In July 2001, Professor Sir Ian Kennedy published his report, 'The Inquiry into the Management of Care of Children Receiving Complex Heart Surgery at the Bristol Royal Infirmary'.1 This inquiry investigated the deaths of children undergoing heart surgery at Bristol Royal Infirmary. The report describes the failings in NHS organisation and culture, which meant that one-third of all children who underwent open-heart surgery at the hospital received less than adequate care. The following case study, written in first person, is told by Dr Phil Hammond,2 who joined the Bath GP training scheme in the late 1980s and in 1990 formed the whistleblowing3 comedy double-act 'Struck off and die' with Dr Tony Gardner.
Heard it on the grapevine
Although I'd heard rumours about the poor performance of an adult heart surgeon (nicknamed 'Killer') in Bristol when I was a house officer in Bath, there were no such rumours about paediatric heart surgery. When I spoke to one of my former consultants in November 1998, he said they had never heard anything bad about the Bristol unit until 1995, when the mainstream media finally caught up with Private Eye. However, he did say that when he worked at the Hammersmith Hospital in London in 1985, he noticed an abnormal referral pattern coming out of South Wales. Babies with more complex heart defects requiring surgery appeared to be bypassing the Bristol area. This was corroborated by an anaesthetist who worked on the paediatric cardiac surgery unit at Guy's Hospital in the late 1980s. He noticed that his unit, and the unit at the Royal Brompton Hospital, were receiving many difficult referrals from Cardiff and the South West. When he asked the referring doctors why they did not send them to the nearby unit in Bristol, he was told, 'Difficult cases die in Bristol. So we only send them the easy ones.' This pattern of doctors far away from Bristol realising there was something wrong with the paediatric heart surgery unit, but those closer not having a clue is one of the most perplexing things about the Bristol heart tragedy. A consultant paediatric gastroenterologist who worked at Bristol Children's Hospital told me: 'We honestly had no suspicion at all that anything bad was happening. I suppose it was because, although we may have been working in the same building, specialities often don't mix at all. I would know if someone was mucking up the endoscopes, but I wouldn't necessarily know about heart surgery.'