Sam Lee explores how one hospital’s malpractice sparked a nationwide conversation about the importance of ethics in the NHS, and led to a revolution in patient-doctor relationships.
*Content warning: Surgery, Death, Hospital controversies
Suppose your newborn child arrives with a heart problem that can only be fixed through major surgery. Handing your baby over, you are confident in the surgeons and team that have performed many of these operations before. You trust that they will take care of your child.
In the 1980s and ‘90s, hundreds of parents handed over their newborn children to undergo life-saving heart surgery at the Bristol Royal Infirmary. The tragedy that played out affected many lives and has profoundly impacted the NHS we know today.
To mend a broken heart
Normally, the right side of the heart takes deoxygenated blood from the body and pumps it to the lungs to be oxygenated. This blood then returns to the left side of the heart and is pumped out, back to the body.
Occasionally, children can be born with transposition of the great arteries1, whereby the vessels leaving the heart are swapped. Essentially, blood returning from the body is pumped straight back out without oxygenation in the lungs, and the oxygenated blood coming in from the lungs is immediately sent back to the lungs. This means oxygenated blood is not reaching the body, which will prove fatal unless corrected.
Open heart surgery, through the “arterial switch” operation, is required to swap these vessels over. Bristol Royal Infirmary was one such hospital that carried out these operations. In the late 1980s, a new anaesthetist arrived in Bristol and noticed that the arterial switch and other procedures were taking longer to complete2, and more children were coming to harm, compared with other UK centres.
Despite raising concerns, it wasn’t until 1998 that a public inquiry was instigated. It revealed failings far beyond the operating room and ultimately concluded that between 30-35 children died3 during cardiac surgery at Bristol that might have otherwise survived elsewhere.
A lasting legacy
The Bristol Inquiry accelerated the move from a paternalistic "Doctor knows best" relationship to a patient-centred dynamic4. Patients are now included in decision making, consulted at all stages, and treated as equals. The duty of candour (being honest and open when something goes wrong) has since become contractually enshrined for NHS staff and became a legal obligation in 20145. A necessity for the continued professional development of staff arose, alongside other recommendations, which have improved patient safety.
Bristol displayed the difficulties faced with raising concerns in the healthcare system. Despite improving mortality, the anaesthetist who first raised concerns emigrated to Australia after receiving threats.
In the wake of the 2013 Francis inquiry, "Freedom to Speak Up" Guardians were established6 in the NHS to enable staff to raise concerns. However, difficulties remain. Whilst failure to report concerns can result in disciplinary action, whistle-blowers could still be disciplined for undermining colleagues7 - a catch-22 scenario. Clearly, there is room for improvement.
For mortality to improve, the inquiry advised that fewer centres should be conducting paediatric cardiac surgery. The rationale being that surgeons would gain more first-hand patient experience, improving safety and achieving better outcomes.
After a protracted series of reviews, this move was suspended by the Health Secretary in 20138. Again, lessons from Bristol are still to be learnt.
Some 30 years on, the events of Bristol are still felt today. Bristol Royal Infirmary is now one of the leading centres for paediatric cardiac surgery in the UK, with mortality on par with other units. And while the moral, ethical, and political challenges it presents are still of concern, today's NHS has been shaped for the better by the recommendations that emerged from it. The patient is now, rightly, front and centre of our thoughts and efforts - for the betterment of the patient, and for the good of us all.
1. Martins, P. and Castela, E. (2008) ‘Transposition of the great arteries’, Orphanet J Rare Dis., 3 (27). doi: https://doi.org/10.1186/1750-1172-3-27
2. Savulescu, J. (2002) ‘Beyond Bristol: taking responsibility’, Journal of Medical Ethics, 28 (5), pp. 281-282. doi: http://dx.doi.org/10.1136/jme.28.5.281
3. Dyer, C. (2001) ‘Bristol inquiry condemns hospital's "club culture"’, BMJ (Clinical research ed), 323 (7306), p. 181. doi: https://doi.org/10.1136/bmj.323.7306.181
4. Coulter, A. (2002) ‘After Bristol: putting patients at the centre’, BMJ (Clinical research ed), 324 (7338), pp. 648-651. doi: 10.1136/bmj.324.7338.648
5. Wijesuriya, J.D. and Walker, D. (2017) ‘Duty of candour: a statutory obligation or just the right thing to do?’, British Journal of Anaesthesia, 119 (2), pp. 175-178. doi: https://doi.org/10.1093/bja/aex156
6. Hughes, H. and Churchill, N. (2017) ‘Speaking up in the NHS in England: the work of the National Guardian and NHS England’, Br J Gen Pract., 67 (658), pp. 198-199. doi: 10.3399/bjgp17X690581
7. Bolsin, S., Pal, R., Wilmshurst, P., and Pena, M. (2011) ‘Whistleblowing and patient safety: the patient's or the profession's interests at stake?’, Journal of the Royal Society of Medicine, 104 (7), pp. 278-282. doi: 10.1258/jrsm.2011.110034
8. Gallagher, J. (2013) Child heart surgery reform suspended. Available at: https://www.bbc.co.uk/news/health-22857214
From SATNAV Issue 24, pages 6 and 7.