Stephen Bolsin

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Stephen Nicholas Cluley Bolsin (born in Ajmer, India 1952) is a British anaesthetist. His parents were Cyril Edward Bolsin and Beatrice Doreen Cluley Bolsin.

Education

Colchester Royal Grammar School (1963 - 1970), University College London (1970 - 1973), University College Hospital Medical School (UCHMS) (1973 - 1977).

Work

As a new consultant anaesthetist at the Bristol Royal Infirmary in 1989, 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. By doing this Dr Bolsin developed a higher ethical standard in health care. This standard related to a higher quality of care and introduced the measurement of performance and performance monitoring in the NHS. This led to a fall in mortality rates for children’s heart surgery in Bristol from 30% to less than 5%. These dramatic improvements have been sustained and ongoing in Bristol as well as affecting all areas of healthcare in the UK.

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. Dr Bolsin was appointed the First National Audit Coordinator for the Association of Cardiothoracic Anaesthetists of Great Britain & Ireland (ACTA) in October 1991; he resigned in 1996.

Over a period of six years Dr Bolsin identified and significantly reduced high death rates 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. This required significant cultural change in the medical profession as well a significant amount of bravery on the part of Dr Bolsin. Despite a lack of support and growing isolation from many colleagues locally, this notable change was achieved by Dr Bolsin. It remains to this day the most important single-handed improvement brought about in the NHS. The consequences of Dr Bolsin’s actions have been so far reaching that they have affected every specialty in every hospital in the NHS. At the time of his actions in Bristol, standing up for principles of improved practice was largely unheard of, therefore this action required considerable courage and sacrifice on the part of Dr Bolsin. Dr Bolsin was the only professional who was prepared to make a stand on behalf of these children in Bristol. Furthermore Dr Bolsin was the one professional with humanitarian values who considered that the persistent poor performance of children’s heart surgery in Bristol might be professional misconduct and was willing to initiate the GMC inquiry. 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.

Dr Bolsin’s actions have irrevocably improved the standard of clinical and medical practice in the UK. This has been achieved by introducing performance measurement and monitoring, which affects all areas of medical practice in the UK. The initial affect of Dr Bolsin’s actions was to achieve a significant reduction in the number of children dying in the Bristol Royal Infirmary. Following the Bristol experience, the mortality rate for heart surgery in children fell in all cardiac units in the UK. The far-reaching consequences of this sustained improvement represent innumerable children’s lives saved.

By introducing the concept of monitoring quality in medicine Dr Bolsin has established a higher ethical and clinical standard in modern health care. This improved ethical standard is continuing to develop and has been widely adopted by all specialties in the medical profession globally. Ten years from now the ethical standards that Dr Bolsin initiated will still be saving lives in as demonstrable a fashion as they did ten years ago in Bristol.

For seventeen years Dr Bolsin has been contributing to the goal of improved ethical and clinical standards in medical practice. Since his appointment in 1989 to the Bristol Royal Infirmary Dr Bolsin has been committed to a reduction of mortality and morbidity in health care by insuring best practice is achieved in all medical specialties. Today Dr Bolsin is still contributing 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. These diverse activities all aim to improve medical practice in many specialties. Dr Bolsin’s commitment to these improved ethical and clinical standards represents a lasting and growing legacy to the medical profession in all countries. The adoption and development of these standards will continue to improve the quality of medical care in many countries and for years to come. 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. This legacy of ‘Clinical Governance represents a boundless contribution by a dedicated, passionate and committed British Consultant to all health care professionals, especially doctors but more particularly a legacy to all patients in these countries.

Dr Bolsin’s achievements are so outstanding because at the time of his actions there was no one else in his position. He wasn’t the only professional who knew of the high mortality rates for babies at the Bristol Royal Infirmary, but he was the only person with the necessary humanitarian standards willing to stand up for these young patients. Over the years that this case has been discussed in the House of Commons debates as the Members of Parliament have rightly and repeatedly pointed out, he knowingly sacrificed his job, popularity and ultimately his young family’s life in Britain in defence of what he knew was morally right. Ethically and professionally he stood alone. After six years of trying to draw attention to the problem at Bristol from within the system, with no response and increasing numbers of child deaths, Dr Bolsin faced public scrutiny by exposing the alarming mortality rates for the Bristol cardiac unit through the media. Dr Bolsin never attempted to attract publicity to himself, but rather used it to bring to an end the unnecessary deaths of babies. A remarkable achievement, which he accomplished at great personal cost. As a result of his principled stand Dr Bolsin has become an icon of ethics in health care in the NHS and internationally. This contribution stands to this day as a testament to Dr Bolsin’s belief in the primacy of patient care over professional indifference. The stand that Dr Bolsin took has not been matched or surpassed by any other individual in any other health profession in the last century. His contribution will continue throughout this century and beyond.

Sadly Dr Bolsin's achievements in establishing Clinical Governance across the UK and globally has never been formally acknowledged in the UK.

Awards

Victorian Public Healthcare Awards Commendation 2005

Honorary Doctorate of Letters, The University of Buckingham 2004

Lambie-Dew Medal and Oration, The University of Sydney 1999

Civil Justice Award, Australian Plaintiff Lawyers Association 1998

Quotes on Bolsin

‘British medicine will be transformed by the Bristol case’ ‘dramas like the Bristol case are powerful levers for change’

in 'WHY DID THEY ALLOW SO MANY TO DIE?', 1 April 1996 The Times Newspaper, London- Sir William Rees-Mogg

Babies' champion vindicated at last. Stephen Bolsin was forced out of Britain for trying to expose practices that killed 29 children in a Bristol hospital. Now working in Geelong, his actions have been backed by a public inquiry - but he has paid a heavy price.By Angela Mollard 22 July 2001
Sunday Herald Sun, Melbourne

Who killed Cock Robin? Whistleblower Dr Stephen Bolsin emerges as the hero of the piece. He began his dogged campaign to draw attention to the high mortality in 1990—and suffered the traditional fate of whistleblowers, ostracism and a collapse in earnings—after which he emigrated to Australia. Whistleblowers certainly earn their eventual canonisation by television, but it must seem poor recompense for the high personal price they pay.- Tony Delamonth, BMJ, June 1998; Vol. 316: 1757 All changed, changed utterly -Richard Smith, Editor BMJ in Editorial June 1998; Vol. 316:1917-8 We owe him a great deal.

- Ross Cranston, MP 17 January 2002, Hansard

Let us not forget that the actions of Dr. Stephen Bolsin as a whistleblower led to the suspension of heart surgery at Bristol in 1995. We owe him an enormous debt of gratitude. It is not easy to speak out in such circumstances but, fortunately, I have never felt under the pressure that he must have been under. It is not easy to speak out and challenge authority, not least when one's job may be on the line. In his case, it clearly was. Stephen Bolsin spoke out, made himself deeply unpopular and put his employment prospects at severe risk. We must give credit where it is due.

- Richard Berry MP, 17 January 2002, Hansard

On the principled stand of the anaesthetist to whom my hon. Friend referred, he is, as she says, one of the few people who comes out with any credit. covered by the inquiry, and that those responsible for pushing him out will be identified.

- Frank Dobson Health Secretary, 18 June 1998, Hansard

From the time of his appointment in 1988, Dr. Stephen Bolsin, the consultant anaesthetist, expressed concern. Over the years, his anxieties grew, as did his efforts to get others to take them seriously.

- Frank Dobson, MP, 17 January 2002, Hansard

I want to recognise the part played by Stephen Bolsin. It is perhaps not well known that he is in Australia now and has written about the benefits of a new electronic personal professional monitoring scheme that trainee anaesthetists are using. That scheme is bringing greater clarity and openness to the system, and it makes us realise that the impact of Bristol—which resulted, sadly, in the professor having to leave Bristol for Australia—is causing international ripples around the world.

- Valerie Davey, MP, 17 January 2002, Hansard

Many people knew what was happening, but no one acted. The fact that it took a whistleblower, Dr. Stephen Bolsin, to bring the problems to the fore is perhaps the most serious indictment of the culture prevailing at that time.

- Alan Milburn, Health Secretary, 17th January 2002, Hansard

It was left to a whistleblower, an anaesthetist in the hospital, Dr. Stephen Bolsin, to trigger the chain of events which led eventually, in 1995, to the suspension of children's heart surgery. As the report says, Dr. Bolsin is owed a debt of gratitude for what he did. - Alan Milburn, Health Secretary, 18th July 2001, Hansard

Dr. Bolsin did people an enormous favour.

- Alan Milburn, Health Secretary, 18 July 2001, Hansard

As long as I live, I shall never forget the look on the face of Dr. Steve Bolsin, the anaesthetist in the case, when he came to see me and the Financial Secretary to the Treasury, my hon. Friend the Member for Bristol, South (Dawn Primarolo)--who is in her place--and said, "If you were going to put a child to sleep tomorrow, how would you feel if you felt pretty certain that the child would not wake up?" He is not simply a whistleblower; he is the one person to emerge from the case with any credit. The great tragedy is that his undoubted skill and commitment have been lost to this country, because he was squeezed out of anaesthetics in the United Kingdom and has had to earn his living in Australia.

- Right Hon Jean Corston MP, (now Baroness Jean Corston), 18 June 1998, Hansard

We should not forget to congratulate Steve Bolsin, one of the anaesthetists concerned, who played a great part in bringing the affair to public recognition.

- Right Hon Doug Naysmith, 18th June 1998, Hansard

At Bristol, since the events that led to the inquiry and after considerable changes in the paediatric cardiac surgery service were introduced from 1995 onwards, mortality for open operations in children aged under one has fallen markedly, so that it is no longer an outlier.

- P. Aylin et al BMJ, 2004

In 1995, the tragedy in paediatric cardiac surgery at the Bristol Royal Infirmary, exposed by a whistleblower, ended the laissez-faire approach to patient safety, management of clinical quality and professional self-regulation in the National Health Service (NHS). Indeed, the impending impact of the Bristol case was poignantly captured by an editorial in the British Medical Journal, entitled “All changed, changed utterly". - Sir Donald Irvine (President of the General Medical Council) Medical Journal of Australia 2004; 181:27-28.

Now, Dr Steven Bolsin was the world's most famous whistleblower. He was the chap who blew the whistle on the Bristol Royal Infirmary with the paediatric cardiac surgical deaths. - Dr Nankivell (specialist surgeon) in Evidence to the Commission of Inquiry into Bundaberg Hospital, Queensland, Australia 2005.

Positions held

Senior Principle Research Fellow & Honorary Associate Professor Department of Clinical & Biomedical Sciences Faculty of Medicine University of Melbourne Victoria 2005 – Present

Honorary Associate Professor Department of Epidemiology & Preventive Medicine Monash University Victoria 2003 – Present

Honorary Associate Professor Department of Pharmacology Faculty of Medicine University of Melbourne Victoria 1997 – Present

Director Department of Perioperative Medicine, Anaesthesia & Pain Management The Geelong Hospital Ryrie Street Geelong Victoria 1996 – 2007

Specialist Anaesthetist Department of Perioperative Medicine, Anaesthesia & Pain Management The Geelong Hospital Ryrie Street Geelong Victoria 1996 – Present

Consultant Anaesthetist The Bristol Royal Infirmary, The Bristol Eye Hospital England 1989 – 1996

Honorary Senior Lecturer The University of Bristol England 1989 – 1996 Department of Health Advisor The Department of Health London England 1992 – 1995

First National Audit Co-ordinator Association of Cardiothoracic Anaesthetists of Great Britain & Ireland London England 1991 – 1996

External links

* [http://news.bbc.co.uk/2/hi/health/532006.stm Bolsin: the Bristol whistleblower]