Although anesthetist Dr. Stephen Bolsin made his anxieties about high death rates known to colleagues in 1991, the Bristol babies tragedy only came to the public's attention in 1995, when the Bristol Royal infirmary (BRI) admitted that it had halted a pioneering technique for infant open-heart surgery after nine out of 13 babies died over an 18-month period in the early '90s. This chronology follows the controversy from its beginning through developments that unfolded after Innocents first aired in the United Kingdom in 2000.
Dr. Stephen Bolsin joins Bristol Royal Infirmary. He notices that children's heart operations last up to three times as long as they should, and that babies are dying from routine operations.
Dr. Janardan Dhasmana performs 38 arterial switch operations; only 18 patients survive.
Dr. James Wisheart performs 13 atrioventricular septal defect, or "hole-in-the-heart," operations. Nine of the young patients die.
Wisheart stops operating on children to concentrate on adult heart surgery.
Parents of children who died after heart surgery at BRI write to the General Medical Council (GMC), the doctors' regulatory body, asking for an investigation into the professional conduct of surgeons Wisheart and Dhasmana and the chief executive of the United Bristol Healthcare National Health Service (NHS) trust, John Roylance.
In March, an independent review shows that surgeon Wisheart's open-heart surgery patients were four times more likely to die than those treated by his colleagues. As a result, Health Secretary Stephen Dorrell announces an inquiry into cardiac surgery at the hospital.
In October, Roylance and surgeons Wisheart and Dhasmana are charged with professional misconduct and face a GMC disciplinary tribunal investigating the 53 BRI operations in which 29 patients died and four were brain-injured. The proceedings hear evidence from 67 witnesses and cost more than £2 million ($3 million).
In May, the GMC tribunal finds that the two surgeons carried out the operations "without regard to their safety" and that Roylance failed to respond to warnings and prevent the operations from going ahead. As a result of the findings, Wisheart, Dhasmana, and Roylance are banned from children's heart operations for three years, a penalty later extended for a fourth year. In addition, Wisheart was struck from the British medical register.
Appearing on the news shortly after the decision, Health Secretary Frank Dobson expresses outrage that Dhasmana was not banned from practice. He announces a public inquiry to be chaired by medical law and ethics specialist Professor Ian Kennedy. Later in the year, Dhasmana is fired by BRI; he appeals the decision to no avail.
The Department of Health (DOH) announces a raft of measures to ensure high standards in the NHS, including setting national guidelines for best practices, forming the Commission for Health Improvement to ensure that practitioners meet those standards, giving patients a say in doctors' merit-award payments, and publishing the death rates at hospitals.
In October, a week before preliminary inquiry hearings are scheduled to begin, the British Senate of Surgery issues proposals to ensure that doctors monitor their own performance, to create teams of specialists to take over surgery at hospitals with unacceptably high death rates, and to institute regular appraisals to establish that they are still fit to practice.
In February, families discover that the BRI kept the hearts and other organs of more than 170 babies who died after operations without parental consent, a practice it claimed was standard procedure.
In March, under Professor Kennedy's chairmanship, a full public inquiry opens to investigate the care and management of children undergoing complex heart surgery at BRI. The inquiry investigates nearly 2,000 patients treated there between 1984 and 1995, when the surgeons stopped performing the arterial switch operation for which they had a much higher death rate than elsewhere. Kennedy says up to 35 infants died unnecessarily at the hospital between 1991 and 1995 because of substandard care. The attorney for the parents, Richard Lissack QC, claims that the DOH, the Royal College of Surgeons, and the BRI covered up the scandal. The Bristol Surgeons Support Group appears before the panel hoping to restore the reputation of the three doctors involved.
In May, Kennedy's interim report is released, calling for a code of practice entrenched in law to ensure that organs and tissues are removed from children's bodies only with the consent of parents. At a press conference he describes the attitude of BRI doctors as "arrogance born of indifference."
In July, the Bristol Royal Infirmary inquiry report, known as the Kennedy Report, is officially published.
In August, the government publishes its proposal creating the Council for the Regulation of Healthcare Professions, a regulatory watchdog for the NHS professions, one of the Bristol report's recommendations.
In September, the government issues "Involving Patients and Public in Healthcare," a white paper that proposes a more patient-centered NHS.
In November, Parliament considers the NHS Reforms and Healthcare Professions Bill, the legislative basis for post-Bristol reforms like the strengthening of the NHS inspectorate and the Commission for Health Improvement.
In January, the British government publishes "Learning from Bristol," a formal response to the public inquiry, which details its plans to make the NHS safer, more open, and more accountable to its patients, the British people.
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