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What the doctors got wrong
Bristol Royal Infirmary
Several doctors were criticised
The Bristol Inquiry may have focussed on serious flaws in the hospital but it also condemned some of the individuals involved.

Mr James Wisheart - medical and clinical director

Mr Wisheart was attacked at being "too close to the issues to act objectively as a manager and a director".

The report says that he "would have had great difficulty separating the personal from the professional".

It adds: "It is no surprise that his response was denial and inaction.

"He lacked the insight to understand or admit the inherent conflict of interests in which he found himself."

He was part of the 'club culture' which fostered a sense of 'them and us'

Bristol Inquiry report on James Wisheart
The report also says he found plausible explanations for poor results, and did not accept results, and in particular his own, were poor until "very late in the day".

It adds: "He was part of the 'club culture' which fostered a sense of 'them and us'", which meant junior colleagues were reluctant to come to him with concerns.

As a manager, he failed to show leadership, and he misled the trust board about results achieved in paediatric cardiac work - warranting "strong criticism."

He also failed to tell a special meeting about the care of Joshua Loveday, one of the babies who died, that an independent review of children's heart surgery was planned.

As a clinician, the report says Mr Wisheart should have recognised his lack of objectivity and introduced some form of checking system on the specialty.

He should also have seen the need for, and provided, better clinical leadership.

Janardan Dhasmana - 'the second surgeon'

The report does not examine Dr Dhasmana's role in as much detail as that of his colleagues.

It finds he was wrong not to tell the parents of Joshua Loveday, one of the children who died, about the clinical meeting prior to the operation, and whether they wished the surgery to go ahead.

"He was, in short, wholly caught up in his surgery.

"He should have displayed a wider vision and told Joshua's parents about the surgery."

But the report adds it acknowledges and appreciates the regret Dr Dhasmana expressed when he gave evidence to the inquiry.

Dr John Roylance - chief executive of Bristol Royal Infirmary

The report looks at Dr Roylance's role as a manager.

It says his behaviour was initially characterised by inaction.

It also attacks him for relying too heavily on Wisheart.

He was criticised for not acting on concerns raised by Dr Bolsin in a 1990 letter - though they may not have been expressed "sufficiently clearly or strongly"

His decision to leave the supervision of children's heart surgery to Dr Wisheart could be said to be "appropriate", but his advice could be seen as "inevitably tainted by personal involvement".

And the fact he did not get involved in deciding whether the operation on Joshua Loveday should go ahead, was consistent with Roylance's style of management, but showed the "rigidity of his thinking", the report concluded.

After Joshua died, he rightly instigated an independent review. But he was wrong to assign the organisation of that review to Dr Wisheart.

Dr Steve Bolsin - anaesthetist and whistleblower

Dr Bolsin's role has been lionised and attacked. But the inquiry says that although he did not follow the usual route for raising concerns, the "oblique way" he proceeded was understandable.

Steve Bolsin: whistleblower
Steve Bolsin: whistleblower
Mr Wisheart occupied two of the three "wise men" positions - the people clinicians would normally go to with concerns - making it difficult for Dr Bolsin.

The report says: "The difficulties he encountered reveal both territorial loyalties and boundaries within the culture of medicine and of the NHS, and also the realities of power and influence".

It concludes: "While Dr Bolsin's actions may not always have been the wisest, and sometimes he gave mixed signals, such as his assurance ... that all was well, he persisted and he was right to do so."

Margaret Maisey - the trust's nurse advisor and director of operations

Mrs Maisey described herself as the "Rottweiler of the trust".

In effect she was Dr Roylance's "eyes and ears".

The report says that despite being the trust's nurse advisor, she gave too much time to her other role as director of operations.

It says: "The nursing staff were let down by Mrs Maisey."

Department of Health

The Department of Health also comes in for some stinging criticism in the report.

When whistleblower Steve Bolsin took his data to Dr Doyle, a senior medical officer, "he did not read it but put it away in a filing cabinet without further scrutiny."

The report deems that "a seriously inappropriate response."

Dr Doyle, it says, should have both examined the data and acted on it.

Full coverage of the Bristol heart babies inquiry report

Government response

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Key figures

Parents' stories

Background briefing


Bristol year by year
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