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The Bristol heart babies Friday, 5 November, 1999, 09:33 GMT
Bristol: Surgery may not be to blame
wisheart at work
Dr James Wisheart's skills may not have been at fault
Operating table failures by surgeons may be only a minor factor in the grim toll of death and disability among children with heart defects treated at the Bristol Royal Infirmary, say experts.

The Bristol Heart Babies
Instead sub-standard care both before and after the operation, and even lack of resources could have been a bigger factor in many of the cases of at least 170 children who died or were left disabled following treatment at the hospital.

The inquiry heard on Wednesday that Bristol, when compared with 11 other major heart surgery centres, had by far the worst results for open heart surgery on babies - but this new analysis suggests that factors other than the operative skill of shamed surgeons James Wisheart and Janardan Dhasmana may not be to blame in most cases.

Professor Stephen Evans, a consultant statistician, was a member of an expert group that conducted a clinical review of the way the hospital treated 80 children with heart defects - 40 of whom died.

He told the inquiry that 50% of the children in the study - which focused on particularly complex cases - had received less than adequate clinical care.

Death or disability avoidable

In one in three cases death or disability could have been avoided if overall care had been up to scratch.

But Professor Evans' team considered a report drawn up by two paediatric specialists that showed that an alternative approach to surgery might have improved the outcome in only nine out of 100 operations examined in the review.

Other factors in the majority of cases were:

  • Mistakes in the initial assessment and diagnosis
  • The wait between diagnosis and surgery
  • Operating theatre mistakes made by anaesthetists
  • The quality of care post-operatively in the intensive care unit

The waiting time between initial diagnosis and surgery might have been influenced by lack of resources, said the report.

On the basis of the review cases, Professor Evans said the expert team had calculated that 170 out of the 1,827 cases being considered by the public inquiry had received less than adequate care that might have contributed to death or disability.

Sub-standard clinical care can cause brain damage, respiratory problems and liver and lung damage.

Professor Evans said: "I think it is clear that there is a pattern over the whole of care that was the problem, particularly in regard to open heart surgery.

"It is more like a system failure, than surgery failure."

The authors of the report wrote: "When care was considered to be less than adequate in any patient there were a number of aspects that appeared to have an even greater influence on poor outcome than the actual operation. These involved all specialities in the service.

Intensive care crucial

"It was of particular note that pre-operative factors would often set the scene for a sequence of events which would lead to poor outcomes, and that post-operative care on the ITU was a major determinant of outcome."

The report did pick out recurrent problems in the technique of surgeons which could have been significant in some cases. In particular, the operations on some babies took far longer than usual - the reviewers said the speed of working would have been more customary two decades ago.

The BRI public inquiry follows a General Medical Council disciplinary hearing in which BRI surgeons Mr Wisheart and Mr Dhasmana, and former BRI chief executive Dr John Roylance, were found guilty of serious professional misconduct.

The GMC inquiry examined 53 operations in which 29 patients died and four were left brain injured.

See also:

01 Nov 99 | The Bristol heart babies
04 Nov 99 | The Bristol heart babies
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