Stephen Bolsin
Encyclopedia
Stephen Nicholas Cluley Bolsin (born in 1952) is a British anaesthetist who became famous as the whistleblower
whose actions to prevent incompetent paediatric cardiac surgery
at the Bristol Royal Infirmary
lead to the implementation of clinical governance
reforms in the United Kingdom.
, The Bristol Eye Hospital England in 1989. He was the first National Audit Co-ordinator Association of Cardiothoracic Anaesthetists of Great Britain & Ireland London England 1991 – 1996.
, Dr 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
. 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.
From 1989 to 1995 Dr 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. 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. Over the same period Dr Bolsin was also 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.
for children’s heart surgery in The Bristol Royal Infirmary. This was the first time that such a serious problem had been identified and then rectified in the NHS. It remains to this day the most important single-handed clinical outcomes improvement brought about in the NHS. 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. The concept of ‘Clinical Governance’ that has emerged and taken root in the UK NHS
, Australia, New Zealand
and globally, arose directly out of Dr Bolsin’s actions in Bristol. The GMC have confirmed that Dr 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
. 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. Dr Bolsin's achievements in establishing Clinical Governance
across the UK and globally have never been formally acknowledged in the UK.
in Australia
.In 1996 he became Director Department of Perioperative Medicine, Anaesthesia & Pain Management The Geelong Hospital Ryrie Street Geelong Victoria. In 1997 he became an Honorary Associate Professor Department of Pharmacology Faculty of Medicine University of Melbourne
Victoria 1997. In 2003 he became Honorary Associate Professor Department of Epidemiology & Preventive Medicine Monash University
Victoria. In 2005 he was appointed Senior Principal Research Fellow & Honorary Associate Professor 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. He has also promoted the idea of personalised digital recording of adverse incidents (including near-misses) as a means of impoving healthcare quality by medical professionals, particularly those involved in anaesthesia and surgery
. Dr 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.
Whistleblower
A whistleblower is a person who tells the public or someone in authority about alleged dishonest or illegal activities occurring in a government department, a public or private organization, or a company...
whose actions to prevent incompetent paediatric cardiac surgery
Cardiac surgery
Cardiovascular surgery is surgery on the heart or great vessels performed by cardiac surgeons. Frequently, it is done to treat complications of ischemic heart disease , correct congenital heart disease, or treat valvular heart disease from various causes including endocarditis, rheumatic heart...
at the Bristol Royal Infirmary
Bristol Royal Infirmary
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 medical faculty of the nearby University of Bristol, and the Faculty of Health and Social Care at the University of the West of England, also in...
lead to the implementation of clinical governance
Clinical governance
Clinical governance is the term used to describe a systematic approach to maintaining and improving the quality of patient care within a health system. The term became widely used in health care following the Bristol heart scandal in 1995, during which anaesthetist Dr Stephen Bolsin exposed the...
reforms in the United Kingdom.
Career background
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 InfirmaryBristol Royal Infirmary
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 medical faculty of the nearby University of Bristol, and the Faculty of Health and Social Care at the University of the West of England, also in...
, The Bristol Eye Hospital England in 1989. He was the first National Audit Co-ordinator Association of Cardiothoracic Anaesthetists of Great Britain & Ireland London England 1991 – 1996.
The Bristol paediatric cardiac surgery scandal
In 1989, as a new consultant anaesthetist at the Bristol Royal InfirmaryBristol Royal Infirmary
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 medical faculty of the nearby University of Bristol, and the Faculty of Health and Social Care at the University of the West of England, also in...
, Dr Bolsin identified that too many babies were dying during heart surgery
Cardiac surgery
Cardiovascular surgery is surgery on the heart or great vessels performed by cardiac surgeons. Frequently, it is done to treat complications of ischemic heart disease , correct congenital heart disease, or treat valvular heart disease from various causes including endocarditis, rheumatic heart...
. 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
News media
The news media are those elements of the mass media that focus on delivering news to the general public or a target public.These include print media , broadcast news , and more recently the Internet .-Etymology:A medium is a carrier of something...
and became a whistleblower
Whistleblower
A whistleblower is a person who tells the public or someone in authority about alleged dishonest or illegal activities occurring in a government department, a public or private organization, or a company...
. Bolsin's actions led directly to a major government inquiry, the Kennedy Report which made wide-ranging recommendations about reform of clinical governance
Clinical governance
Clinical governance is the term used to describe a systematic approach to maintaining and improving the quality of patient care within a health system. The term became widely used in health care following the Bristol heart scandal in 1995, during which anaesthetist Dr Stephen Bolsin exposed the...
in UK hospitals.
From 1989 to 1995 Dr 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. 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. Over the same period Dr Bolsin was also a Department of Health Advisor on performance measurement
Performance Measurement
Performance measurement with a process is the complement to process execution. Based on measured performance, the feedback control loop may be closed. The metrics to assess performance is set according to a determined econometric model...
and risk adjustment in cardiac surgery. The Department of Health Committee, supported by the then Chief Medical Officer
Chief Medical Officer
There are four Chief Medical Officers in the United Kingdom who are appointed to advise their respective governments on health related matters: Her Majesty's Government, the Northern Ireland Executive, the Scottish Government and the Welsh Assembly Government...
Sir Kenneth Calman
Kenneth Calman
Sir Kenneth Charles Calman, KCB, DL, FRSE is a Scottish cancer researcher and former Chief Medical Officer of Scotland, and then England. He was Warden and Vice-Chancellor of Durham University from 1998 to 2006, before becoming Chancellor of the University of Glasgow. He has held the position of...
, was provided with £3 million to introduce audit of cardiac surgical activity in the NHS and was chaired by Professor Taylor.
Significance of Bolsin's whistleblowing
Dr Bolsin's actions significantly reduced high death ratesMortality rate
Mortality rate is a measure of the number of deaths in a population, scaled to the size of that population, per unit time...
for children’s heart surgery in The Bristol Royal Infirmary. This was the first time that such a serious problem had been identified and then rectified in the NHS. It remains to this day the most important single-handed clinical outcomes improvement brought about in the NHS. Particularly as a result of widespread adoption of recommendations from the Kennedy Report, Bolsin’s actions have affected clinical governance
Clinical governance
Clinical governance is the term used to describe a systematic approach to maintaining and improving the quality of patient care within a health system. The term became widely used in health care following the Bristol heart scandal in 1995, during which anaesthetist Dr Stephen Bolsin exposed the...
in each specialty in every hospital in the NHS. The concept of ‘Clinical Governance’ that has emerged and taken root in the UK NHS
National Health Service
The National Health Service is the shared name of three of the four publicly funded healthcare systems in the United Kingdom. They provide a comprehensive range of health services, the vast majority of which are free at the point of use to residents of the United Kingdom...
, Australia, New Zealand
New Zealand
New Zealand is an island country in the south-western Pacific Ocean comprising two main landmasses and numerous smaller islands. The country is situated some east of Australia across the Tasman Sea, and roughly south of the Pacific island nations of New Caledonia, Fiji, and Tonga...
and globally, arose directly out of Dr Bolsin’s actions in Bristol. The GMC have confirmed that Dr 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
Bristol Royal Infirmary
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 medical faculty of the nearby University of Bristol, and the Faculty of Health and Social Care at the University of the West of England, also in...
. 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
Conscience
Conscience is an aptitude, faculty, intuition or judgment of the intellect that distinguishes right from wrong. Moral judgement may derive from values or norms...
, what he knew was morally right. Dr Bolsin's achievements in establishing Clinical Governance
Clinical governance
Clinical governance is the term used to describe a systematic approach to maintaining and improving the quality of patient care within a health system. The term became widely used in health care following the Bristol heart scandal in 1995, during which anaesthetist Dr Stephen Bolsin exposed the...
across the UK and globally have never been formally acknowledged in the UK.
Patient safety work in Australia
Being unable to obtain work in the UK after the scandal, Bolsin took up a senior appointment at the Geelong HospitalGeelong Hospital
The Geelong Hospital is an Australian public hospital located in Ryrie Street, Geelong, Victoria. The hospital is part of Barwon Health, Victoria's largest regional health care provider, which has 21 sites. It is the largest hospital in regional Victoria and the only tertiary hospital outside of...
in Australia
Australia
Australia , officially the Commonwealth of Australia, is a country in the Southern Hemisphere comprising the mainland of the Australian continent, the island of Tasmania, and numerous smaller islands in the Indian and Pacific Oceans. It is the world's sixth-largest country by total area...
.In 1996 he became Director Department of Perioperative Medicine, Anaesthesia & Pain Management The Geelong Hospital Ryrie Street Geelong Victoria. In 1997 he became an Honorary Associate Professor Department of Pharmacology Faculty of Medicine University of Melbourne
University of Melbourne
The University of Melbourne is a public university located in Melbourne, Victoria. Founded in 1853, it is the second oldest university in Australia and the oldest in Victoria...
Victoria 1997. In 2003 he became Honorary Associate Professor Department of Epidemiology & Preventive Medicine Monash University
Monash University
Monash University is a public university based in Melbourne, Victoria. It was founded in 1958 and is the second oldest university in the state. Monash is a member of Australia's Group of Eight and the ASAIHL....
Victoria. In 2005 he was appointed Senior Principal Research Fellow & Honorary Associate Professor Department of Clinical & Biomedical Sciences Faculty of Medicine University of Melbourne
University of Melbourne
The University of Melbourne is a public university located in Melbourne, Victoria. Founded in 1853, it is the second oldest university in Australia and the oldest in Victoria...
Victoria.
In Australia
Australia
Australia , officially the Commonwealth of Australia, is a country in the Southern Hemisphere comprising the mainland of the Australian continent, the island of Tasmania, and numerous smaller islands in the Indian and Pacific Oceans. It is the world's sixth-largest country by total area...
he has collaborated with other academics in assisting other healthcare whistleblowers. He has also promoted the idea of personalised digital recording of adverse incidents (including near-misses) as a means of impoving healthcare quality by medical professionals, particularly those involved in anaesthesia and surgery
Surgery
Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...
. Dr 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.
Awards
- Victorian Public Healthcare Awards Commendation 2005
- Honorary Doctorate of Letters, The University of BuckinghamUniversity of BuckinghamThe University of Buckingham is an independent, non-sectarian, research and teaching university located in Buckingham, Buckinghamshire, England, on the banks of the River Great Ouse. It was originally founded as Buckingham University College in the 1970s and received its Royal Charter from the...
2004 - Lambie-Dew Medal and Oration, The University of SydneyUniversity of SydneyThe University of Sydney is a public university located in Sydney, New South Wales. The main campus spreads across the suburbs of Camperdown and Darlington on the southwestern outskirts of the Sydney CBD. Founded in 1850, it is the oldest university in Australia and Oceania...
1999 - Civil Justice Award, Australian Plaintiff Lawyers Association 1998
External links
- BBC, Bolsin: the Bristol whistleblower
- Monash University Alumni Profiles, including Bolsin
- BBC, 15 March 1999, Parents welcome scope of Bristol inquiry
- BBC, 8 September 1999, Heart nurse's 'gut feeling' about Bristol
- BBC, 18 November 2002, Software 'picks up medical errors'