Babies' deaths to transform British medicine

Twenty-nine babies died during or after surgery performed by James Wisheart and Janardan Dhasmana at Bristol Royal Infirmary between 1988 and 1995. Others were left seriously brain-damaged after heart surgery.

The longest hearing ever held by the British General Medical Council (the GMC, equivalent to the Medical Council here) found that the surgeons had continued to operate on children despite their poor success rate and without sufficient regard to the safety and best interests of their patients.

A consultant haematologist, Dr Stephen Bolsin, alerted the authorities to the poor standards in the Bristol case. Other witnesses said they had been afraid to come forward when they believed things were wrong.

The GMC found the two surgeons and the hospital manager, Dr John Roylance, guilty of serious professional misconduct. Mr Wisheart and Dr Roylance were banned from operating. Mr Dhasmana was banned from performing heart surgery on children for three years.

The case shook the British medical establishment. The British Medical Journal ran an editorial headed "All changed, changed utterly". It predicted: "British medicine will be transformed by the Bristol case."

The government set up a public inquiry. The GMC published an advice booklet, Maintaining Good Medical Practice, which emphasised that doctors should take action if a colleague's performance put patients' lives at risk.

The booklet and the general shock following Bristol had an immediate effect. In Britain the number of doctors being suspended rose from one to around 12 per month, according to the doctors' defence body, the Medical Defence Union. Most complaints related to an alleged lack of patient consent to various procedures. Before Bristol complaints against hospital doctors accounted for 20 per cent of all serious complaints. This figure has risen to 50 per cent.

Professional bodies representing doctors began a fundamental reappraisal of self-regulation. A paper from the British Medical Association, the Academy of Medical Royal Colleges and other medical bodies identified several gaps in the self-regulation procedure. Of course, they took the opportunity to press some demands concerning working conditions.

The scandal also injected urgency into the implementation of recommendations contained in a British government White Paper published last December, before the Bristol scandal. The White Paper announced a new Commission for Health Improvement which would have patient representation. It will visit hospitals every three to four years and have statutory powers to investigate concerns about clinical quality.

THE Senate of Surgery of Great Britain and Ireland issued guidelines on clinical performance in October. It supported the establishment of standards and guidelines; regular reappraisal of the competence of consultants; greater team work among those carrying out advanced medical procedures; more attention being paid to patients' perspectives; and the possible establishment of confidential means of reporting poor medical practice. The White Paper said hospital doctors would all have to take part in external audits from next year. Currently clinical audits are voluntary. The government also proposed publishing league tables of the death rate at hospitals. Doctors' performances could then be compared on a national basis and, according to the British Health Secretary, Frank Dobson, those with particularly poor results would be retrained or told to stop operating.

However, some doctors warned that these league tables and audits could be misleading, as the best hospitals would have the most difficult cases referred to them, but might therefore also have high death rates.

The same criticism is made of the plan to publish statistics on the quality of hospital operations. The best centres perform the most difficult operations and therefore have artificially high failure rates, specialists say. Statistics must be weighted to take these factors into account.

Indeed, the doctor who performed the exceptionally high number of Caesarean hysterectomies in Ireland is understood to have made precisely that argument, that the most difficult cases were referred to him, and this partly explained his high figure.