Jane Hampson

HE BLEW THE WHISTLE ON DEAD BABIES. THE NHS SHOWED HIM THE DOOR. Dr Stephen Bolsin joined Bristol Royal Infirmary (@uhbwNHS) in 1989 as a consultant anaesthetist. Within months, he identified that too many babies were dying during heart surgery. He spent six years trying to fix it from the inside. Mortality rates for children's heart surgery in Bristol eventually fell from 30% to less than 5%. You'd think that'd be the end of the story. It wasn't. He wrote his first letter of concern to the trust chief executive in 1990, five years before Joshua Loveday, the last of 29 babies and toddlers, died after complex open heart surgery at the hospital. A further four were left with brain damage. His letter received a dismissive telephone call in response. The inquiry found mortality in Bristol for children under one was probably double the England average, and around a third of children who underwent open heart surgery received less than adequate care. It described a unit with poor teamwork, too much power in too few hands, and surgeons who lacked the insight to stop operating. The Kennedy Report was published in 2001. It found an old boys' culture among doctors, a lax approach to safety, secrecy about doctors' performance, and a lack of monitoring by management. And Bolsin? He found it impossible to find another position in the UK and moved to Australia, where he became director of critical care services at Geelong Hospital and achieved world-class outcomes. The NHS got a new governance framework. He got a one-way ticket to Melbourne. Members of Parliament confirmed that Bolsin knowingly sacrificed his job, his professional standing, and his young family's life in Britain in defence of what he knew was morally right. His achievements in establishing clinical governance across the UK and globally have never been formally acknowledged in the UK. Sources: @BBC, @Independent, @guardian

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