First lessons from the “Bristol case”

Abstract

On May 29, as Sir Donald Irvine, President of the UK General Medical Council, prepared to read out the preliminary decision on three doctors charged with serious professional misconduct, the silence of the packed chamber was broken by a man in the chamber gallery shouting “This is a damage-limitation charade”. The man, Jim Stewart, who was hastily removed from the chamber by police, has a son who underwent cardiac surgery at the Bristol Royal Infirmary and is now brain damaged. The doctors facing the charges are two cardiac surgeons and the then chief-executive of the United Bristol Healthcare Trust. They stood accused of proceeding with paediatric surgical procedures, despite excess mortality and morbidity among their patients, and despite concerns raised by their colleagues. The 8-month “Bristol case”, as it has come to be known, is the GMC's lengthiest and most complex. Stewart's outburst symbolised the high emotions that have surrounded the investigation, and contrasted with the expressions of quiet shock on the faces of the doctors as Sir Donald proceeded to declare that the Committee had indeed found sufficient evidence to support a finding of serious professional misconduct for each clinician (see p 1707). The final judgment, however, has not been made, and the GMC is to hear testimony on the doctors' characters and previous work later this month. Nevertheless, the inquiry deserves scrutiny. From the GMC Committee's judgments on a detailed breakdown of the charges, several key issues emerge. First, in the case of both surgeons, James Wisheart and Janardan Dhasmana, there was a conspicuous lack both of self-audit and of willingness to seek and obtain retraining. Second, in the case of chief-executive John Roylance; there was an unwillingness to use the power of a managerial position to intervene in clinical activities. Third, all three clinicians, at some point, ignored the concerns about excess mortality expressed to them by professional colleagues. What has also become clear from the intense media storm surrounding the GMC case is that professional bodies outside Bristol, such as the Royal College of Surgeons and the Department of Health, were aware of the poor success rates in paediatric cardiac surgery at Bristol, yet either failed to act or did not use their position of authority to apply consistent pressure to force a change in practice. Formal action was taken only after a consultant anaesthetist, Stephen Bolsin, “blew the whistle” on his colleagues. Bolsin has since taken up a post in Australia, and claims that he would be unable to practise in the UK as a consequence of his actions. Indeed, he said in an Australian radio interview last year “I was seen as the problem rather than the death rate being seen as the problem”. Clearly, if Bolsin's quote accurately reflects the prevailing culture at Bristol at the time—and that culture might currently be in place at any hospital in the UK—medicine is in serious need of reform. In recent months, various organisations such as the GMC, the British Medical Association, and the Royal College of Surgeons have been falling over themselves in the scramble to announce actions they have undertaken to ensure that there are no more Bristol cases. The “action statement” of the British Medical Association reads “The profession intends to take a lead role in achieving change towards a culture of openness and critical self appraisal which will render the need for ‘whistle-blowing’ obsolete.” However, statements on how these various bodies will work together to impel whistle-blowing's obsolescence, are less forthcoming. Traditional rivalry between the various professional bodies may be the undoing of their laudable intentions. The picture that emerges from the Bristol case is one in which many professionals, from nurses in the operating theatre to government officials, were aware that there was a problem. Yet there was no clear chain of command and communication to ensure that the difficulties were remedied at the earliest possible point. If the organisations that regulate the medical profession do not put their heads together now and create a system to pick up—and deal with—problems in clinical practice as they emerge, the Bristol story is bound to be retold elsewhere. Professional self-regulation cannot be left entirely to the disciplinary function of the GMC—by then it will often be too late.