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The notebook that recorded deaths and forced Bristol to change · Healthcare Scandal Investigations

• 0:03
  Speaker 1: One infant. Twelve minutes. And the man with the power
• 0:08
  Speaker 1: to stop the operation chose not to. In January of 1995,
• 0:13
  Speaker 1: a baby named Joshua Loveday was wheeled into a cardiac
• 0:15
  Speaker 1: surgery unit at the Bristol Royal Infirmary. His parents waited outside,
• 0:19
  Speaker 1: in a corridor they had never had a reason to doubt.
• 0:21
  Speaker 1: The anesthetist already in that room had told the surgeon directly,
• 0:24
  Speaker 1: do not operate. His numbers were too grim. His concern
• 0:28
  Speaker 1: was specific, and it was not new. He had been
• 0:30
  Speaker 1: raising it, in one form or another, for four years.
• 0:34
  Speaker 1: The surgeon overruled him. The operation went ahead. Joshua did
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  Speaker 1: not survive it. What came after was not a swift reckoning.
• 0:42
  Speaker 1: It was six more years of silence, denial, and institutional protection.
• 0:46
  Speaker 1: By the time the full scale of what had happened
• 0:48
  Speaker 1: in that unit became public, estimates would place the number
• 0:51
  Speaker 1: of children who died there between 1986 and 1995, children
• 0:54
  Speaker 1: who might have survived at another hospital, at 170. That
• 0:59
  Speaker 1: number comes from Lawrence Vick, a lawyer who worked closely
• 1:01
  Speaker 1: with the families. is an estimate not a case-by-case confirmed
• 1:05
  Speaker 1: finding but even as an estimate it reshaped british medicine
• 1:09
  Speaker 1: this is not simply a story about surgical mortality rates
• 1:12
  Speaker 1: it is about what happens when one doctor keeps raising
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  Speaker 1: his hand keeps filing his numbers keeps pushing the data
• 1:18
  Speaker 1: in front of the people who are supposed to act
• 1:20
  Speaker 1: and is ignored year after year for nearly a decade
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  Speaker 1: it is about what a hospital can hide when nobody
• 1:25
  Speaker 1: is required to make its outcomes public and it is
• 1:27
  Speaker 1: about what parents were never told and what it would
• 1:30
  Speaker 1: later emerge was taken from them without their knowledge or
• 1:33
  Speaker 1: their consent. Before this ends, it will reach a children's
• 1:36
  Speaker 1: hospital in Liverpool, a parliamentary inquiry described as the largest
• 1:40
  Speaker 1: ever conducted into the National Health Service, and a piece
• 1:43
  Speaker 1: of legislation that rewrote the rules of what can be
• 1:45
  Speaker 1: kept from a body after death. Stay with it. Stephen
• 1:50
  Speaker 1: Bolson arrived at the Bristol Royal Infirmary in 1988 as
• 1:53
  Speaker 1: an anaesthetist. He was careful, and he was data-driven. The
• 1:56
  Speaker 1: kind of clinician who kept records not because anyone required
• 1:59
  Speaker 1: it of him, but because the numbers were the only
• 2:01
  Speaker 1: honest language medicine had. In the operating theater, an anesthetist
• 2:04
  Speaker 1: sees things a surgeon does not always see. The small margins.
• 2:07
  Speaker 1: The moments where a heart takes too long to recover
• 2:09
  Speaker 1: its rhythm. The gap between what was promised to a
• 2:12
  Speaker 1: family in a consultation room and what actually happens once
• 2:14
  Speaker 1: the child is asleep. The pediatric cardiac surgery unit he
• 2:18
  Speaker 1: walked into would later be described by the formal inquiry
• 2:21
  Speaker 1: as operating with laxity. Simply not up to the task,
• 2:24
  Speaker 1: the inquiry would eventually conclude. Bolson did not know those
• 2:27
  Speaker 1: words yet. What he had was a notebook and a
• 2:30
  Speaker 1: habit of watching how long operations took and how often
• 2:32
  Speaker 1: children did not recover the way they were supposed to.
• 2:35
  Speaker 1: He began comparing Bristol's outcomes for complex infant heart surgery
• 2:39
  Speaker 1: against outcomes at other hospitals across the country. The gap
• 2:42
  Speaker 1: was not marginal. Set against comparable institutions, Bristol's children were
• 2:46
  Speaker 1: dying at rates that should have triggered an immediate review.
• 2:49
  Speaker 1: Picture him in 1991 sitting across a table from the
• 2:52
  Speaker 1: people who could have ordered that review, NHS management, the
• 2:55
  Speaker 1: Department of Health, the royal colleges, the professional bodies that
• 2:59
  Speaker 1: govern how medicine is practiced in Britain. He has a
• 3:01
  Speaker 1: folder of numbers in front of him, weeks of careful
• 3:03
  Speaker 1: comparison reduced to columns and percentages. He is a relatively
• 3:06
  Speaker 1: junior anesthetist, and the surgeons whose outcomes those numbers describe
• 3:09
  Speaker 1: are senior men with decades of standing, men whose names
• 3:12
  Speaker 1: sit on committees and whose judgment nobody in that room
• 3:14
  Speaker 1: has ever been asked to question out loud. He pushes
• 3:17
  Speaker 1: the folder forward. Nothing happens. Not a denial. Not an argument.
• 3:23
  Speaker 1: No one tells him he is wrong. Something quieter and
• 3:26
  Speaker 1: harder to fight. A silence that let the unit keep
• 3:28
  Speaker 1: operating exactly as it had before he walked in. The
• 3:31
  Speaker 1: same surgeons, the same schedule, the same theater. He goes
• 3:34
  Speaker 1: back to Bristol. The following week, another child is booked
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  Speaker 1: in for the same procedures his numbers had just described.
• 3:40
  Speaker 1: He raises it again. The response does not change. The
• 3:44
  Speaker 1: inquiry would later have a name for the culture that
• 3:46
  Speaker 1: produced that silence. An old boy's culture among doctors. A
• 3:50
  Speaker 1: world where seniority bought insulation. where the idea that a
• 3:53
  Speaker 1: junior anesthetist might be right and the senior surgeons catastrophically
• 3:56
  Speaker 1: wrong was not a scenario the institution had built itself
• 3:59
  Speaker 1: to process. Three men sat at the center of what
• 4:02
  Speaker 1: that culture protected. James Wishart was a surgeon who also
• 4:05
  Speaker 1: held administrative authority inside the trust, a figure of real
• 4:08
  Speaker 1: institutional weight, someone whose word carried further than any junior
• 4:11
  Speaker 1: anesthetists ever could. Janardhan Dasmana was the other surgeon named
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  Speaker 1: in what followed, junior to Wishart but carrying operational authority
• 4:17
  Speaker 1: over the cases that would come to define this story.
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  Speaker 1: the surgeon whose hands were actually on the smallest and
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  Speaker 1: most difficult operations. And John Roilands, chief executive of the
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  Speaker 1: United Bristol Healthcare NHS Trust, was a radiologist by training,
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  Speaker 1: which meant he held medical knowledge and the administrative reach
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  Speaker 1: to order a systemic response, and did neither. In 1994,
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  Speaker 1: while Bolson's numbers sat inside the institution unread by anyone
• 4:38
  Speaker 1: outside it, Roilands received an OBE, an Honor for Service,
• 4:42
  Speaker 1: presented to the man who ran the building where the
• 4:44
  Speaker 1: dying was happening. None of this reached the parents. There
• 4:49
  Speaker 1: was no requirement, in British medicine at that time, for
• 4:51
  Speaker 1: a hospital to publish its outcomes broken down by procedure
• 4:54
  Speaker 1: or by surgeon. A family bringing their infant in for
• 4:57
  Speaker 1: open-heart surgery had no way to learn that Bristol's results
• 5:00
  Speaker 1: were worse than Great Ormond Street's, or any other specialist centers.
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  Speaker 1: There was no chart to check, no published table, nothing
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  Speaker 1: to compare against. They signed the consent form. They handed
• 5:09
  Speaker 1: their child to strangers in scrubs. They trusted the white coat,
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  Speaker 1: the title, the calm and reassuring language of clinical confidence,
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  Speaker 1: because that trust was the only tool they had been given.
• 5:19
  Speaker 1: If you had been that parent, standing in that corridor
• 5:21
  Speaker 1: with your child carried off in someone else's arms, you
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  Speaker 1: would have trusted it too. You would have had no
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  Speaker 1: reason not to. That trust was the architecture of the silence.
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  Speaker 1: It was not stupidity. It was the only rational response
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  Speaker 1: available to a family facing a system that told them nothing.
• 5:35
  Speaker 1: Then came a morning in January of 1995, when a
• 5:38
  Speaker 1: family carried their son through those same doors, believing, as
• 5:42
  Speaker 1: every family before them had believed, that the people waiting
• 5:45
  Speaker 1: inside were ready for him. Joshua Loveday was less than
• 5:48
  Speaker 1: one year old. Stephen Bolson, who had spent four years
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  Speaker 1: compiling the numbers that said this unit was failing its
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  Speaker 1: smallest patients, told the surgeon assigned to the case not
• 5:57
  Speaker 1: to proceed. Gennardin Dasmana overruled him. Joshua died on the table.
• 6:03
  Speaker 1: It reached the press within days. It reached the General
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  Speaker 1: Medical Council. For Stephen Bolson, the man who had tried
• 6:08
  Speaker 1: to stop it, the aftermath was not vindication. Being right
• 6:11
  Speaker 1: did not make his position easier. Colleagues who had spent
• 6:14
  Speaker 1: four years dismissing his numbers did not suddenly welcome the
• 6:16
  Speaker 1: man who had been proven correct at the cost of
• 6:18
  Speaker 1: a child's life. His position at Bristol became impossible to hold.
• 6:21
  Speaker 1: He emigrated to Australia. The institution that had absorbed four
• 6:25
  Speaker 1: years of his warnings did not reform itself from the inside.
• 6:28
  Speaker 1: It was forced open from the outside, by a dead
• 6:30
  Speaker 1: child and a headline. There is a version of this
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  Speaker 1: story that resolves clunely right here. A story about mortality statistics.
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  Speaker 1: About a junior doctor ignored by a senior hierarchy. About
• 6:40
  Speaker 1: a system that protected its own until it no longer could.
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  Speaker 1: That version is real. The inquiry confirmed almost every part
• 6:46
  Speaker 1: of it. But it is not the whole shape of
• 6:48
  Speaker 1: what happened at Bristol, and the rest of it does
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  Speaker 1: not come from an operating theater at all. In 1996
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  Speaker 1: or 97, the record is silent on the exact date.
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  Speaker 1: A woman named Helen Rickard learned something. Her son had
• 7:00
  Speaker 1: died at Bristol in 1992, three years before Joshua. She
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  Speaker 1: had grieved him. She had buried him, attended the small coffin, believed,
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  Speaker 1: as anyone would, that the ceremony was complete. She had,
• 7:11
  Speaker 1: as much as anyone can, tried to move forward. Then
• 7:14
  Speaker 1: she found out that the hospital had kept her baby's
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  Speaker 1: heart after the post-mortem. Without her knowledge. Without her consent.
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  Speaker 1: Without a single word said to her at the time.
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  Speaker 1: That is not a mortality statistic. That is a different
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  Speaker 1: kind of wound entirely, the kind that does not close
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  Speaker 1: the way ordinary grief eventually does, because it reopens the
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  Speaker 1: burial itself, years after the fact. The child you thought
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  Speaker 1: you laid to rest whole was not whole, and no
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  Speaker 1: one had told you that before you walked away from
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  Speaker 1: the grave. Helen Rickard did not stay quiet with it.
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  Speaker 1: She started asking other Bristol families the same question, one
• 7:46
  Speaker 1: conversation at a time, and the answers came back the
• 7:48
  Speaker 1: same way, again and again. This was not one administrative mistake,
• 7:52
  Speaker 1: it was a practice. Children had died. Parents had been
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  Speaker 1: told their sons and daughters were buried complete. Inside the hospital,
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  Speaker 1: in storage, organs remained, catalogued and kept, while the families
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  Speaker 1: who had lost them carried on believing there was nothing
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  Speaker 1: left to know. Out of that discovery, something else happened,
• 8:08
  Speaker 1: something worth sitting with before the story gets darker again.
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  Speaker 1: Mothers and fathers who had grieved alone for years, each
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  Speaker 1: of them certain their loss was theirs alone to carry,
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  Speaker 1: found each other. Helen founded a support group. They sat
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  Speaker 1: in rooms together and said out loud what none of
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  Speaker 1: them had been able to say to anyone who hadn't
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  Speaker 1: lived it. Parents who had each believed their tragedy was
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  Speaker 1: private discovered they were part of the same pattern, and
• 8:27
  Speaker 1: that discovery, terrible as its cause was, gave them something
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  Speaker 1: the hospital had never offered them. Each other, and the
• 8:32
  Speaker 1: plain relief of not being the only one. That did
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  Speaker 1: not stay contained to Bristol for long. When the Bristol
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  Speaker 1: Royal Infirmary Inquiry opened in 1998 under Professor Ian Kennedy, QC,
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  Speaker 1: it became the largest public inquiry ever undertaken into the
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  Speaker 1: National Health Service. It had been convened to examine surgical mortality.
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  Speaker 1: But the testimony it received kept expanding, past Bristol, past surgery,
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  Speaker 1: past the very years it had been asked to look at.
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  Speaker 1: In September of 1999, a heart specialist from Great Ormond
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  Speaker 1: Street named Robert Anderson took the stand. He had been
• 9:04
  Speaker 1: called to speak about surgical outcomes. Instead, under questioning, he
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  Speaker 1: testified that retaining organs after post-mortem without parental consent was
• 9:11
  Speaker 1: not something Bristol alone had done. It was common practice
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  Speaker 1: across British hospitals, ordinary enough that no one inside those
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  Speaker 1: institutions had thought to flag it as a scandal. And
• 9:20
  Speaker 1: then he named one specifically, Alder Hey Children's Hospital, in Liverpool.
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  Speaker 1: That single sentence, spoken almost in passing inside a hearing
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  Speaker 1: room built to examine one hospital, detonated a second inquiry.
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  Speaker 1: For years, The tidy explanation for what happened at Bristol
• 9:35
  Speaker 1: was institutional negligence, a hierarchy so rigid it could not
• 9:38
  Speaker 1: process a warning that came from below it. That explanation
• 9:41
  Speaker 1: is well documented, and the inquiry backed most of it.
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  Speaker 1: But it collapses the moment you look at what came
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  Speaker 1: after the inquiry closed. In 2015, an NHS England report
• 9:49
  Speaker 1: went back to check what had actually changed since the
• 9:51
  Speaker 1: 2001 findings. It found no coordinated program of change. It
• 9:55
  Speaker 1: found that the same concerns had remained. 14 years after
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  Speaker 1: the largest inquiry in the history of the National Health Service,
• 10:02
  Speaker 1: the system it examined still had not built what that
• 10:04
  Speaker 1: inquiry told it to build, which means the four years
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  Speaker 1: Bolson spent being ignored, 1991 to 1995, were not a
• 10:10
  Speaker 1: failure of information. The information was there. It was read
• 10:14
  Speaker 1: and set aside over and over by people who had
• 10:16
  Speaker 1: the authority to act on it and chose the quieter
• 10:18
  Speaker 1: option instead. Dasmana said something to the GMC proceedings that
• 10:22
  Speaker 1: has survived in the record because of exactly how ordinary
• 10:25
  Speaker 1: it sounds, how easily it could be said in a
• 10:27
  Speaker 1: hallway without anyone flinching. Whenever you start any new operation,
• 10:30
  Speaker 1: he said, you are bound to have, unfortunately, high mortality.
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  Speaker 1: It is the sentence of a man describing dead children
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  Speaker 1: as tuition, a cost of the learning curve, without ever
• 10:39
  Speaker 1: asking whether the families paying that tuition had been told
• 10:41
  Speaker 1: class was still in session, or that their child was
• 10:44
  Speaker 1: part of the curriculum at all. No criminal charges were
• 10:47
  Speaker 1: brought against anyone at Bristol. the General Medical Council found
• 10:50
  Speaker 1: serious professional misconduct. Wishart was struck off. Roy Lance was
• 10:54
  Speaker 1: struck off, and the OBE he had received in 1994,
• 10:57
  Speaker 1: while the mortality data already existed inside his own trust,
• 11:00
  Speaker 1: was revoked in 2001. Dasmana was barred from operating on
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  Speaker 1: children for three years and lost his position at Bristol.
• 11:07
  Speaker 1: Stephen Bolson's notebook, the one he started keeping in 1988,
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  Speaker 1: became the foundation the whole inquiry was built on. In 2013,
• 11:14
  Speaker 1: the Royal Colleges of Anesthetists awarded him the Frederick Hewitt Medal,
• 11:18
  Speaker 1: In the 2025 birthday honours, his adopted country gave him
• 11:21
  Speaker 1: the Medal of the Order of Australia. Same data. Same
• 11:25
  Speaker 1: numbers he had once pushed across a table and watched
• 11:27
  Speaker 1: land in silence. 37 years between writing them down and
• 11:30
  Speaker 1: being thanked for it. At 2001, the Retained Organs Commission existed,
• 11:35
  Speaker 1: built for one purpose, returning stored organs to the families
• 11:37
  Speaker 1: they had been taken from. Helen Rickard's support group was
• 11:40
  Speaker 1: still standing by then, still growing. The Alder Hay Inquiry,
• 11:43
  Speaker 1: opened that December after Anderson's testimony, confirmed what Bristol had
• 11:47
  Speaker 1: already shown. that this was never one hospital's failure. In 2004,
• 11:51
  Speaker 1: the Human Tissue Act became law, requiring informed consent before
• 11:54
  Speaker 1: any organ or tissue could be kept, and it created
• 11:56
  Speaker 1: a new authority, the Human Tissue Authority, to enforce it.
• 12:00
  Speaker 1: The numbers moved too eventually. The 30-day mortality rate for
• 12:03
  Speaker 1: children undergoing cardiac surgery in Britain stood at 4.3% in
• 12:07
  Speaker 1: the year 2000. By 2009 it had fallen to 2.6%.
• 12:12
  Speaker 1: Broader surgical progress across the country accounts for some of
• 12:14
  Speaker 1: that fall, not all of it. But it moved in
• 12:16
  Speaker 1: the right direction. after a decade in which the numbers
• 12:19
  Speaker 1: pointing the other way had been kept inside one building.
• 12:22
  Speaker 1: Here is what the numbers can not hold. Bert Loveday,
• 12:25
  Speaker 1: Joshua's father, hanged himself at Winson Green prison in Birmingham.
• 12:29
  Speaker 1: The record notes depression and trouble with the law in
• 12:31
  Speaker 1: the years after his son's death. A man who did
• 12:33
  Speaker 1: not survive the aftermath of an operation he never consented
• 12:36
  Speaker 1: to in any real sense because no one had given
• 12:38
  Speaker 1: him the numbers that would have let him refuse it.
• 12:40
  Speaker 1: Four other parents of children who had gone through that
• 12:42
  Speaker 1: Bristol unit took their own lives too. These are documented facts,
• 12:46
  Speaker 1: not estimates. and they sit outside every statistic this story
• 12:49
  Speaker 1: has produced, because grief does not show up in a
• 12:51
  Speaker 1: mortality rate, and a support group cannot undo what a
• 12:53
  Speaker 1: hospital already did. Lawrence Vick's estimate holds one more figure
• 12:57
  Speaker 1: that does not disappear no matter which argument surrounds it.
• 13:00
  Speaker 1: Alongside the dead, he believed 25 to 30 children came
• 13:03
  Speaker 1: through that unit with permanent brain damage, injuries that do
• 13:06
  Speaker 1: not end a life, but reshape its entire length, and
• 13:09
  Speaker 1: never once appear in a mortality table. And between 1991
• 13:12
  Speaker 1: and 1995, The four years Bolson spent raising the alarm
• 13:16
  Speaker 1: and being waved off, an estimated 34 infants under the
• 13:20
  Speaker 1: age of one underwent cardiac surgery at Bristol and did
• 13:22
  Speaker 1: not survive, who, by that estimate, would have survived somewhere else.
• 13:26
  Speaker 1: 34 children who had not yet reached their first birthday.
• 13:31
  Speaker 1: Joshua Loveday had not reached his either. He died in
• 13:33
  Speaker 1: January of 1995, during an operation the anesthetist in the
• 13:37
  Speaker 1: room had already told the surgeon not to perform. One infant,
• 13:40
  Speaker 1: 12 minutes, or however long it took, is all it
• 13:43
  Speaker 1: took to turn a family's whole future into something else.
• 13:46
  Speaker 1: His father survived him by some years before Winson Green Prison.
• 13:49
  Speaker 1: His mother's grief was never written into a proceeding or
• 13:51
  Speaker 1: a report the way the rest of this story was.
• 13:53
  Speaker 1: Most of what these families carried never made it into
• 13:56
  Speaker 1: any record at all. What did make it into the
• 13:58
  Speaker 1: record is this. A unit that knew. Administrators who were told.
• 14:03
  Speaker 1: Numbers that existed for years before a single family was
• 14:05
  Speaker 1: shown them. And a system that described its own dead
• 14:07
  Speaker 1: children as the ordinary cost of learning, without once asking
• 14:10
  Speaker 1: whether the people paying that cost had agreed to. The
• 14:13
  Speaker 1: mortality rate is lower now. The Human Tissue Act exists now.
• 14:17
  Speaker 1: The anesthetist who left his career behind in Bristol holds
• 14:20
  Speaker 1: two medals now. Helen Rickard's support group gave grieving parents
• 14:23
  Speaker 1: each other, and it still does. None of it walks
• 14:26
  Speaker 1: Joshua Loveday back out of that theater, and none of
• 14:29
  Speaker 1: it returns him to the morning his parents carried him
• 14:31
  Speaker 1: through the doors of the Bristol Royal Infirmary, believing, the
• 14:34
  Speaker 1: way every parent before them had believed, that the people
• 14:36
  Speaker 1: waiting inside were ready for their son. This show is
• 14:40
  Speaker 1: made by Obomedia.