Professionalism/The Case of Wisheart, Dhasmana, and Roylance

Background
The Bristol Heart Scandal occurred during the mid-1980s through 1990s in Bristol, England when an alarming number of babies died as a result of having heart surgery at the Bristol Royal Infirmary (BRI). Dr. Dhasmana and Dr. Wisheart were the cardiac surgeons who performed the "switch" surgery on "blue babies", children born with their two main heart arteries transposed. Despite having a death rate of roughly 2 in 3 while the national average was 1 in 10, their boss, Dr. Roylance, the Chief Executive of the United Bristol Healthcare National Health Service (NHS) trust, allowed them to continue operating. Until Dr. Stephen Bolsin arrived at BRI as an anesthetist in 1988, staff members had not brought up their concerns with the surgeons or Roylance for fear that they would be fired or otherwise punished for criticizing influential doctors. Bolsin began documenting the death rates in October 1993 to substantiate his claim that Dhasmana and Wisheart should not be pediatric heart surgeons, drawing attention to BRI, but failing to cause any meaningful change due to systemic failings within the NHS. Conditions were finally investigated after Dhasmana recommended the switch operation for a patient during a time when the surgery was put on hold at BRI. The patient died as a result, sparking a series of inquiries that ultimately led to a General Medical Council (GMC) hearing. Wisheart and Dhasmana were found guilty of professional misconduct.

The Whistleblower
Upon joining BRI as a consultant anesthetist, Bolsin quickly noticed the surgeons were taking far longer to complete their operations than their colleagues in nearby hospitals. "When you're operating on the heart," Bolsin explained in an interview, "you're cutting off blood supply to the heart, and it starts to die. And obviously the longer you take when there's no blood supply to the heart, the less likely the heart is to work after the operation. So time is crucially important." On Bolsin's first day at the job, he helped Dr. Wisheart perform pediatric cardiac surgery on two patients, which would only have taken a morning at the Brompton Hospital, but Bolsin did not get home until after 9:00 at night. Both children were in poor condition after their operations when Bolsin returned to check on them later that night.

In August 1990, Bolsin wrote to Dr. Roylance with his concerns about the death rate at BRI. In response, he received a dismissive phone call from Roylance and was admonished by Wisheart for taking his complaint to someone outside the cardiac unit. Then in October 1993, Bolsin started to keep track of the number of children dying at the hospital and finds the death rate at BRI to be twice the national average. Upon bringing his unofficial audit to Gianni Angelini, a professor of cardiac surgery at Bristol University, Angelini confronted Wisheart and Roylance. When the switch operation and high mortality rate continued, senior medical office Dr. Peter Doyle asked the hospital trust for a review into cardiac surgery. After concern spread and BRI’s cardiac unit was dubbed the “killing fields”, heart operations at the hospital were temporarily stopped.

The Tipping Point
The death of 18-month-old Joshua Loveday finally brought attention to the conditions at BRI. In January 1995, an emergency meeting was held about Loveday's severe heart condition that required an arterial switch operation. Dhasmana was the assigned surgeon despite his survival rate for these surgeries being less than the national average. Bolsin attempted to have the surgery stopped because he knew the child would likely die. He involved the Department of Health who had officials contact Roylance, who ignored the request, allowing Wisheart and Dhasmana to operate.

On the night before the operation, the Lovedays met with Dhasmana, who had come directly from the meeting during which it was decided to carry forth with the operation on Joshua, but made no mention of this heated meeting. Bert Loveday, Joshua’s father, asked Dhasmana, “Can you do it?” to which Dhasmana responded that it was not a simple operation, but that he’d done enough of them to know what he was doing. Mandy Evans, Joshua’s mother, reports having a gut feeling that something was wrong as she felt unable to send her son into the operating room. According to Evans, one hospital staff member had a look of fear on his face but no one spoke up. Joshua's parents were never informed about BRI's poor record and he died on the surgery table, leading to national uproar.

Haunted by Joshua’s death, Bert Loveday became increasingly depressed. Though he had never gotten into legal trouble before, he participated in an armed robbery and received a 3-year sentence, during which he committed suicide. He was one of four “Bristol parents” to commit suicide.

Public Inquiry
In 1996 the parents of children who had undergone cardiac surgery in Bristol, organized and called for a Public Inquiry. The Inquiry did not officially begin until 1998 and was not published until 2001. The report highlighted poor teamwork and "too much power in too few hands." It also stated that the physical setup was inefficient and dangerous, the surgeons were on-site, but pediatric cardiologists were several hundred meters away in the children's hospital. Additionally, the operating room and intensive care unit were on different floors requiring transport by a busy elevator in potentially time sensitive situations. The report concludes with this statement "to a very great extent, the flaws and failure of Bristol were within the hospital, its organisation and culture, and within the wider NHS as it was at the time. That said, there were individuals who could and should have acted differently."

April 1995
The British Royal Infirmary (BRI) death rate for the switch operation was 66%, while the national average was only 10%. This information was suppressed by health officials fearing legal action and only one surgeon was sent to retrain. The British Royal Infirmary halts the use of the technique.

March 1997
Stephen Dorrell, health secretary, announces an inquiry into cardiac surgery at BRI. An independent review found Wisheart's open-heart surgery patients four times more likely to die than those treated by his peers.

April 1997
Roylance, Wisheart, and Dhasmana were summoned to give evidence to the GMC inquiry regarding 53 operations on babies between 1988 and 1995. Twenty-nine of these patients died and four were left with serious and lifelong brain damage.

May-June 1998
Roylance, Wisheart, and Dhasmana were found guilty of serious professional misconduct. Wisheart & Roylance had retired by this point and face no serious career impacts. Wisheart and Roylance are struck off the medical register. Dhasmana was banned from operating on children for three years and lost his job at the Bristol Royal Infirmary. Frank Dobson, health secretary, announced a public inquiry into pediatric heart surgery at RBI.

Oct 1998
The NHS offered parents of the children who died £20,000, parents rejected the money and stated it was "insulting."

June 2001
Dhasmana's ban for operating on children was renewed; however, he could now operate on adults under direct supervision.

Overall Outcome
This case brought to light a need for change within the medical field focused on professional self-regulation, clinical competence, and healthcare quality. At the world conference of general practitioners following the GMC inquiry, there was a shift from patients being passive recipients to active partners in all decisions. Additionally, the GMC inquiry sparked the movement to provide patients with data on the performance of doctors and hospitals as a whole. Other areas that remain a large focus for the future are the need for clear clinical trials, training doctors in advanced procedures, improving how doctors explain risks to patients, and the need for doctors to take action early when peers are facing difficulties.

Professionalism
Wisheart, Dhasmana, and Roylance neglected their professional duties to provide patients with an appropriate standard of care in the selfish pursuit to prove they were as qualified as surgeons in neighboring hospitals.

Although Bolsin eventually sacrificed his career in England to stop children from dying unnecessarily, a true professional would have stopped Wisheart and Dhasmana long before the case started gaining attention from parents demanding a Public Inquiry. Similarly, Dan Applegate, the Director of Product Engineering at Convair, a McDonnell Douglas subcontractor, had the opportunity to warn the public about the potentially catastrophic consequences of not properly fixing the door latching mechanism on the DC-10 plane which he was working on. Instead, he chose only to alert his superior to the problems with the design that he believed could result in catastrophic failure, but these concerns did not produce any change as the upper management felt making changes would drive up the cost too much. On March 3, 1974, a cargo door of a DC-10 airplane blew open and resulted in "the worst crash in the history of commercial aviation" at the time, leaving no survivors. Researchers believe that if his memo reached the media, it would have grounded all DC-10s until they were safely manufactured, preventing the crash and deaths altogether.

Dhasmana reflected on the surgeries saying, "unfortunately, at that time there were no clear guidelines. Every surgeon was doing the best available practice." Although it’s true that death rates rose at all hospitals while the operation was first being introduced, they decreased at all hospitals except at BRI. This quote from Dhasmana is strikingly similar to the formal non-apologetic statement released following the thalidomide tragedy. In 2012 Harald Stack, Grünenthal’s chief executive, apologized to families for the first time as he unveiled a memorial statue for the victims of Thalidomide. Despite his apology he refused to accept any legal liability for the effects of the drug his company created, claiming that thalidomide was tested according to the standards of the time and that nobody realized a drug could cross the placental barrier. In both cases the responsible parties claimed to have done everything by the standards of the time and never truly apologized for the suffering which followed.

A report led by Professor Ian Kennedy on heart operations at BRI blames the “club culture” of surgeons at the hospital, or an imbalance of power, with too much control in the hands of just a few individuals. Vulnerable children were not a priority at BRI or throughout the NHS. The report also accuses Dr. Wisheart of adopting an optimistic, rather than realistic, approach in justifying the poor surgery results.