The scandal of babies and children dying unnecessarily or being left brain damaged as a result of heart surgery at Bristol Royal Infirmary came to light after anaesthetist Steve Bolsin raised concerns about operations at the hospital in the late 80s and 90s. To mark the tenth anniversary of the publication of the public inquiry report into the scandal, the whistleblower shares his views of what happened exclusively with the Evening Post

November 1988

ONLY the hands of the surgeon, the scrub nurse and the operating theatre clock were moving. They were all moving slowly.

The senior surgeon, James Wisheart, wore the grey plastic headdress of an operating headlight and large surgical magnifying glasses over a blue paper hat and green surgical gown.

Shiny plastic tubes carrying bright red blood ran over the drapes from the surgical field to the perfusion pump. White swabs provided a sharp contrast to the uniform green of the sterile field. Some of the swabs were stained red with blood from the patient’s wound. The wound in this case was a harsh, deep cut in a small chest, outlined by cruel-looking silver metal retractors ratcheted open to reveal a child’s beating heart.

A smooth-running, well-trained team was performing paediatric cardiac surgery, but the consultant anaesthetist was still worried.

He knew it had to be done quickly. He knew there was no time to waste now.

He wanted the surgeon to complete the operation, not to talk to him or the medical students, who were supposed to watch and learn and be taught.

This child needed a complex cardiac operation and the whole process needed to go as smoothly and quickly as possible for him to survive intact. He had to try to protect the child.

Steve felt that now was not the time for talking or teaching; now was just a time for operating as quickly and as well as possible before the cardiac cells in the child’s heart started to die.

And he was becoming only too well aware that wasted time now could kill this child.

He feared that every minute the cross-clamp remained on this child’s aorta without the operation proceeding was valuable time wasted and could lead to serious complications. Steve willed James to keep operating. He failed.

“I have listed this as an arterial switch operation,” James said.

“I know that we will also have to repair this child’s VSD. I hope that there is no more to this child’s condition than either the cardiac catheter films or the ultrasound scans have definitively demonstrated, because I have limited experience with the ‘switch’ operation. In fact, this is my first.”

The arterial switch operation would effectively disconnect the aorta and the pulmonary artery from the right and the left ventricles respectively and reconnect them the other (correct) way round.

The major technical difficulty in this operation is that the arteries supplying blood to the heart, the coronary arteries, arise so close to the heart that they must be separately reconnected to the new aorta, and the most challenging part of all is the small size of the vessels in babies.

Steve suspected that this may be why Mr Wisheart was carrying out his early arterial switch operations on larger children, like this six-year-old, and not on the neonates and infants who had been the usual candidates for the operation when Steve had worked at the Brompton in London.

Steve had told the gathered group of students that he would make sure Mr Wisheart went over the complex procedure with them after the operation and not during it.

But he had gone further. Today, for the first time, he had told the students that if he thought Mr Wisheart’s teaching was jeopardising the safety of the child he would signal them to leave the operating theatre.

This was the only way he could think of to reduce some of the delays that seemed to be occurring during these major operations.

Steve was already very worried about the length of time the operations in Bristol appeared to take and the number of deaths and complications that he had seen. He was prepared to do anything he thought reasonable to speed up the operations, and reducing pleasant, time-consuming conversation and medical student teaching was one thing that he could do.

They needed to get on with the operation. Steve signed to the medical students to leave.

The perfusion technician was looking serious and worried. He had added more blood to the pump and was trying hard to control the consequences of the long operation, but it was proving difficult.

Steve discussed the problems with him and suggested some possible solutions. They both quietly agreed that what was needed was a rapid end to the operation so that they could get the child back to the intensive care unit. The clock indicated that it was now mid-afternoon and they had been working since before 8am.

Finally the patient could be re-warmed to normal temperature and finally, hopefully, the bypass could be ended.

The operation was moving into the later stages. Soon the cross-clamp would be removed.

The heart still had to be weaned from the bypass machine; they still had to try to stop the bleeding; they still had to get the chest closed and they still had to get the child to the intensive care unit; but the worst part of the operation was over.

Survival was by no means guaranteed and the recovery was still at a very early stage, but they were re-warming the little patient.

The circulation was restored. Many minutes passed while the clock looked down and the tiny, damaged heart did nothing.

It continued to do nothing when James tapped it with his instruments to try to make it beat. When it did contract, all it managed was ventricular fibrillation. This was more bad news. A heart that beats is in much better condition than a heart that can only fibrillate.

Steve gave anaesthetic to the perfusion technician, checked the blood gases and pH again and prayed that the heart would beat after the next defibrillation.

The combination worked and the heart started to beat slowly when they next defibrillated.

The child would need pacing wires to help manage the heart rate after this operation, but at least that would give the team a bit more control. Now his task was to increase the strength of contraction of the heart to the point at which it would support the circulation for the body.

All the staff waited, watched, prayed and hoped. The scrub nurse looked exhausted; the perfusion technician was drained; James was quiet and downcast; Steve was nervous and watched the screen like a hawk.

He requested small volumes of blood from the pump when the blood pressure dropped and the heart needed more filling. This was a bad sign, but they all knew that if the patient had to go back on bypass the chances of survival would be very much reduced.

Incredibly, slowly but discernibly, the child’s condition stabilised. The heart beat more strongly, albeit with more support, but at least it did not look as if he would have to go back on bypass.

Soon, after the skin wound was stitched, cleaned and dressed, the surgical drapes would be removed and the child that they had all been operating on would be exposed again. Then Steve would be supervising the transfer of the little patient upstairs to the cardiac intensive care unit two floors above.

Later, the anaesthetist drove the short distance from his home in Redland back to the hospital to arrive at 10.30pm and was surprised to see James Wisheart already in the ICU. Usually if the child was progressing satisfactorily James went home and came back closer to midnight. If James was worried about the patient he would stay in his office and work, but available to advise the surgical registrar immediately if necessary. Only for matters of extreme urgency would he come to the bedside on the ICU.

Steve looked at James and reported his findings for discussion of further management plans.

“So we have evidence of heart failure with a high oxygen requirement, significant inotrope requirement, signs of mild pulmonary oedema and also signs of early peripheral oedema,” Steve said.

“My feeling is that he is coming to the end of the postoperative honeymoon period and things will get more difficult overnight.”

“Well, he’s done very well so far. Technically the operation was a complete success,” James offered to Steve and Peter’s mother. “I’m reasonably pleased with the progress so far.”

At 1am Steve was woken at home by the telephone. Nick, the anaesthetic registrar, was calling him because Peter had become very unstable, with a low blood pressure and worse blood clotting. When Steve arrived on the ICU ten minutes later, he immediately saw that the child’s abdomen was distended and tense like a drum and deduced that he must be bleeding into his abdomen, but could not imagine why such bleeding should have suddenly started.

Steve made rapid arrangements to transfer the boy downstairs to the operating theatre with blood products and blood clotting factors ready for immediate transfusion.

James Wisheart prepared to open the chest and abdomen. As soon as the abdomen was open, more than a litre of blood and clots, equivalent to most of the circulating blood volume of the child, was sucked from the cavity and the bleeding point easily identified.

One of the drains had been put directly through the left lobe of the liver, causing a large laceration. This laceration had caused the postoperative problems that Steve and the team had subsequently experienced.

James did what he could at the second operation and Steve gave lots of blood and clotting factors to the small boy. Now Peter needed more drugs to support his heart than before and he was a much sicker child than when he was last in theatre. They eventually managed to get him back to the ICU, but it was morning and they had been up all night. Steve had an afternoon ophthalmology list to complete and the patients to visit before their operations, so he went home to have a quick shower before the ICU ward round at 8am.

On the ward round, Steve was surprised by the number of children being operated on in the unit and also by how sick they became after their operations. He saw things he had never seen before.

There were large numbers of children with brain damage after heart surgery, children whose chests could not be closed after surgery because of the swelling of their hearts during the operation and high rates of renal failure.

This morning he was more worried about Peter than the other ward round attendees were, so he visited him before they started. Peter seemed to have continued on his perilous course after the operation in the early hours.

When he returned to the ICU late in the afternoon Steve was surprised to see that the ICU bed where Peter had been nursed was empty. At first he thought that he had been moved to another, long stay bed and looked to see if there was a child in the isolation room at the end of the ward, but there wasn’t. Then one of the nurses explained that he had died two hours earlier, with the bleeding never fully controlled from the early morning operation.

Steve almost cried in the ICU, but managed to control his emotions. He shed his tears quietly, climbing homewards up the hill.

“There has to be some way to deal with this,” he thought.

EDITED BY VICKI MATHIAS