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Ann Thorac Surg 2001;71:1403-1404
© 2001 The Society of Thoracic Surgeons
a Gorsehill, 3a Southfield Rd, Westbury-on-Trym, Bristol BS9 3BG, United Kingdom
To the Editor
As the two cardiac surgeons found guilty of Serious Professional Misconduct by the General Medical Council (GMC) on June 18, 1998, we welcome the Editorial written by James L. Monro [1]. The profession, and in particular cardiothoracic surgeons, who have had little information other than that available in the press and media, should have access to information that is both detailed and accurate. Our purpose in writing is to clarify further some issues raised by Mr Monro and to draw attention to one or two others.
The GMC hearings and verdict focused on the complete atrioventricular septal defect (AVSD) operations performed by Mr Wisheart and the arterial switch procedures carried out by Mr Dhasmana; for each of us this amounted to 3% of our pediatric cardiac surgical practice. There was no criticism of the remainder of our practice. The eventual verdict was based on three AVSD operations, two neonatal arterial switch procedures and one switch operation in an older child [2].
That the results for these two operations were worse than those in other units at the time was known by us and was not in dispute. The question was, "Why were the results worse?" Initially there were charges against each of us that the operations " ... were beyond the limits of your clinical competence and technical expertise," but these were rejected by the GMC. Case-mix and risk stratification were major issues before the GMC. The experts on both sides agreed that there were a disproportionately high number of significant additional risk factors in the small series of patients under consideration, but this did not apparently influence the Professional Conduct Committee in reaching their verdict. Here is another lesson: risk stratification must be given due weight in outcome assessment. Otherwise, not only will some surgeons be wrongly criticized, but more importantly, and as Mr Monro points out so clearly, high-risk patients may suffer by being denied operations.
The GMC found that serious concerns had been expressed by colleagues which, it was alleged, were disregarded. The evidence before the GMC on this point was at best contentious. One operation only, the switch operation in January 1995 on an 18-month-old child, followed what could have been regarded as an expression of concern. In response to those concerns, two meetings of the full clinical team, in December 1994 and in January 1995, considered whether proceeding with the operation was in the child’s best interest; only then was it scheduled and carried out. The results of switch operations in nonneonates in our unit were presented and found to be within the range of published outcomes and were accepted by all as satisfactory. Without presuming to anticipate the findings of the Bristol Royal Infirmary Inquiry (BRII), it is clear from the evidence given to it, and available on the Internet [3], that these concerns were not articulated to us or to our pediatric cardiological colleagues before the final stages of this affair.
The editorial states, "The operations had continued until, following the death of a child in January 1995, they were stopped and another surgeon appointed." This is not correct. Mr Dhasmana made his own decision to stop doing the neonatal switch operation in October 1993, and Mr Wisheart stopped correcting complete AVSDs in the autumn of 1994. The circumstances of the operation in January 1995 have been described in the preceding paragraph. Bristol’s first full-time pediatric cardiac surgeon was appointed in September 1994 in recognition of the need to improve the pediatric cardiac surgical service for the future.
The United Kingdom Cardiac Surgical Register (UKCSR) is one of the prized achievements of the specialty in the United Kingdom. Sadly, it has been criticized for lack of validation and potentially significant inaccuracies [4, 5]. The importance of this is that information from the UKCSR has been the comparator against which our results have been judged. If the comparator is unreliable to a significant extent, how valid are the comparisons?
Mr Monro points to the need for a "whistle-blower" to be able to act without fear. We agree absolutely that any colleague should be able to raise issues openly and fully in a constructive forum, with the goal of improving patient care. In Bristol we had a multidisciplinary audit process that was evolving, thorough, openly undertaken, and provided such opportunities regularly.
Rhetorically, Mr Monro asks why the pediatricians continued to refer patients to the Bristol surgeons. The answer lies in their knowledge of the results and the patients. The cardiologists joined with the surgeons in regular audits of the results and in a detailed review of each patient who died; thus they were familiar not only with the figures but also with the individual cases making up those figures. For example, the arterial switch data were formally presented on at least three occasions between June 1992 and January 1995. The Hospital Trust published the pediatric cardiac surgical results for 1990 to 1995 in January 1996 [6]. In commenting on them, Mr Marc de Leval stated that "the Bristol performance over the last 3 years in terms of mortality matches with the average U.K. results as published by the U.K. Cardiac Surgical Register, including open heart surgery in infants, with the exception of the results of AVSD and arterial switch procedures" [6].
Not everything was right at Bristol and there are lessons to be learned, but the reporting of what happened has been inaccurate and distorted to an alarming degree. Finally, we would like to draw your attention to the remarks of the Legal Assessor to the committee of the GMC before it retired to reach its verdict. He said, "You have heard evidence that all the practitioners before you are of unimpeachable character. Their integrity and their commitment to the interests of patients have not been questioned. Their honesty in giving evidence has not been challenged" [7].
References
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