Alarm unheard or unheeded?

Helen Stratton began to feel uneasy about Bristol Royal Infirmary's paediatric cardiac surgery six months after she started work there in 1991.

Her job as a liaison sister was a newly created role in the unit, so she decided to compare notes with nurses in similar posts in Birmingham and London. She quickly realised that children in similar units spent less time in theatre, less time in intensive care, and apparently had a greater chance of survival.

'The majority of my role seemed to be spent on bereavement counselling and dealing with distressing situations. When I asked the other nurses whether it was the same for them, they said no.'

Further disquieting thoughts about the unit's performance started when she attended two study days at which senior surgeons showed slides illustrating mortality rates at various units performing the same paediatric cardiac procedures carried out at Bristol Royal Infirmary.

Each graph showed an ominous 'outlier' - a unit with a much higher mortality rate than the rest. The surveys were anonymous, but Ms Stratton had a strong feeling that the children represented by the peaks in the graphs were dying in Bristol.

She started to keep a record of the operations undertaken on her patients, noting the time spent in theatre, time spent on by-pass machines and in intensive care - and whether or not the child survived.

The notes in her 'red book', which were handed in as evidence to the General Medical Council hearing, confirmed her suspicions, but it was very hard to get colleagues to admit to themselves that something might be wrong.

Senior nurses she spoke to said the unit received all the difficult cases. Of course the unit - as a regional centre - was admitting very sick children, but she could find no reason to believe the case-mix was different from that of other regional centres she had visited.

'I felt very isolated until I had a discussion with Steve Bolsin. He was an anaesthetist and very much involved with the children when I took them to theatre. I found he shared my concerns. It was like meeting a fellow soul.'

Dr Bolsin had started to raise the issue of mortality rates and met the same blank wall as Ms Stratton. She told him about the notes she was keeping and about her conversations with nurses on other units.

'We spent many evenings at his house with Maggie, his wife, saying 'What are we going to do about this?''

The burden, she felt, was greater on Dr Bolsin because he was actually anaesthetising the children for hours on end in the theatre. She decided to stop going down to the theatre.

'I felt I was in league with 'them',' she recalls. 'Parents used to say, 'See you later' to their babies, and I used to stand there thinking, 'No you won't'.'

She explained her change of routine by saying she found the theatre handovers too distressing. 'They probably thought it was a weakness.'

But stopping the handovers did little to relieve the general stress of working life on the unit. She still found herself talking anxious parents through the long hours of surgery described at the hearing, believing that the procedure would be performed more swiftly and effectively at another centre.

She said the child would go down at 8am and not be back before 9pm. 'At Birmingham they were back by lunch or early afternoon, depending on the complexity of the procedure.'

Denial of the problems was a constant theme. Ms Stratton recalls one dreadful weekend when she and Dr Bolsin were on duty and did 'a ward round from hell'.

They found three children whose parents had been told they were doing well after their operations when in fact none of them was doing well, and they were destined either to die or live on with brain damage.

Dr Bolsin and Ms Stratton sat down with each set of parents and told them the truth about their child's condition. The bad news came as a great shock to them.

'The reason we found the ward round so difficult was that we had to decide whether to leave the parents or tell them. It was an emotionally exhausting afternoon.'

Among nursing colleagues, too, Ms Stratton found an endemic feeling that 'nothing could be done'. She is not unsympathetic to their situation. She says the unit existed in an atmosphere in which nothing changed unless surgeon James Wisheart said so. She recalls being reprimanded by Mr Wisheart when she suggested that a frightened teenage boy should go home because his psychological state was too poor to cope with a serious operation he was due to undergo.

She had used her judgement and consulted the hospital chaplain, but Mr Wisheart took her aside and told her not to interfere with his clinical practice. The boy's parents accepted her advice and he had his operation later at another unit.

'Unless you have an understanding of how hospitals run, you don't know that it's impossible to go and knock on someone's door and say that something has to stop.'

Ms Stratton, who left Bristol in 1994 and now works in medical communications, says many of her nursing colleagues were married and bringing up children. They did not want to rock the boat.

'It's all very well for people to say, 'Why didn't you do something about it?', but it's not as easy as that.'

In fact, when those evening discussions with the Bolsins reached a conclusion, it was decided that Ms Stratton's name would be left off any reports, letters and memos. Given the status of nursing, especially in the cardiac surgery unit, they agreed her signature would not help the cause.

'I think that's very sad and I don't agree with it, but I was very happy to work in the background because I knew this course of action would be more productive.'

She regrets that the whole affair has done nothing to improve the position of the whistleblower. Dr Bolsin felt forced out of his post and now works in Australia.

He still works as a consultant anaesthetist, but has paid the high price of being far away from extended family and friends.

'It doesn't make it any easier for the nurse on the ward to stand up and say, 'This is wrong'.'

The positive effect, she believes, is that the case has already prompted changes at the clinical level and there is more general acceptance that rigorous clinical audit is vital to patient safety. She encounters many consultants in her new job who spontaneously mention that new audit procedures started 'after all that cardiac business'.

She is entitled to some satisfaction at the knowledge that her 'red book' made a contribution to that change.