I congratulate Professor Joan Higgins for her informed article about NHS inquiries into sub-standard care, which contained many important insights ('The listening blank', 13 September).

One important correction: I was and still am a British citizen. I graduated from University College Hospital medical school, London (where I was president of the students' union), after completing all my schooling in north east Essex (school captain, Colchester Royal Grammar School). I undertook anaesthetic training in London, spending one year in Perth, Western Australia.

I strongly agree with Professor Higgins' conclusions about the five causes of failure from the Bristol Royal Infirmary and other reports. It is notable that Professor Gianni Angelini also believed the unit was backward in many of its paediatric and adult cardiac surgery practices when he was appointed in 1992.

The failure of leadership was very apparent, and became worse as the criticisms mounted and the power of the same individuals (notably James Wisheart and John Roylance) grew.

A measure of this power was Mr Wisheart's ability to resist, with apparent impunity, the requests for a review from the professors of surgery and cardiac surgery.

The systemic failures were related to the lack of appropriate or enforceable responses from the hospital, royal colleges and the Department of Health.

With respect to the BRI board chair, I should point out:

My original letter of June 1990 was also sent to Peter Drury (then chair of the hospital board).

Professor Angelini also sent copies of his letters relating to paediatric cardiac surgery to Mr McKinlay, the subsequent board chair.

The desire for local inquiry by both chairs was apparently very low.

On the issue of medical managers, I would offer my own experience as director of anaesthesia at the Geelong Hospital, Victoria, since 1996:

Implementing a perioperative service achieving 93.7 per cent day-of-surgery admission rates - this represents world best practice for a service of this kind and has saved the organisation more than $2m. The unit has achieved recognition of the role of nurse practitioners.

Setting up a new cardiac surgery service - the unit has achieved the lowest wound infection rate in the world literature and the second lowest renal failure rate in the published literature. It has level of service monitoring, which has achieved a cultural and performance change in all staff.

Introduction of a novel method of monitoring anaesthetic trainee performance.

Completion of a masters degree in public health at Monash University, including a graduate diploma of health services management.

I endorse Professor Higgins' conclusions that effective medical management requires leadership by example and a genuine desire to put patients at the centre of medical processes, whatever the setting.

My deepest regret is that I have not been able to develop these achievements for patients in the NHS.

Associate Professor Steve Bolsin Director of anaesthesia, perioperative medicine and pain management Barwon Health The Greenlong Hospital Victoria Australia