The Wisheart affair: responses to Dunn The Bristol cardiac disaster

I wish to express my disappointment and concern at the publication of Peter Dunn’s article.¹ The article raises several important points, which need to be addressed, and I feel that my knowledge and position in Bristol at the time give me some authority to comment.

Attitudes in Bristol

• The “many senior colleagues” referred to in the article are exhibiting exactly the same behaviour patterns that allowed the Bristol cardiac disaster to occur in the first place. These are lack of insight, failure of critical appraisal, and muddled thinking.

• In the first half of the article Dunn presents the case that there was not a problem but then asks, “Why wasn’t the responsibility of the hospital administration recognised?” This leaves unanswered the question “responsibility for what?” For allowing a problem not to develop? Was there or was there not a problem? I and others believe that there was a serious problem.

• If, as Dunn suggests, his three colleagues were treated unjustly, why did they not make use of the GMC’s appeals mechanism and appeal not just against the sentences but also against the verdict of the disciplinary committee?

Excess mortality for operations

Dunn asks, “Why were the surgeons judged only on a small selected fraction (4%) of their paediatric surgical workload during 1990-5?” I find his answer less satisfactory than the alternative explanation that the United Bristol Healthcare Trust only provided to the GMC’s disciplinary committee the details of the operations that it had requested at such short notice that the GMC was unable to deal with anything other than the operations for atrioventricular canal and arterial switch. Even in these limited cases the excess mortality for these two operations was sufficient for the disciplinary committee to reach its verdict.

However, we now learn that there were other operations with equally bad records for mortality. On 27 October, BBC television’s Newsnight disclosed that in Mr Wisheart’s series of operations for truncus arteriosis repair in patients under 1 year of age, nine out of 12 patients died. One of the survivors is Ian Stewart, who suffered massive permanent brain damage. The programme also reported that, in the series of operations for total anomalous pulmonary venous drainage, Wisheart also has an unenviable record. Thus Dunn’s suggestion that 96% of the paediatric cardiac surgical work for this period was acceptable is open to question.

In this context it may be important to note that an independent inquiry, commissioned by the United Bristol Healthcare Trust, into the adult cardiac surgical work of Mr Wisheart concluded that his risk adjusted mortality for adult cardiac surgery was four times that of his colleagues in Bristol.²

The inevitable conclusion is that the record for the paediatric operations used by the GMC inquiry was not the isolated imperfections that Dunn is suggesting in his article but may more truly represent a level of achievement in clinical activity that required urgent review and improvement.

Institutional considerations

• I agree that the failure of two cardiologists and one anaesthetist to give evidence to the disciplinary hearing gave the impression of guilt and that they should have been urged to give evidence to the GMC inquiry. Their attendance at the public inquiry will be compulsory and informative.

• The audit that Dr A Black and I carried out was never secret. The perception of secrecy was attributable to the lack of effective communication between the directorates of anaesthesia and surgery and may also be attributable to Mr Wisheart’s failure to recall some important meetings with myself, Professor John Farndon (at which contemporaneous notes were made), and Professor Gianni Angelini, where concerns about performance were expressed.

• The director of anaesthetics had always been used as the vehicle for channelling concerns expressed by the cardiac anaesthetists to the cardiac surgeons; it had been agreed as early as 1991, by a meeting of all cardiac anaesthetists, that I should “keep my head down,” as my audit activities were already attracting adverse criticism from the department of cardiac surgery.

• A proper audit of work was never conducted despite Dunn’s assertion, and this is evidenced by the alteration of the unit’s arterial switch data at the meeting on the night before the fatal operation on Joshua Loveday. Had a complete and full audit been undertaken before this, the correction of data at the last minute would not have occurred. Also, the miserable record for these operations would have been revealed at an early stage and possible lifesaving action taken. Mr Wisheart was asked on several occasions to provide a full audit of the unit’s activity but this was tragically never forthcoming; the reason for this omission has never been made clear.

• I agree that all members of the paediatric cardiological team agreed that the operation should go ahead. My argument was not medicopolitical but that there was an institutional problem in Bristol, which meant that the safety of the child could not be guaranteed if the arterial switch operation was undertaken in Bristol. When the question was put—“Should this operation go ahead in Bristol tomorrow?”—I was the sole dissenter, and I requested that my dissent from the view be minuted as I was sure that the child’s life was being jeopardised.

Bias and restricted reporting

The lack of insight shown by Mr Wisheart in comprehending the implications of his adult cardiac surgery (commented on by Treasure²) has, as reported by BBC1’s Panorama in July, now extended to the unit’s prior performance of paediatric cardiac surgery and beyond the three doctors involved. While I can understand the natural psychological defence mechanisms of denial and rationalisation exhibited by the three doctors, I am not convinced that this is justifiable in senior colleagues or warrants publication in the BMJ. I believe that the propagation of the emotional and biased views expressed in Dunn’s article does not reflect well on medical staff in Bristol or on the wider medical community in the United Kingdom.

The publication of such a one sided article in the BMJ is reminiscent of the time when, under legal threat from the United Bristol Healthcare Trust, the journal was prevented from publishing any letters or articles that had not been approved by the senior management of Bristol Royal Infirmary. This allowed the publication of a letter by Joffe, which glossed over many of the important criticisms that were being made at that time,³ but prevented the publication of a considered response from Dr Black and myself. I would like the editor to confirm to his readers that the threat of legal action by the United Bristol Healthcare Trust has now been lifted from the BMJ.