Ep 45-Bristol’s Broken Heart Unit and the Dangers of Club Culture

A newborn’s first breaths should be a promise. For too many families in Bristol during the 1980s and 1990s, that promise was broken by a system that mistook confidence for competence. We walk through how a respected pediatric cardiac unit drifted into preventable tragedy—where prolonged surgeries, poor post-op pathways, and a “club culture” sidelined data, silenced concerns, and cost lives. Then we connect the dots to the reforms that followed: centralizing complex surgery, raising volume thresholds, validating outcomes, and demanding transparency that patients can trust.

If you care about patient safety, surgical outcomes, and how real change happens, you’ll find both caution and hope here. Subscribe, share this episode with someone who trusts medicine to get it right, and leave a review telling us: what should be public by default—surgical volumes, complication rates, or both?

Resources: 

Gresham College Lecture 

https://pmc.ncbi.nlm.nih.gov/articles/PMC1120824/ 

https://www.ahajournals.org/doi/10.1161/hc3201.097067 

https://www.bristol-inquiry.org.uk/final_report/Summary.pdf 

http://pmc.ncbi.nlm.nih.gov/articles/PMC1174641/ 

http://news.bbc.co.uk/2/hi/health/547035.stm 

https://www.bmj.com/rapid-response/2011/10/27/mr-james-wisheart 

https://www.enablelaw.com/news-and-insights/bristol-childrens-heart-scandal-20-years-on-from-the-gmc-hearings/ 

https://www.theguardian.com/uk/2001/jul/23/jamesmeikle2 

http://news.bbc.co.uk/1/hi/health/558959.stm 

Chapters

• 0:00 Banter, Weather Swings, Baby Shower
• 5:52 Teasing The Case And Sponsor Read
• 11:22 Enter Bristol: A Parent’s Worst Nightmare
• 18:12 How Pediatric Heart Surgery Evolved
• 23:42 Data, Denial, And Dangerous Outcomes
• 29:12 Structural Flaws And “Club Culture”
• 34:22 Media Pressure And Mounting Warnings
• 39:12 The Joshua Loveday Tragedy
• 43:42 Inquiries, Sanctions, And Public Outrage
• 49:52 What Makes A Center Of Excellence
• 56:02 Reform, Centralization, And Lessons Learned
• 1:02:12 Medical Mishap: The Glass Table Incident

Transcript

SPEAKER_00: 0:48

Hey girly, how are you? I was just like, oh, I wasn't holding my microphone, but I see it still picked up my Jenna. So that's good.

SPEAKER_02: 0:57

I'm glad you picked me up. I always pick you up.

SPEAKER_00: 1:02

Oh, how are you doing? Um good. I had a surprise baby shower today at work. What?

SPEAKER_02: 1:11

That's awesome.

SPEAKER_00: 1:12

Yeah, I know. So sweet. Our DHH teachers through a baby shower.

SPEAKER_02: 1:20

Aww. To get some good stuff. Get some good stuff, some cute outies, some onesies. Oh my god, I love this.

SPEAKER_00: 1:28

Well, no, no outfits, but just you know, more things we need. This kid has so many books. It's gonna be Smarty Pants kid. Never have too many books. And like a lot of cool, like sensory books and sensory toys, and that's awesome. Yeah. I just was like not expecting that at all. So I was like, oh, hi. I love that.

SPEAKER_02: 1:51

I love that they did that for you. Well done. I and I know those ladies, they did.

SPEAKER_00: 1:56

I know Miss Balazzati listens to the mod.

SPEAKER_02: 2:01

Hey, oh Lori. You're awesome. We love you. I miss you. Yeah, so we had this like, and I think you had this too. It's not just we like way up north. We had this polar vortex coming through where it was like negative, you know, when you walk outside and your nose sections together with a little degrees. I'm doing bleeding. Yeah. And it's so cold, and that's how it was. And then today it just decided to flip 50 degrees, 50 degrees to like 40 degrees Fahrenheit, which is like it's gorgeous out. A lot of degrees. Yeah. So I just a lot of degrees, yeah. And I sure is. I had gotten my so I have this coat that's like this. And my shout out to Nicole. Nicole gave me this coat because she lost all the weight and didn't fit her anymore, and it was perfect for me. But it's like all feather, like super long, like your whole body, like can take you to negative 40, whatever, and you'll be fine. And I just dug that out and wore that, and it was like, I'm sweating. What the hell's happening here? Now I just want to walk out in 40 degrees in shorts because that's that's how it feels. It's like such a disparity, but I know you know that's the nature of Minnesota.

SPEAKER_00: 3:26

I started my Jeep from my phone because I didn't know what the weather really was, and then I walked outside and things were dripping and melting, and I was like, oh, it's warm.

SPEAKER_02: 3:38

I also say very nice. Um, so we have our work Christmas party, which is like this big old potluck, and all the providers are assigned domains, and I'm really nervous because I'm new and I need to be loved. I need to buy people's love, and my love language is food. So I made um You're going to win them over your fabulous cook. I don't know. So I made butter chicken curry. Oh, my gosh, so jealous. So much. And then there's like this butter, garlic, rice to go with it. And oh my god, what am I gonna do if they don't like it, Amanda?

SPEAKER_00: 4:17

Are your fingers colored from the tumor? Yes.

SPEAKER_02: 4:20

I have orange. I knew it. How did you know?

SPEAKER_00: 4:22

And my whole house smells like garlic, and it's been a three-day production. I know because I've had your curry and I'm so jealous that other people get to enjoy it and I don't.

SPEAKER_02: 4:33

Well, there may be leftovers because I don't know. You're like, well, four hours you could be here. Oh, I mean, I'm coming down, and I I I don't know. I don't know. We'll see if people up north can handle because I I put less chili than I normally would, but it's still got a little heat. It's still got a bit of heat. We're still gonna need to be smoking a little bit, so nervous. It's tomorrow, so we'll let you know how it grows next week.

SPEAKER_00: 5:02

You know, I've got pretty Norwegian taste buds, and I like it, so I think they'll be okay. Well, oh okay, y'all. It's my case today, but we're doing an Adam medical mishap. So you'll hear from Jennifer, our sponsors, and then I'll deliver this gripping case and then the medical mishap.

SPEAKER_02: 5:33

Bless your little cotton socks. You've given us the best stories mishap of all time. So I can't wait.

SPEAKER_00: 5:43

But meanwhile, I did, I did, if you saw this, post a teaser on the social media. I saw that, and that's the bloody, the bloody parts, some bloody parts, and I didn't know what what that meant.

SPEAKER_02: 5:56

It looked horrific, and I can't wait to learn it goes with our story behind it. There's like a little half moon shape of some kind of blessed poor Adam Man. It's a wonder he's still surviving.

SPEAKER_00: 6:12

I know, I know. Maybe thanks to you. Yeah, he's uh thriving today, upright, walking forward. We're doing okay. Oh, I love what he said.

SPEAKER_02: 6:22

So he he does he didn't want to come on, but he gave his permission for you to read it.

SPEAKER_00: 6:27

Yeah, yeah, I said as same as last time. I said, you know, do you want to come on and and we can tell? Because like I have a part of the story too, right? Because I get the phone call. And so I was like, you know, what if we did it together and that would be so cool, and like I'll tell my part and then you can tell your part. And he was like, nah, no, I'm not doing that. And I was like, okay, well, same as last time, then you have to sit here and like I'm gonna type from the horse's mouth like what you're saying to retell the story. Cause his he also has just like a wildly impeccable memory.

SPEAKER_02: 7:00

What I wouldn't give for one of those.

SPEAKER_00: 7:02

And I was like, Oh, when did that happen? He's like February 3rd, 2020. I was like, Oh, okay. I mean, obviously the date of the incident would be more memorable to him, but I was like, oh, okay. And so then wasn't, and he was like, no, no, no, no. Then and I'm like, okay, just tell me the story.

SPEAKER_02: 7:21

I can't wait. Oh my goodness. Well, meanwhile, I hope to be sipping a Kencho cocktail crafted by RSRV Collective and found at RSRV Collective.com. These Kencho cocktails are premium, non-alcoholic, ready-to-drink beverages that deliver the sophistication of traditional cocktails without the effects of alcohol. That means so kencho means self-discovery in Japanese. And this reflects the brand's dedication to crafting elevated experiences through bold, complex flavors. Their innovative approach to non-alcoholic drinks sets the kencho cocktails apart, found at RSRTcollective.com. Meticulously crafted with premium botanicals, natural citrus, and spices, these cocktails rival the depth and nuance of traditional mixology while remaining vegan, gluten-free, non-GMO, and low calorie. Each Kencho cocktail offers a distinct and sophisticated flavor. Botanica, inspired by Jin and Tonic, is crisp and refreshing with floral and juniper notes balanced by citrus. Arana pairs smoky charred citrus with wormwood, evoking the bittersweet character of an old-fashioned. Rosata features cherry sweetness with a ginger finish, while Amari channels an Italian aperitif with herbs, spices, and dark citrus, finished with a subtle bitterness. Recognized by BevNet as one of the best of 2023 non-alcoholic beverages, kensho cocktails crafted by RSRV Collective and found at RSRV Collective.com are perfect for any occasion. Serve them chilled with garnishes like lime cherries or raspberries for a luxurious alcohol-free experience. Listeners of our show get an exclusive 30% discount if you use our promo code StaySuspicious at checkout. Go to rsrvcollective.com and use promo code StaySuspicious for 30% off your order of delicious nutritious cocktails that give you that indultant feel without the alcohol as you celebrate the holiday season.

SPEAKER_00: 9:41

Yay, Kincho cocktails. As always, the resources will be in the show notes. Pre-apologies, I have some wicked hot bun today. So there's been a lot of hiccuping, and probably that's gonna be with us forever on this track. So sorry, it's the baby. Yeah. And so, yep. I had Chipotle for lunch today, and I feel like that's what did it. I don't know.

SPEAKER_02: 10:23

Bring it, girl. It's all nature. It's nature.

SPEAKER_00: 10:27

Yeah. So uh no trigger warnings for this case. It's just it's just, we're just gonna have to get right into it.

SPEAKER_02: 10:40

Okay, you go with it. Okay, I'm ready.

SPEAKER_00: 10:43

Bring it. So imagine this. It's early morning. You're cradling your perfect newborn baby who's swaddled in a little blanket, and you've waited months, perhaps years for this exact moment. You marvel at their soft skin and their tiny little hands that instinctively curl around your fingers. God, I love that. Your baby's chest rises and falls in a perfect rhythm, and for a fleeting moment you let your guard down. You made it a successful pregnancy. You allow yourself to believe that this was the last hurdle to cross, and you believe that nothing could go wrong. And then the words arrive like a physical blow. Your baby has a heart defect, will need to perform open heart surgery immediately. Shock immobilizes you. The joy of finally holding this tiny little life in your arms turns to fear. Your mind races, your throat tightens, and your tears sting your eyes. How could this be? What does this mean? What will happen? But you have no time to dwell because there is a path forward. The Bristol Heart Center, one of the most reputable pediatric cardiac units in the United Kingdom. This is where children go when other hospitals cannot save them, where miracles are said to happen. You arrive at the hospital, its walls gleam sterile white, the corridors are long, echoing every hurried footstep. Nurses and doctors rush past, their expressions tight, professional, but hurried and alert. You catch a glimpse of other parents clutching blankets that hold their own fragile infants. Their eyes are wide with exhaustion, fear, and hope in equal measure. Monitors beep, and the baby's tiny hearts are displayed in green light, each flutter a life hanging by a thread. Your baby's diagnosis is transposition of the great arteries, which is a congenital defect where the heart's major arteries are switched, meaning blood flows in the wrong direction. So oxygen poor blood is sent to the body and oxygen-rich blood loops back to the lungs. Without correction, your child's life expectancy is measured in months. The only option is a procedure called an arterial switch. The operation involves detaching and reattaching arteries that are no wider than spaghetti strands, reconnecting coronary arteries, and using a heart-lung machine called Bypass to circulate blood while the heart is stopped. One slip or one second of hesitation could mean life or death for the patient on the table. And now it's your turn. You're about to hand over your baby to complete strangers. For most people, our children are the most important people in our lives. Parents typically exhibit extraordinary levels of protection for their children, shielding them from the dangers of the world. Things like crossing the street, talking to strangers, avoiding animals that could snap, etc., etc. Parents extinctively take on the role of protectors for their children because that's their job, to look after them and nurture them into adult life. When you bring your baby into that hospital, you'd have certain expectations. You'd expect to be confident in the knowledge that you are in a place that is expert, which is specialized, and in which the people that work there are highly trained and are good at their jobs. Those that work there work in high-quality teams that you can trust and believe in, and that they're also people who work in appropriate conditions and have access to everything that they need if things were to go wrong. That somewhere in that hospital, your precious little baby is going to become the center of their universe too. This is a story of when that trust in others was misplaced and the sense of protection was undermined. As Professor Martin Elliott, British surgeon and professor of cardiothoracic surgery at Gresham College London, paraphrased Sir Ian Kennedy. In fact, this is a story of people who cared greatly about human suffering, were dedicated and well motivated. But some lacked insight, had flawed behavior, communicated badly, and failed to work together in the interest of the patients. This is a story of a breakdown of trust and letting others down and of terrible harm to lovely children. In the 1980s and 1990s, the Bristol Royal Infirmary became the stage for one of the most devastating healthcare failures in modern British history. Children, some just a few months old, died not by chance but due to systemic weaknesses, professional error, and insufficient oversight. Many of these children might have survived had they been operated on at different centers or by other surgical teams. The tragedy did not emerge through routine auditing or internal controls. It was brought to light by the relentless efforts of grieving parents, courageous whistleblowers, and a vigilant press willing to challenge official reassurances. The story of Bristol is a cautionary tale and a lens through which we can examine structural weakness in the broader National Health Service, as well as human costs when ambition, power, and inadequate oversight collide. For a little further insight into that, people kept referring to how this hospital, or specifically the heart unit, was around cardiac unit, was a club culture.

SPEAKER_03: 16:47

Oh no. Yeah.

SPEAKER_00: 16:51

To understand the failures at Bristol, it's necessary to consider the broader context of pediatric cardiac surgery in the UK during the 1970s. At that time, most heart surgery focused on adult patients, primarily addressing valve disease and coronary artery disease. Children were often treated by surgeons who split their practice between adult and pediatric patients. Dedicated pediatric cardiac units were rare, and hospitals retained adult-focused structures, staffing, and postoperative care pathways. These arrangements, while functioning reasonably well for adult cardiac disease, were ill-suited to congenital heart conditions in infants. Open heart surgery was still a relatively young field, barely two decades into its development. Diagnosis relied heavily on clinical assessment, auscultation, electrocardiography, and x-rays, while echocardiography just beginning to improve anatomical understanding. In Bristol, children were initially assessed by the pediatric cardiologists at the children's hospital. Minor procedures could be performed there, but all open heart surgery took place at Bristol Royal Infirmary, which was the adult hospital, because it had the surgical rooms, staff, and the ICU capacity necessary for complex cases. Post-operative care was largely managed by surgeons themselves, as specialist pediatric intensivists had not yet been established. In the early 1970s, Bristol's pediatric cardiac service was small, performing around 100 operations annually, primarily straightforward cases. International outcomes were improving, and so expectations rose and demand increased. To expand the service, the hospital appointed James Weishart, a cardiac surgeon tasked with growing the program. Under his leadership, the unit grew rapidly, and by 1985, they were performing over 430 cases a year. That's only 15 years. That's a big increase. Yeah. That same year, the Department of Health officially designated Bristol as a specialist children's heart center, and Janarden Desmana was appointed as a junior surgeon. Across the UK, pediatric cardiac surgery was also strengthening, highlighting how Bristol's expansion coincided with a broader transformation of the specialty. And I don't know if I mentioned this in here, but I think at the time this story takes place, there were 13 centers that were providing pediatric cardiac surgery, open heart surgery. So for them to grow by 150 cases a year in no math, Amanda. 330 cases a year in 15 years. Well, there's 13 places for people to go to? That's a lot. Yeah. Like, how many people need heart surgery? I know. Sad. Crazy. The 1980s marked a transformative decade for pediatric cardiac surgery. Surgical practice shifted toward operating on babies earlier in life, often aiming for a single definitive procedure before a prolonged strain could cause damage to the heart or lungs. Pioneers such as Aldo Castaneda in Boston and Roger Mee in Melbourne led these approaches, significantly improving outcomes for conditions like atrioventricular septal defect and transposition of the great arteries, T G A. Surgical culture was inherently competitive and ambitious, pressuring units to adopt the Advanced procedures, and Bristol was no exception. In 1988, Desmana introduced the arterial switch operation for TGA. Over the next several years, he performed 38 operations, but tragically, 20 of those 38 children died. This mortality rate far exceeded reports from centers in Boston, Melbourne, Birmingham, or London's Great Ormond Street Hospital. That same year, Stephen Bolson, a newly appointed anesthesiologist with a special interest in congenital heart disease, joined the Bristol team. He immediately noticed operations were unusually prolonged and the outcomes highly concerning. Determined to understand the situation, he began collecting data on surgical outcomes. Meanwhile, Wiseheart reviewed outcomes only intermittently with the cardiology colleagues, and these discussions were informal and sporadic. Systematic reporting of surgical results were neither standard nor expected. A voluntary UK cardiac surgery registry existed, but participation was inconsistent, data validation was weak, and publications were limited. Between 1990 and 1994, the unit's outcomes became increasingly troubling. Of 15 babies undergoing AVSD repair by WiseHeart, nine of them died, a mortality rate far higher than the sub-5% seen at comparable centers. Bolson, alarmed and frustrated, raised the issue with the hospital's chief executive, Dr. John Roylins, but his concerns were not met with urgency. Tensions grew as he faced hostility from colleagues resistant to scrutiny. By 1991, Bristol's problems began attracting attention beyond the hospital. A senior hospital consultant was invited to consider a position at Bristol, potentially chairing cardiac surgery. Upon visiting, they quickly declined after assessing the split site arrangement, outdated facilities, and inadequate post-operative care structure. So this post-operative care structure, the operating rooms and the ICU were on different floors. And so the children had to be transported by a lift that could be called upon by anyone else at any given time. So, like obviously, if you need to get somewhere quickly because your heart is failing and someone else called this lift, then it's like, how the heck are you supposed to get there? So that was problematic. Children were being cared for postoperatively by rotating adult cardiac surgeons, while pediatric cardiologists were physically distant because they were at the children's hospital, which further complicated the echo monitoring. Despite these structural shortcomings, Wisehart was promoted to medical director, consolidating power at the same time that Desmana's arterial switch outcomes remained poor. For Bolson, witnessing this must have been absolutely infuriating. Ambition and hierarchy trumped patient safety. And I think we've all probably, well, hopefully not all of us, but I've certainly worked somewhere where I've seen the wrong person keep tripping up the ladder. And wow, is that frustrating? Yep.

SPEAKER_02: 23:58

Absolutely.

SPEAKER_00: 24:00

Media exposure further escalated concerns. Phil Hammond, a local GP and contributor to Private Eye, highlighted the poor reputation of Bristol's ICU, grimly nicknamed the Killing Fields.

SPEAKER_01: 24:15

Oh God.

SPEAKER_00: 24:16

Bolson. Yeah, right. Not good. Bolson, whose audit was still incomplete, alerted the Department of Health, but actionable steps were limited. The Royal College of Surgeons considered revoking Bristol's status as a specialty center in 1988 and again in 1990, but ultimately they didn't. Weird. Desmana voluntarily stopped performing arterial switch operations, but the systemic problems persisted. In 1994, the Royal College conducted an inspection, issuing a report that reflected weaknesses in oversight reporting and the postoperative care. But before we get more into that, it's time for a chart out. That's all I've got to do.

SPEAKER_01: 25:06

No. No, no, no.

SPEAKER_00: 25:14

I feel like I need a little like handbell. I like I'm still so full from lunch, was which was like over five hours ago that your baby's sitting on your chipotle. Like every time I feel like a hiccup, I I feel like I'm gonna like puke. So if it sounds like I'm out of breath, I am because I'm wearing hard pants, as Kylie Kelsey would call them. Not good. And if you've ever worn maternity pants, I mean over like the seam of where it be like stops being hard pants and goes on to like the belly band. Like that is just like squeezing. I'm sitting Indian style, which is probably not the best. It's like, look at this new trampoline instead of mom's bladder. We've got her Chibole. Oh. Okay. Enough about me. So I guess this is kind of about me still, but I wanted to know how many cases a year a specialty service would need to complete in order to be considered or recognized as specialists or have the facility recognized as a center of excellence. Yeah. Unfortunately, I don't know that I have the best answer, but we'll go through it. Based on accreditation standards and professional guidelines. So what I found was that in many health systems, specialist status isn't set by law except for some regulated procedures, but accreditation programs are commonly used by hospitals to demonstrate expertise. These volume thresholds come from accreditation bodies like the Surgical Review Corporation, SRC, Center of Excellence programs. These programs set a minimum number of procedures per year to qualify facilities as specialists in a surgical area, and they vary by procedure type and program. So I just I have like a few surgical areas that I'll mention, and then the approximate annual volume of cases that they would have to see a year. And again, if you want to look all this up, sources are in the show notes.

SPEAKER_02: 27:18

So super interesting. Yeah.

SPEAKER_00: 27:21

So in the area of colorectal surgery, 100 cases a year. Minimally invasive surgeries, 150 to 175 cases a year. Various robotic surgeries, 50 to 200 cases a year. It says it varies by program. Orthopedic surgeries, 200 a year, joint replacements, 175 to 200 a year, neurosurgery, 150 to 200, thoracic surgery, 125 to 150 cases per year, bariatric surgery, 80 to 100 cases a year, cosmetic surgery, and they noted high volume. So that was 300 to 400 cases a year, and then breast treatment slash cancer care, 125 to 150 cases a year.

SPEAKER_02: 28:14

So what this tells me is that basically two to four cases a week. Yeah. For most of these specialties.

SPEAKER_00: 28:25

And then I'm thinking like isn't a lot. No. And then I'm like, is that per surgeon then also? Or right? Because they need to maintain their So let's say you and I are the surgeons.

SPEAKER_02: 28:43

Yeah.

SPEAKER_00: 28:44

If we're if we're doing two a week, but each of us is only then doing one a week.

SPEAKER_02: 28:52

Unless you're both doing each case together, it doesn't, I shouldn't I shouldn't think it should count because you need your hands on for that experience and that project and to keep up your skill set. So I would say most of these are like four cases of eight a week. And most of these surgeons have at least one surgery day where I'm sure they do more than four cases a day. So yeah, if you're not meeting this threshold, you're barely touching the surface.

SPEAKER_00: 29:25

Yeah. Because it's like you don't want just the center to be called a center for excellence, but then hope you didn't get the surgeon that didn't do that many cases. Yeah. So big picture of what I learned, or what this tells us, is there aren't universal laws. The thresholds are not universal legal requirements. They are examples from voluntary accreditation standards used by hospitals to show expertise in quality. Different accrediting bodies, such as national health authorities or specialty societies, may set different thresholds depending on procedure complexity and local healthcare systems. Research shows that the higher surgical volumes often correlate with better patient outcomes. Duh. This is why many accreditation systems use volume thresholds. Makes sense. These numbers can vary by company and organization. Of course, if you're in a more rural area versus an urban setting, your numbers are going to be much different. And then different countries and specialty societies have their own guidelines. So in short, a specialist surgical unit needs to demonstrate that it performs a substantial number of given procedures annually. Often I'd say that 100 to 200 case mark per year, depending on the complexity and specialty, to meet the accreditation criteria. So I guess if you're going somewhere and they say they're a center for excellence, probably will I I feel confident is. Yeah. Yeah. Like a necessary life-saving procedure versus like uh plastic elective surgery.

SPEAKER_02: 31:47

Are you gonna Botox me? Are you gonna move my nose bridge? I don't know. Even so, I would feel like if I want plastic surgery, I want to know that you at least do a couple of these a week. Like I was gonna say, I still don't want my Botox botched. Right, maybe even less than my heart. I don't know.

SPEAKER_00: 32:09

Yeah. Okay, back to the story. The crisis reached its tragic climax in 1995 with Joshua Loveday, an 18-month-old boy with TGA. Despite advice from Dr. Peter Doyle of the Department of Health cautioning against surgery, the cardiology team persuaded Desmana to operate. And remember, he voluntarily sat out at this point. His outcomes were not good. The operation unfortunately failed, and Joshua sadly died on the operating table.

SPEAKER_03: 32:46

Oh.

SPEAKER_00: 32:47

I guess a trigger warning for this episode could have been children dying. Yeah. And maybe. Yeah. Coming from the print, maybe.

SPEAKER_02: 32:59

No. Okay.

SPEAKER_00: 33:03

This tragedy prompted an external review by Professor Mark DeLaval from Great Ornburn Street Hospital and Dr. Stuart Hunter at Newcastle, who found disorganization, poor communication, and weak data systems. It was estimated that 35 babies under a year old died unnecessarily, and a third of all heart babies referred to Bristol Royal Infirmary received less than adequate care. About 160 of them probably suffered long-term as a result. Their recommendations led to the appointment of an experienced pediatric cardiac surgeon. The secession of pediatric surgery at Bristol, and the transfer of all of the other children there to go to other centers. Public and professional reaction was immediate and intense. Obviously, if we have children dying from inadequate care. Parents formed the Bristol Heart Babies Action Group. Bolson resigned and moved to Australia, and Wisehart stepped down as the medical director, and the General Medical Council initiated investigations. A BBC panorama program criticized both the Department of Health and the Royal College of Surgeons for ignoring repeated warnings. Because remember, Bolson turned these people in multiple times. He tried to say something multiple times. By 1998, the hearings had concluded. Wiseheart and Roylance were struck off and Desmana suspended. And since we're not in the UK, others in the US may not know what that means to be struck off, but they lost their license and they can't practice. And they were removed from the surgical registry.

SPEAKER_03: 34:51

Yeah.

SPEAKER_00: 34:52

So Desmana was found guilty of serious professional misconduct. When speaking publicly for the first time since being found guilty, he said, quote, whenever you start any new operation, you are bound to have, unfortunately, high mortality. Unfortunately, at that time, there were no clear guidelines. Every surgeon was doing the best available practice, end quote. Desmana had admitted that there had been a five-year gap between his assisting an arterial switch operation and performing the first one himself. That is insane. Five years.

SPEAKER_02: 35:28

Right.

unknown: 35:32

Okay.

SPEAKER_00: 35:32

The first nine patients he performed the surgery on had died.

SPEAKER_02: 35:36

Okay. Well, that's I mean, at what point do you go, well, this doesn't work? I'm gonna kill my patient.

SPEAKER_00: 35:44

Yeah. Like, hey, do you guys have um a practice lab? And it's like, okay, we're in the 70s, but yeah.

SPEAKER_02: 35:53

I mean, after the first one, I would have been running to the lab, but nine. Nine. Yeah.

SPEAKER_00: 36:03

And knowing that you had that five-year gap, my friend. Oh, I hate this guy. He was banned from operating on children for three years and lost his job at Bristol Royal Infirmary, which didn't want to work there anyway. Is that it?

SPEAKER_02: 36:17

Is that all that happened to him?

SPEAKER_00: 36:20

To him, yeah. But, you know, he did apologize to the families whose children had died at the Heart Center. And this whole scandal has been called the Bristol Heart baby scandal. He had broken down in tears when addressing the family, saying that he wished he could turn the clock back. He said, quote, whatever suffering I have gone through is no match to the suffering of losing a child. I'm not a cavalier surgeon. I did not, and I do not risk any patient's life unless I believe fully I can benefit them. Unfortunately, it didn't work. I wish I had not operated on those children. I never believed in using patients as guinea pigs. I followed the practice at the time as I saw my elders and seniors doing. I do not consider myself an incompetent doctor, and I hope the inquiry finds that out. End quote.

SPEAKER_02: 37:12

But I mean, nine. You try this technique a couple of times, but nine times and it results in death. Why are you still trusting the system at this point? Like the common sense goes, Oh, a couple of times, something's not working out. Like I don't I don't understand. No, I d I don't give him any credence for that. Yeah. He should have checked in after the first, the second, the third, the fourth, the fifth. Come on.

SPEAKER_00: 37:46

Yeah. Well, you know, he who he would have been checking into is Wiseheart, who was getting all this money for growing this program. So WiseHart was also found guilty of serious professional misconduct for continuing to do the two types of complex operations despite the high death rates. Wiseheart and hospital manager John Roylance were struck off. Oh, and I wrote meaning they lost their license, blah blah blah. I already said that. So we know that now. He said that he wanted to appeal against the GMC verdict, but you know, he had been advised that he would just lose. No kidding, sor. I mean, with the reason, right? Yeah. He said, quote, I felt my surgical skills had achieved a great deal, but it was clear some aspects of those skills were under criticism. I think my own view was that I had done my best, but on what had appeared to be the figures and judgment at that time, there was at least a question mark over whether my skills had been what I had hoped they would be.

SPEAKER_02: 38:47

I mean, do you hope all your patients die? Because that's what the what the hell happened.

SPEAKER_00: 38:52

So Yeah, stats were not good. Okay. Not good. During the inquiry, he broke down in tears as he expressed his regrets to bereaved parents sitting just a few yards away. While you'd expect most parents would be thrilled that the scandal ended with Weisheart losing his license, there were parents that made public statements in support of him. Michelle Cummings shared her experience as the parent of Charlotte, who was born in 1987 with complex congenital heart defects, who later died following surgery performed by Weishart. She emphasized his exceptional dedication, compassion, and meticulous planning in the treating of Charlotte, highlighting that he thoroughly informed her and her husband about the surgical risk, long-term survival changes, I think that's supposed to be chances, and potential complications. Charlotte had underwent surgery in June of 1988 at a time when children were moved between the two Bristol hospitals due to limited resources. Despite a full recovery, she sadly passed away in March of 1989. Michelle stressed that her daughter's death was not due to surgical incompetence. She also noted her family's long history with Wiseheart, including her husband having had successful heart surgeries completed by him in the past, further reflecting his consistent dedication to patients and families over decades. But other bereaved mothers, such as Helen Rickard, did not agree. To add insult to injury, she had found out that her daughter's heart was retained by Bristol without her knowledge. She later learned that Wisehart had continued to receive NHS merit payments topping his pension, for which she described as even further insult. That's right. The government found That these bonuses had not stopped after he was no longer working there. So they have since put in new rules in place for doctors who failed to maintain standards that they would be unable to keep such payments.

SPEAKER_02: 40:56

He got bonuses. Yeah. Wait, he got bonuses for keeping this patient alive that died?

SPEAKER_00: 41:04

He got bonuses for when he was growing the program. Okay. Yeah. So with that, when that news had surfaced, the public learned that he was well first awarded nearly$40,000 a year on top of his salary by senior doctors in 1994. So years after these poor surgical outcomes, still getting that money, honey.

SPEAKER_02: 41:29

Wow.

SPEAKER_00: 41:30

Yeah. Not good. And I'm also like, I didn't see anything about this, but no jail time?

SPEAKER_02: 41:38

Right.

SPEAKER_00: 41:39

Like we're punishment. Just you lost your job and you can't be a surgeon anymore. Okay. And you're still getting 40,000 on top of your pension. Like that's more than a lot of people make in a year. Yeah. So in 1999, the Bristol Royal Infirmary Inquiry, led by Professor Sir Ian Kennedy with Eleanor Gray, produced a comprehensive investigation, and the inquiry issued 198 recommendations, emphasizing systemic failures rather than focusing solely on individual blame. Clinicians had been overextended, ambition exceeded capacity, and power was concentrated in too few hands. Kennedy stressed that complex surgery should be concentrated in high-volume centers, with patient safety taking precedence over convenience. Stephen Bolson, who was our whistleblower in this case, faced scrutiny from those who he had blown the whistle on. He received what he thought was a quite chilling threat from Dr. Roylins. Dr. Bolson was facing a manslaughter investigation after an adult patient received the wrong blood and died. The conclusion of the case was that the death was found to have been caused by coronary artery disease, and the coroner's court returned a verdict of death by natural causes. Dr. Bolson then moved on from Bristol and became the director of anesthesia at Geelong Hospital in Victoria, Australia. He perceived the threats from Roylands as a serious threat to his future as a cardiac anesthesiologist and wanted out. Jim, like these guys that got fired and were like basically running this club culture cardiac unit. Like, who are you to be threatening Dr. Bolson?

SPEAKER_03: 43:24

Uh-huh.

SPEAKER_00: 43:26

Get out of town, sir. Subsequent professional reviews concluded that part pediatric cardiac units should perform at least 300 cases annually to maintain expertise. Implementation, however, was slow, hindered by local loyalties, political caution, and procedural concerns. The legacy of Bristol eventually influenced broader NHS reform. Safe and Sustainable, launched in 2008 under Bruce Keogh, sought to centralize pediatric cardiac services from 11 to 7 centers. A joint committee of PCTs chaired by Sir Neil McKay oversaw the process. Advisory and standards groups, including parents and clinicians, established national benchmarks, and public consultation brought in tens of thousands of responses. Expert assessments reinforced the need for centralization. Implementation faced opposition, minor procedural flaws and legal challenges, but the reforms aimed to ensure that high-volume regional centers delivered superior outcomes, had robust training, and sustainable services. International comparison confirmed this. Concentrating the expertise, collecting the robust data, and ensuring effective oversight would ultimately save lives. The story of Bristol underscores the complexity of healthcare reform where clinical, managerial, political, and societal pressures intersect. Ambition, inadequate oversight, structural weaknesses, and cultural factors led to preventable loss of life. Subsequent inquiries, audits, and reforms demonstrated the capacity for improvement, though obstacles like localism, procedural obsession, and media simplification persist. Rest assured. Speaking of this being a long time ago, because maybe it doesn't seem like that long ago, but I saw this video online the other day, and people were like asking young people like, what age does someone have to be born to be considered old? And the the oldest or like longest ago year that they said was 1990. And I was like, oh, some of them were saying like the 2000s. I was like, oh, okay, I'm old, I made it. Okay. Oh yeah. Oh, I know. Yeah, yeah, yeah. Yeah. So yeah, we can, you know, we can rest assured it's it's safer there now. Safeguards have been put in place. But yeah, this was a really big tragic story for the times and a lot of unnecessary infant deaths just because A, they were not skilled enough to be doing it, but B, you were motivated by like kickback money and just keep doing it. So I did feel a little bad for Desmana when he did bow out himself, like voluntarily did that, and then got pressured into doing another one. Like, yeah, at least he tried to do, I will recognize that. I mean, I think it took too many to finally get to that point, but I don't know.

SPEAKER_02: 46:50

Well, thankfully, cardiac surgery currently is safer, centralized, and better monitored thanks to this combination of rigorous data, concentrated expertise, effective governance, and public accountability that serves as a safeguard to prevent tragedies like this that you mentioned in Bristol. So we can't tolerate mediocrity. Patients need to be safe. There needs to be accountability, and transparency must remain the benchmark. So I love that you brought this up. It's super important. So excellence in healthcare, and you know, we can say we're excellent in healthcare, but we have to be accountable. And when stuff goes wrong, we have to have the courage to report it.

SPEAKER_00: 47:43

Especially like when when things are going wrong, are people losing their lives? This isn't like, oh, we lost the paperwork and now we have to spend more money. I mean, the stakes are never higher, right? Like that's not a patient safety concern.

SPEAKER_02: 48:01

Like Yeah, exactly. It's too late at that point. So definitely, while this is a tragic story, it shows that tragedy can emerge. Lasting reform is we need to learn from our mistakes, and hopefully we have.

SPEAKER_00: 48:18

When I was researching this, I found a separate little rabbit hole that I did not even go down. But that mother Helen, who had found out that her daughter's heart was like kept at the center, it sounded like perhaps that was happening also at Bristol and other hospitals in the UK were like hoarding hearts after people died. I was like, What in the fuck are you guys doing with that? I was like, I can't even go there right now. Oh no.

SPEAKER_02: 48:49

So yep. Well, I appreciate you bringing up that fascination.

SPEAKER_00: 48:55

It definitely was different than usual and not the like gripping, like, oh my god, who's the murderer? But still important, I think, to bring up and definitely a big thing in UK history for healthcare.

SPEAKER_02: 49:08

Absolutely. Absolutely. And we need to understand to think about, you know, what are these implications in healthcare? What's you know, between morality and you know what's actually happening. So I appreciate you bringing that up and you know it's giving us all listeners something to think about. You're welcome. While I like to think, I like to eat cookies. And there's no better time to mention the fact that I want to get over these lifestyle conundrums and and think about cookies. Molly B, pronounced Molly Bee's gourmet cookies, are available at MollyBZ.com. They bring bold artistic small batch craft cookies straight to your pantry. Signature creations include the B Cordial, which are milk chocolate, maraschino cherries, and amarado, Big Joe, which is fresh coffee, milk chocolate, and rum, boba doodles, which are snickerdoodles with boba pearls, hot mess, which are mango, white chocolate, and hot Cheetos. Find them at MollyBeez.com and use Day Suspicious to enjoy 10% of yummy yummy.

SPEAKER_00: 50:25

Okay. Are we ready for another Adam story? I can't. It's not as intense as the first one. I mean, it's it's medically is intense, but yeah.

SPEAKER_02: 50:36

But this poor Adam. I mean, how many medical mishaps has this one got too many?

SPEAKER_00: 50:41

He's got too many. Oh, bless his heart. Oh. I know. I was like, beep, I accidentally thought of that one story from this other story. Can we tell it? Thank you. Okay, so this story starts out with me. So here I am. I'm sitting in grand rounds, and I'm in Bellingham, Washington.

SPEAKER_02: 51:08

Which but what is what do you mean, grand rounds? Talk to the listeners about what that means.

SPEAKER_00: 51:14

Okay, so grand rounds are where a speaker will take a clinical case, and so like let's say I had a really interesting patient, I would take that patient's clinical case and kind of break down what that looked like from start to finish. And like, where do we go from here with that patient? So that's an example of a grand rounds presentation um for a clinical case. I mean, you can do grand rounds on like specific medical things or like research. But for the purpose of this story, it was grand grounds with patient stories. So I'm in grand rounds, I'm in Bellingham, Washington. So I'm 2,000 miles away from where Adam is. He's in Minnesota back home. And I get a notification on my watch that he's calling me. And I'm like, okay, well, obviously this is a butt dial because he knows I'm in grand rounds because we share a calendar, which also was highly necessary at the time because I was two time zones behind him and he worked overnights. So yeah, bad. What a time we've lived through. So anyway, I focus back on grand rounds and then I get another notification on my watch, a voicemail. Highly suspicious because people don't leave voicemails, really. Excuse me. Heartburn hiccup and a gon. Trifecta. So you know when you look at your watch or like on your phone, um, and you can catch a glimpse of like the preview of what the message is saying. So I see that on my watch, and the message starts out, Hi Amanda, this is so and so. And I'm and I see from the emergency department at Mayo Clinic. And I was like, So I got up in the middle of grand rounds, went out to the hallway, listened to this voicemail, which I do still have. We confirmed last night, but I don't think there's a way for me to play it while I'm on the my phone. So basically, the voicemail was like, hi, this is so-and-so, like an emergency department. Adam is here. Um, I'm just calling to tell you what happened, if you can give me a call back. Like, there was not a lot of information. So now we're gonna like flip the switch to Adam, what happened in Minnesota? So Adam was walking out into the living room when he went to take a step. Our puppy at the time, Raven, she was only four months old when this happened. And she was right there. So he tried to do this like awkward step off to the side so that he wouldn't bump into her. And he lost his footing and he fell backwards into and through our glass coffee table. Oh shit. Oh no. Um, so then he quotes as he's retelling a story. My butt was stuck in the coffee table. I couldn't get out because I learned there was a shard of glass sticking out of my back that was no shit, six inches long. So anytime I tried to get up, the glass piece would catch on the frame of the table. I pulled the glass out and made a pressure bandage out of a towel, took a shower to wash the glass off of me, let the dog out to go potty, put her in her kennel, and drove myself to the emergency room. I was nearly passed out by the time I got to the front desk. After imaging, I learned that the glass piece missed my spine by about two inches and luckily didn't make it into my abdominal cavity. I was admitted for three days and then went back home. While there, we had some lovely friends go and clean up all of the glass. And I remember this, they reported that it looked like a glitter bomb went off in the living room from all of the glass everywhere. And we had other friends that watched Raven while he was admitted in the hospital. So he goes on to say he will never own a glass coffee table or any glass table of any sort ever again. So that's your fair warning to not own a glass table.

SPEAKER_01: 55:27

Oh my god.

SPEAKER_02: 55:29

Oh my gosh. He just stuck himself off with a little glass shard stabbing his back. Oh my gosh.

SPEAKER_00: 55:38

We have a picture of the shard. Because of course we would. Why wouldn't we?

SPEAKER_02: 55:42

Oh my gosh. Oh, you're like a cat with nine lives.

SPEAKER_00: 55:48

I'm like, wow, most people would call the ambulance. He's like, oh no, I'm not gonna pay for an ambulance. I'm like, of course, you're also showering and like cleaning up and letting the dog up before you go.

SPEAKER_01: 55:58

He was like, I did X, Y, and Z. We're all good. And I'm like, oh my God. Yeah, he did. Oh my god.

SPEAKER_00: 56:07

So also he worked in the emergency department at the time. So he knew everyone there very, very, very well. And so the social worker that called me, he had told her, he said, you tell Amanda, do not get on a fucking plane and come here. I will be fine. Because he's like, I knew you would buy a ticket and fly home right away. Yeah, and so when I was talking to her, I called back and she was like, He told me to tell you not to buy a fucking plane ticket. I was like, Yeah, that sounds like him.

SPEAKER_02: 56:48

Okay, umestly, because what what wife wouldn't want to fly back?

SPEAKER_00: 56:55

I know, and I wanted to so bad.

SPEAKER_02: 56:59

He was he knew what his injury was, but like honestly, you make sure everything else is okay and cleaned up, and then okay, we'll go.

SPEAKER_00: 57:10

Yeah, he's like, I'm just sitting in the hospital anyway, no, no point in flying home. Which Seattle to Minneapolis, surprisingly, always very expensive flights. Why always right?

SPEAKER_02: 57:24

Well, bless his heart. Adam, you've delivered again. When we need a medical mishap, almost sad to say you're the one.

SPEAKER_00: 57:34

I do have another one for him, actually. Now that I'm thinking of it, I could tell he almost lost part of his foot.

SPEAKER_02: 57:44

I don't, he's a cat. He's got nine lives. Like, I think he's about 42.

unknown: 57:50

Oh my god.

SPEAKER_00: 57:52

Yeah. Oh, well. So anyway, we'll give the listeners some more chances to do, but I do, yeah, we do have more if we ever run out of uh material.

SPEAKER_02: 58:03

Oh my goodness. Yes. Well, thank you, Adam, for sharing. So yeah, uh, what can we expect to hear next week then? Well, I mean, it's the holiday season, so it's like, what could be like lighthearted medical crime? And and so I landed on something that isn't necessarily crime, but it's like healthcare and medically interesting. This guy named Brian Johnson thinks he's never gonna die, and he's got a formula, and I want to talk about how Brian Johnson, this multimillionaire who looks a lot like other multi-billion dollar entrepreneurs, like Elon Musk.

SPEAKER_00: 58:50

I'm like trying to draw up in my mind, like, what does this mean?

SPEAKER_02: 58:53

No, he looks like Elon, but he's not Elon. But like, what science what science is behind this? What medical mysteries does he think he's conquered? Because he thinks that he's got he's like the ultimate medical experiment for how this generation can live forever. So he's just basically, and there's a whole documentary about him called Don't Die. But he thinks he's not gonna die. So we're gonna learn more about Brian Johnson. Okay, cool. I can't wait. I can't wait to learn how to not die. Exactly. Well, and and honestly, as I learn what he's doing with his life, I'm like, I don't know if I want to do that. Okay. Anyway, y'all can be the judge next week. But meanwhile, don't miss a beat. Subscribe or follow Doctor and the Truth wherever you enjoy your podcast for stories that shock, intrigue, and educate. Trust, after all, is a delicate thing. You can text us directly on our website at Doctoringtruth at Buzzbrot.com. Email us your own story ideas and comments at Doctorinthe Truth at Gmail. And be sure to follow us on Instagram at Doctoring the Truth Podcast and on Facebook at Doctoring the Truth. We're on TikTok at Doctor in the Truth and at oddpod e d aud. Don't forget to download, rate, and review because those reviews are really, really helpful. So leave a review. And then we can be sure to bring you more content next week. Until then. Stay safe and stay suspicious.

SPEAKER_00: 1:00:42

I was just thinking like, yeah, review, you're gonna learn how not to die next week. That's a five-star baby. So until then. Bye. Goodbye. Goodbye, Toodaloo Adios. Boop.