe).
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Apart from Bolsin’s complain to the colleagues, he reported this issue to Dr John Roylance, the CEO. But Bolsin did not receive positive reaction from the CEO about the issue. Moreover, a Pediatric Pathologist at Bristol wrote an article to report about the “post-mortem examinations of seventy-six Bristol children who had under gone surgery for congenital heart disease” (Weick & Sutcliffe). In 1989, the article was publish in the Journal of Clinical Pathology. According to the article, “29 cases of cardiac anomalies and surgical flaws that contributed to death” (Weick & Sutcliffe). Furthermore, several articles that criticised about the Bristol Paediatric were published in Private Eye (Weick & Sutcliffe).
3.5. Why did it go undetected for the period of time?
4.1. Patient-centered health service
Patients should be informed about the care that they are going to undergo. Several methods can be adhered to provide information to the patients. With relevant to the inquiry, it is evident that there were certain occasions that the communication between the staff and the parents was poor. During the treatments, some parents were given counselling, while some were not. However, “the United Bristol Healthcare Trust (UBHT) conceded in its evidence that the service it provided was insufficient to meet the needs of some parents” (Kennedy, 2001). Therefore, a good communication is required and the doctors should not judge what information should to be informed. It is parents who should make that decision (Hindle et al., 2006).
4.2. Safety and quality
A safe and quality environment should be created to the patients. In Bristol, the arrangements, the state of equipment and buildings, and the training of the staff did not meet the required standard and these things were possible to create a damage to the service. To mitigate this, the authorities should remove the barriers to a safe and quality service while promoting the openness and publishing required standard of quality and care (Hindle et al., 2006; Kennedy, 2001).
4.3. Healthcare professionals’ competence
Health service providers should possess the required standard of skills, expertise, and educational level. Furthermore, they are capable of good communication and team work. In Bristol, the system did not demand the professionals to keep their skills and knowledge up to date.
BBC. I’m not perfect, says Bristol surgeon Retrieved from http://news.bbc.co.uk/2/hi/health/568511.stm
BBC. (2003). The Bristol Babies Inquiry Retrieved from http://news.bbc.co.uk/2/hi/health/1148390.stm
Hindle, D., Braithwaite, J., Travaglia, J., & Iedema, R. (2006). A comparative analysis of eight Inquiries in six countries.
Kennedy, I. (2001). The report of the public inquiry into children’s heart surgery at the Bristol Royal Infirmary 1984-1995: learning from Bristol.
Walshe, K. (2003). INQUIRIES: LEARNING FROM FAILURE IN THE NHS? :
Weick, K. E., & Sutcliffe, K. M. Hospitals as Cultures of Entrapment: A RE-ANALYSIS OF THE BRISTOL ROYAL INFIRMARY.
Woods, M. (1998). Bristol heart scandal surgeon is dismissed Retrieved from http://www.independent.co.uk/news/bristol-heart-scandal-surgeon-is-dismissed-1197097.html
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