Stephen Nicholas Cluley Bolsin (born 1952) is a British anaesthetist whose actions as a whistleblower exposed incompetent paediatric cardiac surgery at the Bristol Royal Infirmary leading to the implementation of clinical governance reforms in the United Kingdom.
Stephen Bolsin graduated with BSc Hons (Anatomy) London in 1974 and MB, BS London in 1977. He became a fellow of the Royal College of Anaesthetists London in 1982. Bolsin became a consultant anaesthetist at the Bristol Royal Infirmary, The Bristol Eye Hospital England in 1989. He was the first national audit co-ordinator of the Association of Cardiothoracic Anaesthetists of Great Britain & Ireland London England 1991–1996.
In 1989, as a new consultant anaesthetist at the Bristol Royal Infirmary, Bolsin identified that too many babies were dying during heart surgery. He spent the next six years confirming the high mortality rates and attempting to improve the service. This led to a fall in mortality rates for children's heart surgery in Bristol from 30% to less than 5%; it also, however, led to direct confrontation with paediatric cardiac surgeons whom the hospital refused to investigate. Bolsin eventually took his concerns to the media and became a whistleblower. [1] Bolsin's actions led directly to a major government inquiry, the Kennedy Report which made wide-ranging recommendations about reform of clinical governance in UK hospitals. [2]
From 1989 to 1995, Bolsin published numerous articles and chapters in textbooks relating to the provision of high quality cardiac services while he was a consultant anaesthetist at the Bristol Royal Infirmary. [3] He also acted as a Department of Health Committee member advising on the assessment of quality and performance in cardiac surgery in the UK from 1992 to 1995. [3] Over the same period, Bolsin was a Department of Health Advisor on performance measurement and risk adjustment in cardiac surgery. The Department of Health Committee, supported by the then chief medical officer, Sir Kenneth Calman, was provided with £3 million to introduce audit of cardiac surgical activity in the NHS and was chaired by Professor Taylor. [1]
Bolsin's actions significantly reduced high death rates for children's heart surgery in The Bristol Royal Infirmary. [4] [5] [6] This was the first time that such a serious problem had been identified and then rectified in the NHS. [7] It remains to this day the most important single-handed clinical outcomes improvement brought about in the NHS. [8] Particularly as a result of widespread adoption of recommendations from the Kennedy Report, Bolsin's actions have affected clinical governance in each specialty in every hospital in the NHS. [7] The concept of ‘Clinical Governance’ that has emerged and taken root in the UK NHS, Australia, New Zealand and globally, arose directly out of Bolsin's actions in Bristol. [7] The GMC have confirmed that Bolsin was the only doctor in the UK prepared to write to them about the events in the children's cardiac surgery service at the Bristol Royal Infirmary. [9] Over the years that this case was discussed in the House of Commons, Members of Parliament confirmed that Bolsin knowingly sacrificed his job, professional popularity and ultimately his young family's life in Britain in defence of his conscience, what he knew was morally right. [10] Bolsin's achievements in establishing Clinical Governance across the UK and globally have never been formally acknowledged in the UK. [11]
In 2013 Bolsin contributed his case to the Whistleblower Interview Project. [12]
Being unable to obtain work in the UK after the scandal, Bolsin took up a senior appointment at the Geelong Hospital in Australia. [13] In 1996, he became director of the Department of Perioperative Medicine, Anaesthesia & Pain Management The Geelong Hospital, Ryrie Street, Geelong, Victoria. In 1997, he became an honorary associate professor in the Department of Pharmacology Faculty of Medicine, University of Melbourne, Victoria 1997. In 2003 he became honorary adjunct professor, Department of Epidemiology & Preventive Medicine Monash University, Victoria. In 2005 he was appointed senior principal research fellow and honorary associate professor in the Department of Clinical & Biomedical Sciences Faculty of Medicine, University of Melbourne Victoria.
In Australia, he has collaborated with other academics in assisting other healthcare whistleblowers. [14] He has also promoted the idea of personalised digital recording of adverse incidents (including near-misses) as a means of improving healthcare quality by medical professionals, particularly those involved in anaesthesia and surgery. [15] Bolsin has contributed to medical and ethical standards in the UK, Australia, New Zealand, Ireland, US and China by lecturing, publishing in the medical press, teaching medical students and developing innovative technology. [16] [17]
Clinical governance is a systematic approach to maintaining and improving the quality of patient care within the National Health Service (NHS). Clinical governance became important in health care after the Bristol heart scandal in 1995, during which an anaesthetist, Dr Stephen Bolsin, exposed the high mortality rate for paediatric cardiac surgery at the Bristol Royal Infirmary. It was originally elaborated within the United Kingdom National Health Service (NHS), and its most widely cited formal definition describes it as:
A framework through which NHS organisations are accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.
The Countess of Chester is the main NHS hospital for Chester and its surrounding area. It currently has 625 beds, general medical departments and a 24-hour accident and emergency unit. It is managed by the Countess of Chester Hospital NHS Foundation Trust, which was one of the first Foundation Trusts, formed in 2004.
The Alder Hey organs scandal involved the unauthorised removal, retention, and disposal of human tissue, including children’s organs, during the period 1988 to 1995. During this period organs were retained in more than 2,000 pots containing body parts from around 850 infants. These were later uncovered at Alder Hey Children's Hospital, Liverpool, during a public inquiry into the organ retention scandal.
Professor Sir Bruce Edward Keogh, KBE, FMedSci, FRCS, FRCP is a Zimbabwean-born British surgeon who specialises in cardiac surgery. He was Medical Director of the National Health Service in England from 2007 and National Medical Director of the NHS Commissioning Board from 2013 until his retirement early in 2018. He is Chair of Birmingham Women's and Children's NHS Foundation Trust.
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The Bristol Royal Infirmary, also known as the BRI, is a large teaching hospital situated in the centre of Bristol, England. It has links with the nearby University of Bristol and the Faculty of Health and Social Care at the University of the West of England, also in Bristol.
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Sir Ian McColl Kennedy, QC is a British academic lawyer who has specialised in the law and ethics of health. He was appointed to chair the Independent Parliamentary Standards Authority in 2009.
Bristol Royal Hospital for Children, also known as the Bristol Children's Hospital, is a paediatric hospital in Bristol and the only paediatric major trauma centre in South West England. The hospital is part of the University Hospitals Bristol and Weston NHS Foundation Trust (UHBW), which includes eight other hospitals. The hospital is located next to the Bristol Royal Infirmary in the city centre.
The Bristol heart scandal occurred in England during the 1990s. At the Bristol Royal Infirmary, babies died at high rates after cardiac surgery. An inquiry found "staff shortages, a lack of leadership, [a] ... unit ... 'simply not up to the task' ... 'an old boy's culture' among doctors, a lax approach to safety, secrecy about doctors' performance and a lack of monitoring by management". The scandal resulted in cardiac surgeons leading efforts to publish more data on the performance of doctors and hospitals.
Sir Robert Hutchison, 1st Baronet, FRCP was a Scottish physician and paediatrician, who is well known as the original editor of the medical books, Clinical Methods and Food and the Principles of Dietetics.
The University Hospitals Bristol and Weston NHS Foundation Trust is a National Health Service foundation trust in Bristol and Weston-super-Mare, England. The trust runs Bristol Royal Infirmary, Bristol Heart Institute, Bristol Royal Hospital for Children, Bristol Eye Hospital, South Bristol Community Hospital, Bristol Haematology and Oncology Centre, St Michael's Hospital, University of Bristol Dental Hospital and, since 1 April 2020, Weston General Hospital.
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Ramani Moonesinghe MD(Res) FRCP FRCA FFICM is Professor of Perioperative Medicine at University College London (UCL) and a Consultant in Anaesthetics and Critical Care Medicine at UCL Hospitals. Moonesinghe is Director of the National Institute for Academic Anaesthesia (NIAA) Health Services Research Centre and between 2016 and 2019 was Associate National Clinical Director for Elective Care for NHS England. In 2020 on she took on the role of National Clinical Director for Critical and Perioperative care at NHS England and NHS Improvement.
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Professor Gabriel John Scally FFPHM is a Northern Irish public health physician and a former regional director of public health (RDPH) for the south west of England. He is a visiting professor of public health at the University of Bristol and president of the section of epidemiology and public health of the Royal Society of Medicine. Previously he was professor of public health and planning, and director of the World Health Organisation (WHO) Collaborating Centre for Healthy Urban Environments, both at the University of the West of England (UWE), and chair of the Trustees of the Soil Association. He is a member of the Independent SAGE group, formed during the COVID-19 pandemic in 2020.