Home Page Search Final Report Interim Report Evidence - Transcripts - Witness Statements - Submissions - CCNR Report and associated documents - Statistical Reports and associated documents - Background Papers - Expert Papers Inquiry Seminars About the Inquiry Help		Daily transcripts Hearing summary 16TH MARCH 1999 The oral hearings of the Bristol Royal Infirmary Inquiry began this morning in Bristol with opening remarks from the Inquiry Chairman Professor Ian Kennedy. He urged anyone who still has information for the Inquiry to come forward. He said: "It is still possible that there are parents who are not aware of the Inquiry. There may be people working in the NHS who want to get in touch and we would encourage them to do so." Brian Langstaff QC, Counsel to the Inquiry, opened the formal proceedings by setting out the main themes which the Inquiry will follow: start its investigation afresh be comprehensive and inclusive be a public process be careful and cautious in its analysis of the data He said: "We start this Inquiry with a clean sheet...We do not start with a case to be accepted or rejected… We do not begin with and conclusions – conclusions may be where we end up, but never make a good starting place." He also announced that a group of experts will be assembled to assist the Inquiry. Mrs Tracey Clarke today became the first person to give oral evidence to the BRI Inquiry. She told the Inquiry about the circumstances surrounding the treatment and subsequent death of her daughter Melissa, who was born with a heart defect at Tiverton District Hospital, Devon, in November1990. Tests showed that Melissa had been born with transposition of the greater arteries. Following a balloon septostomy operation at Bristol, Mrs Clarke was told Melissa would need a further operation at nine months. Mrs Clarke brought her daughter to Bristol Children’s Hospital in July 1991 to discuss with surgeon Mr Janardan Dhasmana the options for corrective surgery. Following that meeting she was under the impression that Melissa would have a Switch operation, she later learned that a Sennings operation had been performed. Mr Dhasmana operated on Melissa at the BRI in October 1991 and following the operation Melissa spent several days in ITU (Intensive Care Unit), where we she subsequently died from brain damage. Mrs Clarke expressed concern at the way, and timing of how, she learned of her daughter’s brain damage. She also commented that she was unhappy when, six months after Melissa’s death, she had been contacted by the Exeter Hospital asking her why Melissa had missed an out-patients appointment. A full transcript of the day’s hearings follows.

FULL TRANSCRIPT

   1     Day 1, 16th March, 1999
   2   (11.00 am)
   3          OPENING STATEMENT BY THE CHAIRMAN
   4   THE CHAIRMAN: Good morning. Shortly, I will invite Counsel
   5     to the Inquiry, Brian Langstaff QC, to set these
   6     proceedings in motion. Before I do, may I say just
   7     a few words.
   8        Today, as you realise, we reopen the hearings we
   9     adjourned last October. Let me start by repeating and
  10     emphasising what I said last October: this is a Public
  11     Inquiry; it is here to inquire. So the procedure which
  12     we have adopted, and will adopt and the range of issues
  13     which we are focusing on, will be those suitable to an
  14     Inquiry and its terms of reference. This is not
  15     a trial. We are not a court. There are no parties.
  16        Some organisations and groups are legally
  17     represented. Their representatives are here. We had
  18     an opportunity to hear from them in October, and are
  19     grateful. There is no need to hear from them further
  20     now. I remind you that Mr Langstaff will question
  21     witnesses on behalf of the Inquiry.
  22        As regards cross-examination, re-examination and
  23     otherwise addressing the Inquiry by legal
  24     representatives, I refer to the procedure which I set
  25     out in October. I expect this procedure to be observed

   1     by everyone.
   2        May I also say a word to the representatives of
   3     the press and the media. We are grateful for your
   4     interest and my team will work closely with you to aid
   5     you in your role. Equally, we would expect you to
   6     observe the dignity and the privacy of witnesses both
   7     inside this building and away from it.
   8        Since October there are a couple of things which
   9     I should report to you. First, the Secretary of State
  10     has appointed a medical member to complete the Inquiry
  11     panel. He is Professor Sir Brian Jarman, Emeritus
  12     Professor of Primary Health Care at Imperial College
  13     School of Medicine and recently retired as a GP in an
  14     inner city London practice. Professor Jarman is
  15     a distinguished doctor with wide experience of
  16     medicine. We will range over a wide area, looking at
  17     a large number of areas of expertise. No single person
  18     could embody all this expertise, so what we have devised
  19     will give us the best of both worlds. Professor Jarman,
  20     with his breadth of knowledge and experience, experience
  21     supplemented by a group of experts knowledgeable in the
  22     various areas into which we must inquire.
  23        Just for the sake of completeness, I remind you
  24     that the other two members of the panel are Rebecca
  25     Howard and Mavis Maclean, and that I am Ian Kennedy, the

   1     Chairman.
   2        The second matter I wanted to report to you
   3     concerns the Inquiry's group of experts. When I spoke
   4     in October, much had still to be done. Mr Langstaff
   5     will set out what has been done. All that I say here is
   6     to remind you that in keeping with the approach adopted
   7     by the Inquiry, all experts will be experts to the
   8     Inquiry. After wide consultation, we have identified
   9     areas of expertise as regards which the Inquiry will
  10     need and be able to have access to advice. The group of
  11     experts will contain a number of experts in each area.
  12     By this procedure, not only do we expect to derive great
  13     assistance for the Inquiry, but we will also avoid the
  14     often unhelpful spectacle of pitting expert against
  15     expert in an adversarial contest.
  16        In this phase of the Inquiry, we will be hearing
  17     oral evidence. For the sake of clarity, I emphasise
  18     again that this oral evidence is intended to supplement
  19     the much larger amount of documentary evidence and
  20     written statements on which the Inquiry will rely.
  21        We will call as witnesses only those who can
  22     assist the Inquiry further by their oral evidence.
  23        Witnesses will be invited to give their accounts
  24     and tell their stories. They will be taken through them
  25     by the Inquiry's counsel who will also ask them

   1     questions. I make it clear I do not ordinarily
   2     anticipate the need for questioning by others. That
   3     said, there may be occasions from time to time when
   4     someone wants Mr Langstaff to ask a question or raise
   5     a matter which he might otherwise not ask. I am anxious
   6     that nothing be overlooked. I know that Mr Langstaff
   7     will ensure that there is always freedom of access, such
   8     that any matters can be put to him or to other members
   9     of the Inquiry team.
  10        I am going to turn to Mr Langstaff, but before
  11     I call on him, may I invite the various legal
  12     representatives to introduce themselves now?
  13   MR LISSACK: My name is Richard Lissack QC and I appear on
  14     behalf of the Bristol Heart Children's Action Group
  15     together with my learned friend Mr Harry Trusted and
  16     Mr Peter Skelton, instructed by Mr Lawrence Vick of
  17     Tozers and Mr Mervyn Fudge of Toller Beattie.
  18   MR EASTWOOD: My name is Simon Eastwood, a solicitor from
  19     Winckworth Sherwood. I am instructed by the Medical
  20     Defence Union and the Medical Protection Society on
  21     behalf of Drs Jordan, Joffe, Monk and Martin.
  22   MR MILLER: I am Stephen Miller QC. Mr Gregory Chambers
  23     sits on my right. We are instructed by Julie Austin of
  24     Wansboroughs Willey Hargrave representing the United
  25     Bristol Healthcare Trust.

   1   MR CHEN: Good morning. Simon Chen, solicitor,
   2     Le Brasseur J Tickle. I act for the Medical Protection
   3     Society.
   4   MR SHARP: My name is Christopher Sharp, counsel instructed
   5     on behalf of the Surgeons' Support Group. I am
   6     instructed by Mr Ed Allingham of Sims Cooke and Teague.
   7   MS STOCKLEY: I am Jo Stockley, senior officer, Royal
   8     College of Nursing. My colleague is Helen Fovarge.
   9   THE CHAIRMAN: Thank you. Now Mr Langstaff.
  10             OPENING BY MR LANGSTAFF
  11   MR LANGSTAFF: Professor Kennedy, Mavis Maclean, Rebecca
  12     Howard, Professor Sir Brian Jarman, ladies and
  13     gentlemen. The Chairman has already described who I am
  14     and my task at this Inquiry. It is my role to give
  15     independent legal advice to the Inquiry, and to present
  16     the evidence. In this I have the great advantage of
  17     being assisted by two other counsel: Eleanor Grey and
  18     Alan Maclean.
  19        You may not hear quite so much from them as you do
  20     from me during the course of this Inquiry, but they are
  21     in no sense silent partners. It is essential in an
  22     Inquiry such as this that the work of analysing,
  23     presenting and examining the evidence is shared between
  24     the three of us, so no-one should read any particular
  25     significance into the fact that Miss Grey or Mr Maclean

   1     asks questions of a witness rather than me, or vice
   2     versa.
   3        Let me give you an overview of what I hope to
   4     achieve within the next hour or so. It is to explain
   5     where this Inquiry starts from, how it came into being,
   6     and in particular, what it proposes to do and the
   7     processes by which it will do it.
   8        In doing this, I shall develop four main themes.
   9     These are, first, that this Inquiry starts its
  10     investigation afresh. Secondly, that the Inquiry will
  11     be comprehensive and inclusive. Thirdly, it is a very
  12     public process and fourthly, the Inquiry's analysis of
  13     data will be careful and cautious.
  14        The first theme needs to be emphasised at the
  15     outset and it is this: we start this Inquiry with
  16     a clean sheet. When conclusions of fact come to be
  17     drawn and recommendations made of future advantage for
  18     the National Health Service, the panel will do so on the
  19     basis of the material which has been presented as part
  20     of this Inquiry. We do not start with a case to be
  21     accepted or rejected. We do not begin with any
  22     conclusions. Conclusions may be where we end up, but
  23     they never make a good starting place. Preconceptions
  24     have no place in this Inquiry. If it is to inquire
  25     fairly and rigorously, it must assume nothing and be

   1     prepared to question even that which seems most obvious.
   2        Chairman, as a barrister yourself, you will know
   3     that counsel are often accused of repetition. However,
   4     repetition is one of the best ways of ensuring that
   5     a message is heard and understood. I hope, therefore,
   6     that I shall be forgiven for repeating, perhaps in
   7     a number of different ways during the course of this
   8     opening, that this Inquiry does not begin with a view or
   9     a bias which it seeks to justify. As part of the legal
  10     team, I do not present a case; I am not here to
  11     prosecute any surgeon or cardiologist or any other
  12     health professional, any more than I am to put a case
  13     for them. We have both the luxury and the
  14     responsibility of taking no side, and of having merely
  15     a determination to present the evidence and to question
  16     it in a way which we hope will enable the panel to get
  17     to the bottom of things.
  18        As if to emphasise that this is not a trial, you
  19     will notice that this is not a courtroom. The Inquiry
  20     has gone out of its way to organise the rooms and
  21     facilities to allow as many as possible to follow the
  22     proceedings without being intimidated by the
  23     surroundings.
  24        Why the Inquiry? In one sense, it is easy to say
  25     why we are here. The Secretary of State for Health made

   1     a statement to Parliament on 18th June 1998. He
   2     provided the terms of reference which are to inquire
   3     into the management of care of children receiving
   4     complex cardiac surgical services at the Bristol Royal
   5     Infirmary between 1984 and 1995, and relevant related
   6     issues; to make findings as to the adequacy of the
   7     services provided; to establish what action was taken,
   8     both within and outside the hospital, to deal with
   9     concerns raised about the surgery, and to identify any
  10     failure to take appropriate action promptly; to reach
  11     conclusions from these events and to make
  12     recommendations which could help to secure high quality
  13     care across the NHS.
  14        Two observations: first, this is no usual
  15     Inquiry. It is not a case of a single incident with
  16     tragic results. If a ferry sinks, if an airliner
  17     crashes, if a tube station or an oil rig goes on fire,
  18     then there is an incident to inquire into. Secondly, in
  19     any such case, you can be confident from the beginning
  20     of the Inquiry that something has gone badly wrong.
  21        But this is not a case of a single incident. We
  22     are asked to examine a process. Cardiac surgical
  23     services were provided to many children of many
  24     different ages over a 12 year period. All those
  25     children required treatment; they were ill. The

   1     survival of any one child cannot, on its own, show that
   2     the care given to others was adequate. The tragedy of
   3     any child's death -- and I use the word "tragedy"
   4     deliberately, because I defy anyone to maintain that the
   5     death of a child is not a tragedy, however unlikely it
   6     is to have happened. The tragedy of any child's death
   7     cannot on its own demonstrate that the services provided
   8     were inadequate.
   9        One of the focuses which has emerged from the
  10     witness statements which have been submitted to the
  11     Inquiry since it opened last October has been a concern
  12     expressed by many parents about the quality of care
  13     their child or children had at Bristol. Some who were
  14     content in the belief that doctors had tried their best
  15     for their son or daughter, have watched the TV reports
  16     and have read the papers, and have come to question
  17     whether that belief was justified. I hope that the
  18     evidence that we shall produce will enable those parents
  19     to know, if for nothing else, for their own peace of
  20     mind, whether there was anything they might reasonably
  21     have done which could have secured a better outcome.
  22        I said at the outset that we have no answers. The
  23     first question may, however, seem startling. Bear in
  24     mind that an Inquiry such as this must start without
  25     preconceptions if it is to do its job properly, with

   1     integrity, and if it is to carry conviction. The first
   2     question is whether there was indeed a problem with the
   3     treatment provided in Bristol. Did the care provided at
   4     Bristol, taken either overall or individually, match the
   5     standards of care provided elsewhere in the UK?
   6        There may be those who think that imposing that
   7     basic question was Bristol in fact significantly
   8     different from any other hospital carrying out cardiac
   9     surgery on children, that we are merely paying lip
  10     service to the need to appear unbiased and open in
  11     approach? This is not so. If my first theme is that at
  12     this stage of the Inquiry there are no answers, merely
  13     questions, the second theme must be to emphasise the
  14     comprehensive nature of the Inquiry upon which we are
  15     engaged.
  16        At the General Medical Council, I will call it the
  17     GMC for short, 29 deaths were examined in detail,
  18     a series of 53 cases was studied. Two operations -- two
  19     operations alone -- were central: the arterial switch to
  20     repair the transposition of the great arteries, and the
  21     operation to repair the atrial ventricular septal
  22     defect, AVSD for short. The time-frame was much more
  23     limited than the breadth of this Inquiry, which is far
  24     greater. By contrast with the GMC, we will draw
  25     statistical conclusions from over 2,000 cases of

   1     surgery, both open heart surgery and closed heart
   2     surgery.
   3        I say over 2,000: the Trust has been unable to
   4     tell us from its own records the precise number of such
   5     cases, but once the necessary cross-checking has been
   6     done to ensure there is no duplication, we shall be able
   7     to supply it. We shall deal with a range of
   8     procedures. We shall consider surgery over 12 years.
   9     Every case, to a greater or lesser extent, will form
  10     part of that consideration. We shall look at all
  11     paediatric cardiac surgery and at all outcomes, not only
  12     death but also morbidity such as brain damage. Let me
  13     lay to rest once and for all that this Inquiry is into
  14     the death of 29 babies. If it were, it might imply that
  15     the death of any other baby were of lesser importance.
  16     It might, moreover, suggest that where a child survived,
  17     but left let us suppose brain-damaged or with renal
  18     problems, that that is not to be taken into account.
  19     Because of the way the Inquiry will examine the data
  20     which it has obtained, I can assure the parent of every
  21     child who had heart surgery since 1984 that their
  22     child's case will take a part in the evidence upon which
  23     the Inquiry will base its conclusions. Some cases may
  24     have more immediate prominence. Some parents, for
  25     instance, whose children's treatment raises issues

   1     representative of many, will be asked to give oral
   2     evidence. However, prominence must not be confused with
   3     importance and the fact that, inevitably, many will not
   4     give evidence orally does not mean in any way that they
   5     are being passed over and forgotten.
   6        Over half a million pages of clinical records have
   7     been obtained. Not only has the Inquiry managed to
   8     obtain those clinical records, but has been active in
   9     a number of other fairly unseen ways since last
  10     October. The Inquiry has powers given by Act of
  11     Parliament to require documents to be provided to it by
  12     order of the Chairman, and require evidence to be given
  13     and further, to require that evidence will be given on
  14     oath, as indeed it usually will be. Documents have come
  15     into the Inquiry's offices in London and latterly in
  16     Bristol from a number of different sources. We have had
  17     them from the Department of Health; from the
  18     cardiothoracic register of the United Kingdom; from
  19     a number of parents; from the private papers of the
  20     clinical professionals involved; from various regulatory
  21     bodies from the United Bristol Healthcare Trust and from
  22     several others.
  23        As at this morning, those of you who have had the
  24     luxury of having a printed copy of what I am to say in
  25     advance will need to make some alteration here, because

   1     I can bring you up to the minute. As at this morning,
   2     a total of 28,720 documents other than clinical records
   3     have been provided, indexed and scanned into an
   4     electronic database. Many of those documents consist of
   5     10 or more pages. Of the medical records, we have
   6     3,136. As I have said, more than half a million pages.
   7        At one stage in the process, we estimated that if
   8     one person on his own were to read every page at
   9     a reasonable rate, allowing two minutes for an A4 sheet
  10     of paper, it would take him over 20 years of working
  11     time to read each document just once. That is why
  12     a considerable team has had to be recruited to assist
  13     the Inquiry.
  14        So how precisely have the team coped since last
  15     October in uncovering documents, requiring evidence and
  16     analysis and how can we go about a task which is beyond
  17     a reasonable time-scale for any one person? The answer
  18     is, of course, that not all the documents are relevant,
  19     and that of those which are, the degree of relevance
  20     varies from minimal to very considerable. Every
  21     document has been read by a legally qualified member of
  22     the Inquiry team. Unless obviously irrelevant it has
  23     been re-read by a more senior lawyer checking for
  24     importance.
  25        After this process of review and cross-check,

   1     documents which may assist the Inquiry have been made
   2     part of what we call a core bundle. This forms the
   3     essential data tool for the Inquiry, and it will be
   4     published in searchable form on a series of CDs.
   5        Let me deal for a moment with confidentiality of
   6     those documents, because it is a matter which I think
   7     concerns a number of people. Many of the documents
   8     contain confidential material, or material which was
   9     supplied under an assurance of confidentiality. The
  10     Inquiry undertook not to disclose details which tend to
  11     lead to the identification of a patient, a child, unless
  12     a parent or the patient consents.
  13        We regard this as vitally important. Accordingly,
  14     references which could have the result of identification
  15     are blacked out or redacted, of the documents which are
  16     copied. The database intended for presentation of
  17     documents on screen in this hearing chamber is also
  18     edited in the same way, and both the Chairman and I have
  19     a facility to check at the last moment, even, to ensure
  20     that there is no untoward reference, even if others
  21     missed it. May I say that much of the Inquiry team over
  22     the past fortnight has been checking and double-checking
  23     and subsequently checking again the document base to
  24     ensure that our promises on confidentiality have been
  25     and will be honoured. Thus, every effort has been taken

   1     to ensure that unless a parent consents, a child cannot
   2     be identified. Redaction has proceeded on a next-door
   3     neighbour test: although parents are likely to know that
   4     the information relates to their child, would the
   5     material tend to identify the child to their next-door
   6     neighbour? If so, we have redacted it. If it becomes
   7     permissible to lift the redaction, then we may do so,
   8     but always respecting confidentiality and the parents'
   9     or patients' wishes as a prime concern.
  10        Let me return from confidentiality to a second
  11     theme: that the Inquiry intends to be comprehensive. It
  12     has received statements. Any formal statement received
  13     will be published. If, in that statement, anyone is
  14     referred to critically, that is, in a sense relevant to
  15     the Inquiry's issues and of sufficient importance, then
  16     before publication, it will be circulated to the person
  17     criticised for comment. Of course, although we do not
  18     expect it, if there should be any purely abusive or
  19     scandalous material which cannot take the Inquiry any
  20     further, that will be redacted. Statements will come
  21     from a range of sources. This is not just an Inquiry
  22     concerned with patients and surgeons. There is a much
  23     wider range of material to be examined. In particular,
  24     our terms of reference require us to go beyond the
  25     detail of the Bristol Royal Infirmary to the whole of

   1     the National Health Service as a system, including the
   2     build-up to and the impact of the NHS reforms in 1991.
   3        The process of requesting formal statements has
   4     not been conducted randomly. Confidential
   5     questionnaires have been sent out to parents in response
   6     to their requests. 242, and there is a difference to
   7     the figures because overnight we have had 8 more, have
   8     so far been returned. Of those, 156 said they were
   9     members of an action group. 107 identified the action
  10     group as the Bristol Heart Children Action Group; 36
  11     identified the action group as the Bristol Surgeons'
  12     Support Group. I should like, on behalf of the Inquiry,
  13     to thank all parents who have completed and returned
  14     such a questionnaire. The questionnaires have been
  15     extremely helpful to the Inquiry team, and it cannot
  16     have been easy to express their deeply held feelings to
  17     us on paper.
  18        The answer to the questionnaires remains
  19     confidential. They are unseen by the panel. Everything
  20     the panel see is in the public domain. The answers to
  21     the questionnaires therefore form no part of the
  22     material upon which the panel decide whether they can
  23     make recommendations, and if so, what they will be.
  24     People who have sent in the questionnaires have been and
  25     may well be asked to provide written formal statements.

   1     Any statements submitted will be part of the evidence.
   2     Any formal statement, from whoever wishes to submit one,
   3     will be considered. Although we have a mass of evidence
   4     already, there is more to come. In particular, I would
   5     like to encourage everyone, for instance a member of
   6     staff at the Bristol hospitals, if there is anything
   7     they wish to say about what happened in Bristol, good,
   8     bad or indifferent from 1984 to 1985, to come forward
   9     and to speak to a member of the Inquiry staff. The
  10     press here today, particularly local reporters, can
  11     assist by reporting my plea for anyone who feels they
  12     have anything useful to add to the information to come
  13     forward and contact the Inquiry. The Inquiry means what
  14     it says about being comprehensive and inclusive. You
  15     already, I think, have realised that this Inquiry will
  16     be the widest ranging examination of the NHS ever
  17     conducted independently.
  18        What about procedure? The procedure is not that
  19     of a trial. This is an Inquiry. Thus, as the Chairman
  20     explained last October, cross-examination will be
  21     limited. Eleanor Grey, Alan Maclean or I will examine
  22     the witness. After the first few witnesses have been
  23     heard, the written statement which has been published
  24     will be taken as read. There will be an opportunity for
  25     each witness to be re-examined by his or her

   1     representative to ensure they give a fair account of
   2     themselves; a short written statement summarising the
   3     effect and importance of the witness's evidence made
   4     overnight may be published the morning after the witness
   5     has completed his or her evidence. On application, the
   6     Chairman may allow that statement to be given orally.
   7        The purpose of our questioning is to examine the
   8     evidence thoroughly. We would hope that it is fair but
   9     rigorous. What a witness says deserves to be treated
  10     seriously. Witnesses should remember that evidence
  11     which is not carefully examined, not looked at
  12     thoroughly in its important respects, will carry less
  13     weight.
  14        A third theme is the public nature of this
  15     Inquiry. It is unusual. No Inquiry has yet been so
  16     public. The daily transcript will be put on the
  17     Internet. After Easter, the proceedings will be
  18     transmitted live to Barnstaple, Truro and Cardiff. This
  19     is under controlled circumstances for the Inquiry, it
  20     will not be appearing on TV or radio. If anyone should
  21     attempt to use it in this way, sanctions will follow.
  22     When documents are referred to in the oral hearing, they
  23     will be part of the core bundle and they too will be
  24     made public. Because the Inquiry is taking evidence
  25     publicly on paper, not everyone will be asked to give

   1     evidence orally; but those who are not called are not
   2     ignored. In many ways, their evidence may count for
   3     more. This is because we shall ask those to give
   4     evidence where we may need to amplify what they are
   5     saying; to put it in context or to challenge it. It
   6     may, for instance, be inconsistent with that which
   7     another witness has said. On the other hand, witnesses
   8     will not be called where their statement is
   9     self-explanatory and there is perhaps little that
  10     questioning could add. For the witness who is tempted
  11     to feel that his or her evidence has been treated as
  12     being of lesser value because he or she has not been
  13     called to sit in the central chair in the full glare of
  14     the cameras and bear public witness to what he or she
  15     has said, I would simply ask, is a statement likely to
  16     be regarded as of greater value if the evidence is
  17     publicly doubted, as may be the case with some
  18     witnesses, rather than accepted as obviously true?
  19     I would ask them, would they think that evidence which
  20     is full enough on paper so there is no need to ask
  21     anything to expand upon it orally, is not likely to
  22     carry more weight because it is seen to be full and
  23     frank in the first place.
  24        We have endeavoured to select witnesses whose
  25     evidence covers a range of issues, which is broadly

   1     representative of the evidence which we have received.
   2     Let me emphasise again, that no-one should feel that he
   3     or she is being treated adversely merely because her or
   4     his evidence has not been selected for oral scrutiny.
   5     Moreover, each week we will publish in advance the names
   6     of the witnesses whom we expect to call in the following
   7     week. Parents who are not called to give evidence in
   8     block 1 may find that they are being asked to give their
   9     evidence in block 3, or 5, or 6. For the parents'
  10     evidence runs seamlessly throughout the issues we have
  11     to consider. Each witness will be invited to see
  12     whichever of the three of us, Eleanor, Alan or myself,
  13     is going to ask them the questions when they do give
  14     evidence. They may, of course, not wish to avail
  15     themselves of this, but it may help to relieve some of
  16     the anxieties which are inevitable about the process of
  17     being a witness, particularly on a stage as public as
  18     this.
  19        May I say that of course, we are happy to see any
  20     witness with or without their representatives in advance
  21     of the evidence.
  22        One category of witness perhaps deserves special
  23     mention, and that is experts. As the Chairman has just
  24     said, the Inquiry will establish a group of experts
  25     containing a number of experiments in each relevant area

   1     of expertise. The expert group will include experts in
   2     the following areas of expertise, first and perhaps most
   3     obviously: paediatric cardiac surgery. Paediatric
   4     cardiology, paediatric cardiac anaesthesia, paediatric
   5     intensive care, paediatric pathology, nursing, both
   6     paediatric care and intensive care, medical education
   7     and training, specialist surgical training, medical and
   8     clinical audit in relation to methodologies, regulation
   9     of the medical profession, NHS management and finance in
  10     the 1980s and 1990s, including the impact of the NHS
  11     reforms, and statistics and epidemiology.
  12        The aim of the Inquiry's group approach is to move
  13     away from the model of expert evidence used in trials,
  14     where expert evidence is presented in an adversarial
  15     setting. As experts to the Inquiry, those in the group
  16     will be asked to give their opinion in the widest public
  17     interest, rather than in support of the case of one side
  18     or the case of the other. As Professor Kennedy has
  19     already made clear, there are no sides; there is no
  20     case.
  21        The Inquiry is very mindful of the relative
  22     scarcity of expertise in a number of areas of interest
  23     to the Inquiry. We recognise that membership of the
  24     expert group may involve a considerable commitment of
  25     time and energy to the expert and to the institution

   1     where the expert works. Thus, to lighten the load on
   2     any one individual, a number of experts will be invited
   3     to serve in each area of expertise. Appointment to the
   4     group will be by invitation only. The Inquiry has
   5     sought and will continue to seek advice from experts as
   6     to those others whose expertise is well recognised, with
   7     a view to ensuring that the expert group first has
   8     sufficient numerical strength to ensure the Inquiry's
   9     demands are met with the minimum of inconvenience to any
  10     one group or institution, and secondly covers any
  11     principal difference of view or emphasis within a given
  12     specialty, and thirdly, is broadly based, both
  13     geographically or otherwise. I know the Chairman is
  14     always content to listen to suggestions for additions to
  15     the group, where it is considered that will be of
  16     assistance to the Inquiry.
  17        The written opinions of the experts will be made
  18     public. They will be published on the Inquiry's web
  19     site. Although the Inquiry will not necessarily hear
  20     orally from each expert where views differ, it will seek
  21     to take advice and evidence where it seeks to reflect
  22     fairly any divergence of opinion, and where it is
  23     important to explore it. The experts may be called to
  24     give oral evidence in addition to their oral and
  25     published reports. Where they are called to give

   1     evidence, an expert may appear alone, or he may appear
   2     as part of a discussion where two or three experts who
   3     hold what are apparently different views will be invited
   4     to contribute. In the latter case, each will give
   5     evidence at the same time, moderated as it were by
   6     counsel, thus permitting an open panel-type discussion
   7     amongst the relevant experts.
   8        The oral evidence which I have described, both
   9     from lay witnesses and from experts, will be taken in
  10     phases, in blocks. The Inquiry has two phases, and the
  11     oral evidence will be taken in the first phase, Phase I,
  12     of the Inquiry, in six blocks. If the first block
  13     parents will give evidence of their experience of and
  14     the treatment of their children at the BRI and the
  15     Bristol Children's Hospital. It is from their
  16     experience that everything else stems. They will
  17     feature in each of the other blocks of evidence as
  18     well. After setting the scene from their perspective,
  19     we shall move to block 2, to consider the national
  20     scene. Block 3 involves the local scene, the
  21     organisational structure, the staffing side. Block 4 is
  22     the nature of the services provided. Block 5 is their
  23     adequacy, and block 6 the concerns expressed about the
  24     services. Bear in mind that in the earlier blocks we
  25     shall be concentrating on structures, finances and

   1     arrangements. Some witnesses may therefore give
   2     evidence in more than one of the blocks. For instance,
   3     many of you will know that Mr Wisheart, as Chairman of
   4     the Hospital Medical Committee, and later medical
   5     director of the United Bristol Healthcare Trust, had
   6     a central role to play in the administration of the
   7     Bristol hospitals. Accordingly, he will be asked to
   8     give evidence in block 3 about that aspect. He also
   9     will be asked to give evidence in the later blocks.
  10        So there are two phases to the Inquiry: Phase I
  11     divided into the six blocks I have mentioned, and
  12     Phase II, where the wider issues raised by the Inquiry
  13     will be considered; conclusions drawn and
  14     recommendations made.
  15        With such a mass of evidence, with so many
  16     witnesses giving evidence, and with the Inquiry being
  17     into a process rather than one single event, people may
  18     wonder when the Inquiry is going to finish. It will
  19     finish Phase I by Christmas. It has to. If the
  20     recommendations which the panel will make are to be made
  21     at a time when they will have any influence on the
  22     future of the NHS, then they must be made within
  23     a reasonable time-span. It is necessary for parents to
  24     be able to move forward; it is important for the
  25     Hospital Trust to move out of the shadows cast by the

   1     past, so that it gives the service it can to the people
   2     of Bristol. No-one is served by delay.
   3        Remember that the purpose of the oral evidence is
   4     to supplement the written evidence. Because much of the
   5     evidence is in writing, the Inquiry will be able to move
   6     more swiftly to its conclusions.
   7        The timing of Phase II is driven by the same
   8     concerns. We will aim to start it even as Phase I draws
   9     to its completion, with a view to ending Phase II within
  10     the first half of next year.
  11        How shall we manage the evidence? The Inquiry, as
  12     I have said, is not only unusual in being an Inquiry
  13     into a process, into a service delivered over several
  14     years, nor is it only the largest investigation into
  15     practices in the National Health Service for many years,
  16     indeed ever, it is also unique in the sense to which it
  17     will be accessible to any member of the public. I have
  18     emphasised already, it is going to be open,
  19     comprehensive and inclusive.
  20        In front of you are two sets of screens, black and
  21     grey. On the ones which have a black support, you may
  22     see a little old grey-haired man who thinks he is the
  23     Inquiry's equivalent of Jeremy Paxman. That image,
  24     which will not always be of me, I hasten to add, will be
  25     transmitted after Easter from this hearing room to

   1     Barnstaple, Truro and Cardiff; at the health centre in
   2     each. The Inquiry will place the evidence it has
   3     obtained in public libraries throughout the south west,
   4     and indeed South Wales. At the end of each day, the
   5     evidence, every question, every answer, will be placed
   6     on the Internet and we hope that this will inspire more
   7     people to come forward if they have anything useful to
   8     add or any comment to make. This Inquiry is a Public
   9     Inquiry and it takes the word "public" seriously.
  10        The second screen, the grey one, is used for
  11     displaying documents to a witness for comment. I will
  12     show you how that works when I deal in a moment or two
  13     with the way the Inquiry will navigate through the sea
  14     of information available. If I can take that metaphor
  15     further, you, Chairman, as a barrister yourself, will
  16     know how lawyers love analogies, because they help to
  17     picture a process. In some respects, the Inquiry
  18     resembles some of the explorers of old setting out on
  19     a voyage of discovery. Like them, the Inquiry does not
  20     know how it will end up. It has, however, to start from
  21     somewhere, and it must be aware of currents flowing from
  22     different directions that may take it off course, and it
  23     must have a star to steer by.
  24        How do we propose to make sense of the evidence
  25     which has come in, and which will accumulate, and

   1     navigate our way through it?
   2        Our starting place, perhaps, is matters of
   3     historical record. The Inquiry is into paediatric
   4     surgical services. That covers children under 16. It
   5     also covers infants, that is, those under one year of
   6     age, including neonates, those up to 28 days of age. It
   7     is important to keep in mind the distinction between
   8     children over the age of one and under the age of one.
   9     The reason is this: in 1983 the then Secretary of State
  10     for Health designated a number of clinical services as
  11     supra-regional. They were those services which, in
  12     order to be clinically effective, or economically
  13     viable, needed to be provided by centres, each of which
  14     served a population significantly bigger than that of
  15     a single health service region. There were 14 regions
  16     in England and Wales. The advisory group, the
  17     Supra-regional Services Advisory Group -- you understand
  18     why I call that SRSAG -- designated nine hospitals for
  19     the provision of infant and neonatal cardiac surgery.
  20     They did that in 1983. Thereafter, until 1984, infant
  21     and neonatal cardiac surgery was a supra-regional
  22     service. The distinction between infants and neonates
  23     on the one hand and children over one on the other is
  24     that cardiac surgery provided to the latter group was
  25     not provided on a supra-regional basis.

   1        Supra-regional services received funding direct
   2     from what was then the DHSS. Designation as a centre
   3     thus had important financial consequences. Each centre
   4     was required to make a return each year to the
   5     Department, giving the numbers of operations conducted
   6     in any one year. In 1986 there was a review of the way
   7     in which the system was working. Can we have a look,
   8     please, at document 62, UBHT 62/401? Shall we try and
   9     amplify it so we can see? If we focus, please, on the
  10     second paragraph, can we have that highlighted in
  11     yellow? We can see there that in the report it records
  12     that the need was confirmed for a limited number of
  13     centres to perform a complex surgery, and there was
  14     a case for a possible reduction in the number of centres
  15     which were designated. The supra-regional centres are
  16     as follows ... can we scroll down, please? We can see
  17     that the hospitals are listed. If we go down to the
  18     bottom of what is now on the screen, we see the Bristol
  19     Children's Hospital and Royal Infirmary.
  20        We then read this:
  21        "The Bristol centre is one of the smallest centres
  22     in terms of throughput. The total number of operations
  23     on children aged under one year increased from 50 in
  24     1984 to 55 in 1985 .... It has, however, been seen as
  25     having a legitimate claim for development on

   1     geographical grounds and the consideration of this has
   2     included its proximity to the South Wales population."
   3        May I add, for those of you who may be aware of
   4     some of the figures that have been bandied around, that
   5     the figure of 50 and 55 is a combined total of both open
   6     heart surgery and closed heart surgery.
   7        As this document really demonstrates, the
   8     documents we have received have been scanned into an
   9     electronic database. One of the advantages of the
  10     research which had been done by the staff of the
  11     Inquiry, the advantage of the electronic database, is
  12     that documents which may be far-removed in different
  13     files can be matched, displayed to you in a coherent
  14     manner, they can be highlighted, and indeed sometimes
  15     relatively indistinct old documents can be made, by the
  16     use of modern technology, to look rather better than
  17     they did originally.
  18        Returning to the history of the supra-regional
  19     services, in 1992 the Secretary of State, the then
  20     Secretary of State, made an announcement which is to be
  21     found at document -- here we go to a different file --
  22     277/93. May we focus, please, on the centre of the
  23     page, under the heading "Neonatal and Infant Cardiac
  24     Surgery"? We see again the list of hospitals. Can we
  25     go down to paragraph 31? We can read there, some of it

   1     is missing at the edge:
   2        "In its recommendations last year, the advisory
   3     group pointed out that there were effectively 10
   4     designated centres and that some activity was taking
   5     place in other units. This meant that the service must
   6     be considered for dedesignation. The government would,
   7     however, prefer in the interests of patients, that the
   8     service be rationalised into fewer designated units.
   9     Discussions are taking place with professional bodies,
  10     but unless these confer the prospect of early
  11     rationalisation, designation will have to be withdrawn."
  12        So what paragraph 31 suggests is that although
  13     patients benefit by having fewer rather than more
  14     specialist centres for cardiac surgery, because in fact
  15     more rather than fewer centres were actually performing
  16     the service, designation might have to be withdrawn.
  17     You may ask, why should this be, and there is an echo
  18     perhaps here of a letter which was written back in
  19     October 1986 -- may we look, please, at 278/432?
  20     Enlarge that. It is the second paragraph. Just reading
  21     from the bottom of that:
  22        "Supra-regional arrangements apply only to England
  23     and the exclusion of Wales was made clear. Secondly
  24     funding arrangements: we have no powers to determine
  25     referral practices which remain a clinical

   1     responsibility. HN(83)36 discourages health authorities
   2     from providing supra-regional services in units which
   3     are not designated as supra-regional centres", and this
   4     is the sting: "but this is not binding on clinicians."
   5        Referral practices therefore remain and remained
   6     a clinical responsibility. Did private professional
   7     decisions purportedly made in the best interests of
   8     patients, in fact harm patient care overall? No
   9     conclusions can be drawn at this stage. I must
  10     emphasise that, particularly on the basis of two
  11     documents which I have selected largely to impress you
  12     with the technology, but the issue is one for the
  13     Inquiry to consider.
  14        A moment or two ago, I showed you a document which
  15     contained a summary of numbers reported for
  16     Supra-regional Services Advisory Group. You remember
  17     the 50/55 operations. You may have thought that those
  18     numbers were definitive. Sadly, this may not be the
  19     case. Again, as a result of the work which we have
  20     already done, I can tell you that there is some
  21     uncertainty about the accuracy of those figures. For
  22     instance, if one goes back to the Bristol Royal
  23     Infirmary and open heart surgery in 1984, some records
  24     suggest that four open heart operations were conducted
  25     that year; others have it as three. It seems no

   1     definitive data was kept by the Bristol hospitals of the
   2     number of operations conducted. I hope I summarise our
   3     current information accurately and say a number of
   4     different systems, some on card index, some on computer,
   5     were kept for different periods by different
   6     individuals. At least one of those systems was
   7     unreliable, in part because no-one had sole
   8     responsibility for inputting information into it, and
   9     often medical staff did not enter information into the
  10     system which it was supposed to hold.
  11        The information on one system, which was
  12     maintained in recent years by cardiac perfusionists was
  13     maintained for three years or so, and then the computer
  14     and the information stored within it was stolen from the
  15     Trust. I do not want to bore you with the further
  16     details, save to say that they are contained in a letter
  17     of 9th March 1999, only last week, from John Grey on
  18     behalf of the Trust to the Inquiry, which we shall put
  19     before you as part of the documentation. Indeed, if
  20     I can just add, it has taken the Trust some three months
  21     to identify all these relevant clinical records.
  22        What, however, this indicates, is that there is
  23     a very great need for care in drawing conclusions too
  24     readily from data. Everybody here may already know that
  25     concerns were expressed by different people over

   1     a number of years about paediatric heart surgery at
   2     Bristol. The suggestion is that other centres may be
   3     better, or better at least for some if not many
   4     operations to which congenital heart defects give rise.
   5     That is easy to say, but it is actually very difficult
   6     to discover whether there is any truth in it. In 1987
   7     a TV programme was screened in Wales as a result of the
   8     Children's Heart Circle for Wales criticising the
   9     Bristol Royal Infirmary paediatric cardiac surgical
  10     unit. That alleged, and I quote, that a "degree of
  11     concern has been expressed by independent well-informed
  12     sources about the standard of operations carried out at
  13     the receiving centre in Bristol. It has been suggested
  14     that this concern is widely held."
  15        However, the author of those remarks was at pains
  16     to stress that such information -- and again I quote,
  17     "in no way represents hard evidence."
  18        On that occasion, there was a response from two
  19     cardiac surgeons: Mr Wisheart and Mr Dhasmana, and two
  20     cardiologists, Drs Joffe and Jordan, which asserted that
  21     the available figures showed that the allegations were
  22     totally false. They stated that the actual status of
  23     the facilities was better than most, and that the
  24     surgical results were at least equal to those achieved
  25     by other paediatric units elsewhere. Their figures were

   1     used to defend surgical practice at Bristol. I quote
   2     that incident to show how in the past a non-specific
   3     allegation backed up by no figures was met by figures
   4     which in themselves were controversial. Neither
   5     approach is good enough for this Inquiry. We shall not
   6     be using figures as a weapon, rather seeking to
   7     understand what the best available figures may show us.
   8        With that introduction, let me spend a little time
   9     dealing with the whole question of statistics: figures
  10     may help to clarify the picture, but here I come to what
  11     is my fourth main theme: they cannot, in themselves,
  12     provide an answer. Figures must be approached with
  13     care. For a start, they are necessarily general. There
  14     may be much force in a complaint of a parent who
  15     observes that her child is not just a number, but an
  16     individual. We must not lose sight of the fact that
  17     each case is truly individual.
  18        On 7th August 1990, Dr Bolsin, a consultant
  19     anaesthetist, drew attention in a letter to Dr Roylance,
  20     who was then the District General Manager and
  21     prospective Chief Executive of the UBHT, to what he
  22     considered to be excessive mortality in paediatric
  23     cardiac surgery. There followed several years of
  24     professional disagreement about the outcome and quality
  25     of surgery at the Bristol Royal Infirmary. The

   1     disagreement related at least in part to different
   2     interpretations of what the figures showed, and since
   3     then, various sets of figures have been looked at and
   4     interpreted by several others, both within the Bristol
   5     service and external to it.
   6        The panel will have to look at those figures and
   7     look at those interpretations, and ask, amongst other
   8     things, what those particular figures should have
   9     suggested to those who looked at them at the time. But
  10     how are we going to deal with the best figures
  11     available? What is the star by which we must steer?
  12     First, the Inquiry is not bound by the figures bandied
  13     around in the 1980s and 1990s in the Trust and outside
  14     it. Even though the GMC struck off one of the two
  15     cardiac surgeons who conducted open heart operations on
  16     children at Bristol, and censured the other, this
  17     Inquiry would lack integrity if it were not prepared to
  18     think the unthinkable: to contemplate that it may be
  19     possible, when all is said and done, that no valid
  20     conclusions can be drawn about Bristol. Of course, by
  21     contrast, the evidence which we uncover may indeed
  22     validly show that Bristol was the same as or different
  23     from other centres.
  24        This Inquiry has available to it much greater
  25     resources than anybody else who has attempted to examine

   1     the figures thus far, and we intend to use those
   2     resources to ensure that the figures are thoroughly
   3     analysed. This week, we will publish our framework for
   4     handling data. Let me outline the main elements of the
   5     strategy here and now.
   6        There is a range of data sources which is
   7     available at both national and local level, which may be
   8     relevant, first to show whether there is an apparent
   9     difference between the performance of Bristol and that
  10     of other centres in the UK, and secondly, whether the
  11     difference is consistent or sporadic, and if so, to what
  12     aspects of children's heart surgery it relates.
  13        The first of the national sets is the Hospital
  14     In-patient Enquiry (HIPE) which reported on a 10 per
  15     cent sample of deaths and discharges of patients from
  16     hospitals in England and Wales on a national basis until
  17     1985. Regional health authorities established systems
  18     of hospital activity analysis (HAA) similar to each
  19     other, which reported administrative and clinical data
  20     on all in-patients treated in NHS hospitals.
  21     Eventually, the 10 per cent samples, or HIPE, were drawn
  22     from those bases. Data was collected regionally but not
  23     reported nationally between 1986 and 1988. Then, in
  24     1989, following the recommendations of the Korner
  25     committee, a national reporting system based on all

   1     reported episodes of care, not just 10 per cent of them,
   2     was instituted.
   3        Over the period affected by the Bristol Inquiry,
   4     the data derived from patient administration systems
   5     (PAS) were aggregated regionally and transmitted
   6     nationally to an agency which analysed and reported the
   7     data for the Department of Health as Hospital Episode
   8     Statistics (HES). The coding of diagnostic information
   9     used in these systems over the period we are concerned
  10     with is based sequentially on the International
  11     Classification of Diseases, 9th Revision 1975, and 10th
  12     Revision 1992, the latter from 1995. The surgical
  13     operation data was coded according to the Office of
  14     Population Censuses and Surveys' Classification of
  15     Surgical Observations, 3rd Revision (until 1985), and
  16     4th revision from 1989. It became impossible to analyse
  17     and record clinical data in progressively greater detail
  18     and depth.
  19        In respect of paediatric cardiac surgery, data was
  20     sought independently of government from each hospital
  21     performing such surgery throughout such period with
  22     which the Inquiry is concerned, by the Society of
  23     Cardiothoracic Surgeons. They prepared a register of
  24     cardiothoracic surgery. Data from this source were used
  25     extensively at the GMC hearings. The data which were

   1     supplied voluntarily were not always complete, and there
   2     is a need to examine carefully the reliability of these
   3     returns.
   4        There are key questions to be asked about data
   5     coverage, data quality, how the data were collected, how
   6     the data were validated, and indeed, the potential
   7     comparability of data sources. This task, to appraise
   8     the quality of the data, is the first task for the
   9     Inquiry to undertake if it is to have any proper
  10     assistance from the available data sources. It will be
  11     published before any new computations or new tables are
  12     produced, to help to ensure that any conclusions
  13     reached, if indeed they can be reached from the data,
  14     are sound and capable of standing up to scientific and
  15     public scrutiny.
  16        May I please have slide SLD/1/1? Can it be turned
  17     around please? One of the great advantages of the
  18     system is that it allows us, as you see, to deal with
  19     things in landscape as in portrait style, but it may
  20     mean there is a moment or two of glitch.
  21        I can summarise the process of statistical
  22     investigation in this way -- the first stage, which
  23     I have dealt with, is "Preliminary (but vital) critical
  24     overview" of the sources of data. Let me identify each
  25     of the next three stages before dealing with them in

   1     detail. "Exploration", the second stage;
   2     "Confirmation", the third stage; "Explanation", the
   3     fourth stage. "Exploration" is to see whether the data
   4     suggests a difference in any and what respects between
   5     performance at Bristol and elsewhere. "Confirmation"
   6     examines whether the accuracy of the national
   7     performance figures and those from other centres can be
   8     confirmed; to see whether the Bristol performance can be
   9     calibrated against the results obtained on exploration
  10     of the data; and to make a judgment as to the degree of
  11     bias in the results -- "bias" here, of course, I am
  12     using in the technical sense.
  13        The third, "Explanation", looks to see to what
  14     extent explanation offered as to any apparent and
  15     confirmed difference between Bristol and other centres
  16     may be consistent or inconsistent with the data.
  17         Going back to the second of those, exploration is
  18     going to be a very considerable undertaking, and it
  19     involves two aspects: first of all, there is an exercise
  20     to look at the clinical record of every single child who
  21     had surgery at Bristol; to capture information about
  22     each child's diagnosis, the surgical procedure performed
  23     and the outcome. Secondly, it involves independent
  24     analysis of the national data to see what they can tell
  25     us about comparative performance. Although the Inquiry

   1     will be conducting its own analysis from the records
   2     themselves, the results will, where necessary, be
   3     cross-checked against existing local records.
   4        There are several local records, and sadly, none
   5     were complete. They were the surgeons logs, the
   6     operating theatre registers, the patient administration
   7     system (PAS), a cardiologist's card index system which
   8     was maintained from 1984 to 1988; the South Western
   9     Congenital Heart Register maintained by Dr Jordan until
  10     1993; and the Patient Analysis and Tracing System
  11     installed in 1992. Those will be cross-checked against
  12     other incomplete national sources, for instance, there
  13     may be some information to be gained from the National
  14     Confidential Enquiry into Peri-operative Deaths. You
  15     understand why I call that "NCE". In 1989 it conducted
  16     a particular survey of paediatric cardiac surgery, and
  17     you also have the Working Party report, of which
  18     I showed you a brief extract on the screen earlier.
  19        We intend to deal orally with the conclusions
  20     which expert statisticians reach in relation to the
  21     data. Since this is an Inquiry not a trial, we are able
  22     to deal with the issue by having two or three experts
  23     engage in public discussions with the limitations of the
  24     various data sources. Rather than the process of one
  25     expert at a time giving evidence independently

   1     cross-examined by a barrister on the basis of a lawyer's
   2     possibly limited understanding of expert issues, we
   3     anticipate a panel or group discussion, moderated as it
   4     were by me, and the experts should be able to determine
   5     whether the evidence suggests that Bristol has
   6     consistently or sporadically outlying performance, and
   7     hence whether the data raises further questions, and if
   8     so, what those questions are.
   9        Because of the comprehensive nature of this
  10     Inquiry, its determination to draw conclusions justified
  11     by the best available evidence, we cannot begin with any
  12     assumptions as to what those answers are going to be.
  13     Although, for our part, the legal team has looked at the
  14     various analyses produced by others throughout the
  15     history of this matter, it would be wrong to begin with
  16     any one of them. We are, in reality, in a better
  17     position to establish the facts if they can be
  18     established, than those who produced those studies.
  19        In summary, I repeat the fourth theme of my
  20     opening: the data, when it is analysed, may establish
  21     a difference between Bristol and other surgical centres,
  22     either comprehensively or in particular respects. If it
  23     shows this, it will lead us to ask what might be the
  24     reasons for the difference, but it cannot, on its own,
  25     establish what are those reasons. The most the data can

   1     demonstrate is an association between factors. They do
   2     not permit a conclusion about causation.
   3        Terms of reference as wide as they are, the fact
   4     that the Inquiry is looking at a process rather than
   5     a series of events, rather than an individual tragedy,
   6     the inadvisability of drawing conclusions from available
   7     data without private, detailed and public discussion,
   8     the sheer mass of documentary and statement material and
   9     the comprehensive nature of the Inquiry, may lead anyone
  10     to wonder how sense can be made of it all. If
  11     unreliable statistics are the currents which may pull in
  12     the wrong direction, what is the star by which to
  13     steer?
  14        This is where the Issues List comes in -- an
  15     issues list which I am pleased to say appears to have
  16     been well-received. The Issues List is of course
  17     inclusive. It provides a focus, but it must be
  18     remembered that not all of the issues which are listed
  19     in that list are of necessarily equal weight, nor will
  20     they necessarily receive equal treatment.
  21        The Issues List is not of purely intellectual and
  22     analytical significance. To demonstrate how it works,
  23     let me take a human example. First, let me, I think,
  24     remove the slide from the screen and have it blank,
  25     thank you.

   1        Let me take a human example. Suppose a baby is
   2     born some time between 1984 and 1995, so it is some time
   3     ago, and, say, somewhere in North Devon. Suppose that
   4     the baby, unknown to her parents, has a congenital heart
   5     defect. I will follow her through from birth to the
   6     outcome of treatment at Bristol hospitals, and comment
   7     on the issues as I go.
   8        At first the baby may not thrive. She may be off
   9     her food. She may show tinges of blueness, a peripheral
  10     pulse may be absent. The parents take the baby to their
  11     GP or a clinic, a doctor, perhaps, or paediatrician,
  12     notices the problems at the maternity hospital. Since
  13     the quality of outcome depends in many cases on the
  14     speed and quality of referral, the Inquiry has to
  15     examine that. It is issue E1.
  16        "The arrangements and services available to manage
  17     the transfer of sick children from referring hospitals
  18     to the Bristol Royal Infirmary."
  19        The local hospital perhaps it is, after referral
  20     from the GP, refers the child to a cardiologist from
  21     Bristol. This will be the first occasion when the
  22     parents come into contact with Bristol. The
  23     paediatrician chooses Bristol, but he might, arguably,
  24     have chosen Southampton, Birmingham, or even London.
  25     Why? On what basis? It is issues D2 to D5. I need not

   1     perhaps set them out: D2 is the judgment or impression
   2     formed by referring paediatricians or other clinicians
   3     of the paediatric cardiac surgical services provided by
   4     the BRI. D4 is the factors influencing clinicians, in
   5     deciding to refer children to the BRI rather than to
   6     other centres performing paediatric cardiac surgery.
   7        So our baby is referred for investigation and
   8     opinion. That may be by outreach at a clinic organised
   9     by Bristol but not at Bristol; for example, it is in the
  10     West Country. The process of assessment has to be
  11     looked at. The scope of the services provided is
  12     examined under issue B: was such a service readily
  13     available or not? Issue B looks at the BRI and its
  14     Paediatric Cardiac Surgery Unit, the management,
  15     structure, organisation and staffing of the Paediatric
  16     Cardiac Surgical Unit. Much may bear on the speed of
  17     the referral: whether the baby is referred as quickly as
  18     it might be elsewhere is issue C8, the adequacy of the
  19     assessment comes generally under issue E, the
  20     pre-operative management of cases.
  21        Suppose that the little girl in my example is
  22     seriously unwell and has to be admitted urgently to
  23     a Bristol hospital. What arrangements are there
  24     available to transfer her from the referring hospital to
  25     Bristol? If, for instance, she has difficulty in

   1     breathing and may be in heart failure, does a paediatric
   2     team transfer her, or is she in an ordinary ambulance?
   3     If so, are there adverse consequences for her.
   4        One of the questions is whether it is better for
   5     cardiac surgery to be available at a larger number of
   6     district hospitals to ensure immediacy of treatment and
   7     to avoid the adverse consequences of transfer and the
   8     time it takes; or, conversely, whether it is better to
   9     concentrate it in fewer centres of regional, or fewer
  10     still of national excellence, to ensure that surgeons,
  11     cardiologists, intensivists, anaesthetists, are familiar
  12     through repetition with almost any unusual variant of
  13     congenital heart disease. That is where issue A comes
  14     in: the regional and national context.
  15        Our baby arrives in Bristol: is it at the Bristol
  16     Children's Hospital, or is it the Bristol Royal
  17     Infirmary? At the former, it is set up solely for
  18     children, but children undergoing different surgery,
  19     perhaps wards with cancer and heart patients mixed, some
  20     babies, some near adolescents. The latter is an adult
  21     hospital: is it suitable for children? So we find
  22     ourselves looking at issue H, the split site, as well as
  23     issue E, pre-operative care.
  24        Soon after admission, the little girl is likely to
  25     have an echocardiogram, or possibly an angiogram. In

   1     1988, as a matter of fact history, facilities for both
   2     were much improved at the Bristol Children's Hospital,
   3     as they were for catheterisation. The possible impact
   4     of this is to be borne in mind when looking at review
   5     cases of medical audit, issue M, and when drawing
   6     lessons from the data considered as part of issue C,
   7     the nature and outcome of the services provided.
   8        The results of the baby's investigations have to
   9     be considered before any surgery is undertaken. The
  10     decision has to be made as to whether to treat the child
  11     by closed or by open heart surgery; it may be, for
  12     instance, that palliative procedure can be carried out
  13     now, to be followed at a later stage by corrective
  14     surgery. The Inquiry will seek to establish how those
  15     discussions were taken, by whom and what the process
  16     was. Who was it who took ultimate responsibility? What
  17     were the parents told?
  18        Moreover, unless surgery is so urgent that it
  19     cannot wait, it has to be fitted in at some time. As to
  20     timing, delays may have occurred in the surgery of
  21     babies. Did this harm them? Were other delays caused
  22     by what is euphemistically called "shortage of beds"?
  23     That is a phrase suggestive of the inability to afford
  24     a metal bedstead and mattress, but in reality is often
  25     a question of the availability of sufficient trained and

   1     paid staff. Does this mean that although everyone knows
   2     the little girl should ideally be operated on between 9
   3     months and 12 months of age, she may in fact have to
   4     wait until 14 to 15 months to fit in? On the other
   5     hand, did the availability of finance play a part? Did
   6     the fact that surgery for the under ones was paid for
   7     directly out of the national pot mean that surgery may
   8     have been brought forward when it might better have been
   9     delayed? These are all part of issue E, specifically,
  10     E6 to 9, and again, I shall not bore you with reciting
  11     the actual issues.
  12        As to information given to parents, for instance,
  13     whether there may be legitimate grounds for debate as to
  14     the best procedure in the interests of the child, are
  15     the parents of the little girl in my example told?
  16     Suppose that the cardiologist and surgeons know that
  17     they can perform a procedure which may give her life for
  18     some 10 or 20 years, which is of much lower risk than
  19     a procedure which, if it succeeds, will probably give
  20     life for 60 or 70 years? But which, if it fails, will
  21     lead to speedy death. Whose decision is it to perform
  22     such an operation? To what extent are the parents asked
  23     for their views?
  24        We are looking here not only at issue E, but also
  25     at issue L, L being informed consent. Moreover, when

   1     the parents are told of the risk of the operation, are
   2     they told the risk the surgeon has experienced or is it
   3     the risk which the unit has experienced, or is it the
   4     last reported national record, or is it from
   5     a textbook?
   6        Returning to our baby, explanations will be given
   7     to the parents of our child about the condition, the
   8     need for surgery and the risks, but not just about
   9     surgery; also in relation to the continuing care of the
  10     child. If surgery is to be delayed, it may be of great
  11     importance to the parents to know what they should best
  12     do to watch their child and to protect her and to
  13     strengthen the baby for later operation.
  14        Again, issue E, in particular E11 and E15, and E15
  15     I just need to quote. You will understand how it fits
  16     in: liaison of staff with parents and the participation
  17     of parents in the assessment and care of their child.
  18        Eventually, let us suppose that the baby goes for
  19     open heart surgery. The conduct of this is issue F.
  20     Many factors may go to make the operation on the child
  21     successful or the reverse. The British Paediatric
  22     Cardiac Association will tell the Inquiry that to look
  23     just at the role of the surgeon, the skills of whom are
  24     an obvious factor, issue F1, is to take too simplistic
  25     an approach. Systems failure is very important and the

   1     role of others deserves emphasis too. So we shall look
   2     also at the skills of those other than surgeons
   3     assisting at the operation, and we shall look at the way
   4     they work as a team.
   5        The reliability of the pre-operative assessments
   6     with which they begin are one factor, as are the less
   7     obvious ones, such as the design and performance of
   8     equipment, the hours of work, the familiarity with the
   9     work and the effect that this may have on how long the
  10     procedure takes. Timing might be critical: for
  11     instance, the amount of time spent on by-pass, or the
  12     cross-clamping times.
  13        So far as one can tell, were operations carried
  14     out at Bristol in the same manner as they were elsewhere
  15     at the same time? Issue F.
  16        Suppose the baby spends a long time in theatre.
  17     What about her parents? How have they found what is
  18     undoubtedly an anxious time? Issue I: treatment of
  19     families. Were there adequate facilities to help them
  20     and to help them to help their child? Suppose that the
  21     little girl in my example comes through the operation.
  22     What now? She goes to ward 5 in the Bristol Royal
  23     Infirmary, into intensive care where adults and babies
  24     are cared for together in a single ward. It has often
  25     been said that the hours following difficult surgery may

   1     be critical to survival. Our issue G looks at this.
   2        The baby's parents will want to know how far the
   3     ICU, the Intensive Care Unit, meets or met any published
   4     standards. Bear in mind, standards have changed over
   5     the period with which we are concerned.
   6        Issues overlap here, as they do elsewhere. The
   7     split site, which is issue H, may have an impact, for
   8     the care may be provided to the baby in the Bristol
   9     Royal Infirmary, where I have for the purposes of this
  10     journey placed her. As I say, there she will be in
  11     a ward which will have adults undergoing intensive care
  12     and the Association of Paediatric Anaesthetists will
  13     tell the Inquiry that having just one site is a matter
  14     of importance because of the availability of facilities,
  15     clinicians and infrastructure and the Inquiry will have
  16     to consider to what extent its absence, the fact there
  17     was not just one site, makes a difference to our baby.
  18        Intensive care may demand very different things
  19     from those nursing adults to those who nurse children.
  20     How is the mix arranged to avoid potential disadvantage?
  21        At a later stage the baby may be taken from the
  22     BRI for intensive care at the Children's Hospital. That
  23     involves a transfer, with any attendant risks. The
  24     surgeons are no longer on hand for urgent consultation.
  25     But paediatric expertise may be more readily available.

   1        Sadly, let us suppose, that some days after the
   2     operation, our baby loses the fight for life. Issues I,
   3     the treatment of families, including the bereaved, and
   4     issue G, post-mortems and inquests, are raised, and the
   5     Inquiry will want to consider carefully, particularly in
   6     view of recent events, whether appropriate information
   7     is given to her parents first about what may have caused
   8     her death (issue J), and second, whether consent, if it
   9     is required by law, was properly and sensitively sought
  10     for the post-mortem and for the retention of tissue or
  11     organs of the body, and if it was not required, whether
  12     proper and adequate information about that matter was
  13     given to parents in an appropriate fashion.
  14        Finally, was the death of the child reviewed
  15     internally by the clinical staff to see if any lessons
  16     could be learned? Was it placed in context, such that
  17     the clinical staff had a proper appreciation of their
  18     level of success or failure, reviewed in a manner which
  19     might help to aid performance for the future?
  20        Perhaps, more particularly, if in a happier
  21     example, the child survived but had almost died, was
  22     there any attempt to learn from the near miss, so that
  23     the same risks were never taken again?
  24        The journey of the child that I have described
  25     takes place in a particular setting. To understand it

   1     and the factors at play this Inquiry needs to set it
   2     into context. That obviously includes the organisation
   3     of the Bristol Royal Infirmary, physical, managerial,
   4     administrative. It involves the relations between
   5     personnel; the role of outside bodies from the Royal
   6     Colleges to the GMC, and, indeed, the Department of
   7     Health itself. If, for instance, available reports
   8     indicated that Bristol was a significantly poor
   9     performer of paediatric services to the under ones,
  10     should something have been said about it? Was there
  11     a role here for the professional bodies?
  12        In the hypothetical journey that I have described,
  13     I appreciate that I have said, really, very little about
  14     the last issues in the Issues List, issues M and N, the
  15     review of cases, medical and clinical audit and the
  16     expression of concerns. That is because these issues
  17     arise not so much out of the treatment of any individual
  18     baby, they arise out of the history of the service as
  19     a whole, and that is perhaps so well known that I need
  20     not recite it in detail.
  21        I have, I think, for completeness, to touch on it
  22     a little, and some aspects of that history may be known
  23     to many from sources such as Private Eye. Others I have
  24     already touched on when I referred to the December
  25     agreement there had been between Dr Bolsin and others,

   1     and Mr Wisheart and others about the lessons to be
   2     learned from available data. It is unnecessary in this
   3     option to examine the rights and wrongs of that
   4     disagreement. Firstly, the Inquiry does not and cannot
   5     begin with conclusions. My present purpose is simply to
   6     record that it happened as a matter of history. It is
   7     also a matter of history that the concerns which
   8     Dr Bolsin had were expressed both within the local
   9     service, in particular to senior colleagues, and outside
  10     it to the Royal College of Surgeons, and that they came
  11     to the attention of the South West Regional Health
  12     Authority and to the Department of Health. Those
  13     concerns were based at least in part on the figures
  14     Dr Bolsin saw.
  15        Matters came to a head in 1995, the final year of
  16     our terms of reference. That was the year in which
  17     Mr Dhasmana performed an arterial switch operation which
  18     provoked particular controversy. The child died in the
  19     operating theatre. Following that, complex neonatal and
  20     infant cardiac surgery was suspended, pending the
  21     appointment of Mr Ash Pawade in the May of that year as
  22     a specialist paediatric cardiac surgeon. Since then,
  23     media programmes, Despatches, Panorama in particular,
  24     have raised criticisms of the paediatric cardiac
  25     surgeons in Bristol. The GMC has heard and considered

   1     charges against Mr Wisheart, Mr Dhasmana and Dr Roylance
   2     and a number of legal actions have been taken by parents
   3     against the Trust.
   4        The GMC proceedings attracted considerable public
   5     interest. They were monitored closely by the parents on
   6     whose children the surgeons operated.
   7        On 1st June 1998, the BBC aired a programme on
   8     Panorama about the events in Bristol of the doctors
   9     involved and that focused on the unsuccessful switch
  10     operation I have mentioned. The allegations made in the
  11     programme were whether those operations proceeded
  12     without the opposition of Dr Bolsin of the surgical unit
  13     the night before the operation and without the knowledge
  14     of the child's parents, and very shortly, on 18th June
  15     1998, Frank Dobson, Secretary of State for Health,
  16     announced to Parliament that an Inquiry would be
  17     established to enquire into the management of children's
  18     heart surgery at the BRI and to reach conclusions and
  19     make recommendations to secure high quality care across
  20     the whole NHS.
  21        That is our task.
  22        In conclusion, then, I hope I will be forgiven for
  23     yet again repeating and emphasising my four main themes:
  24     first, this Inquiry starts with a clean slate. It has
  25     many questions to ask, but as yet no answers. It has to

   1     be open. The Inquiry is just that: an inquisitorial
   2     process, not a trial. There is no case to win or lose,
   3     there are no sides and accordingly the procedures will
   4     not be those of a court of trial.
   5        Secondly, the Inquiry is comprehensive. It will
   6     and must look at a mass of evidence and do so afresh.
   7     Third, it is a Public Inquiry. It will be the most
   8     accessible Public Inquiry yet, through video links, the
   9     Internet, the publication of formal evidence as it is
  10     received for our consideration and in consequence, much
  11     of it will be in writing. (4) in so far as the figures
  12     are concerned, we must proceed with caution, remembering
  13     that if, after careful expert consideration, they do
  14     demonstrate a difference between Bristol and other
  15     centres, they still do not answer why that difference
  16     exists.
  17        If I had to select a fifth theme, to reflect the
  18     issues that will act as our star, our point of
  19     reference, it is perhaps this: to focus, to the
  20     exclusion of other concerns, on that which the surgeons
  21     did will be to select only a part, albeit a dramatic and
  22     obvious part, of the whole story. Whether an operation
  23     succeeds or not may well depend on many other less
  24     visible but nonetheless real factors. One of the
  25     purposes in sketching through the hypothetical case

   1     history is to emphasise that pre-operative care,
   2     post-operative care, organisational structures,
   3     financial and human constraints and the communication of
   4     information in an effective and sensitive way, are all
   5     likely to have an outcome, an impact, on the outcome of
   6     surgery. Also, to focus solely on the surgeon's role at
   7     operation in Bristol, or anywhere else, prevents our
   8     seeing the wider context and implications.
   9        Finally, let me remind you that the first block of
  10     evidence in Phase I is that from parents. As with all
  11     other witnesses, they will be encouraged to tell their
  12     story as they see it. It is their story that the
  13     Inquiry wants to hear on its way to reaching
  14     conclusions.
  15        It is of course our duty to test recollections and
  16     the view expressed, for instance, if they are
  17     inconsistent or not borne out by documentary evidence,
  18     and equally, it is our duty to put questions which
  19     others will wish to hear the witness deal with, whenever
  20     this will further the Inquiry's interests.
  21        Counsel, in opening the case, often tell a court
  22     or a jury what they are going to hear, and they put
  23     together a picture they wish to paint before the first
  24     brushstroke of the evidence is ever applied. Here there
  25     is no case, as I have said a hundred times, and it is

   1     better that the witnesses tell their own story than that
   2     I give you my version of it in advance. The evidence
   3     should come from them, not from me.
   4        Having set out the procedure which the Inquiry
   5     will adopt, may I simply say that block 1 begins
   6     fittingly, you may think, with some parents telling
   7     their individual stories. However much we may talk of
   8     systems or audit, or self-regulation of the profession,
   9     or statistics, it should never be forgotten that it is
  10     the care of individual human lives that is the centre of
  11     our concern.
  12        Today we will hear from Mrs Clarke. It will be
  13     probably at about half past 1, I suspect. Tomorrow we
  14     shall hear from Mr Wagstaff, whose child survived
  15     surgery, and Mr Parsons, whose child did not. May
  16     I hope that, however you perceive their answers to me,
  17     you accept it as their personal perspective. And please
  18     remember that it cannot be easy to give evidence so
  19     publicly about matters which are inevitably deeply
  20     personal.
  21        Ladies and gentlemen, members of the panel, thank
  22     you.
  23   MEMBER OF THE PUBLIC: I trust you will forgive me for
  24     coming into this meeting. It has been of public concern
  25     for many, many years, regarding paediatric care, which

   1     is limited, seriously flawed and well overdue for public
   2     scrutiny. I trust you dear parents here today will take
   3     and understand that this token that I am putting will
   4     remain on the table right throughout the Inquiry to
   5     bring to realisation your loved ones who will never be
   6     forgotten, and out of their tragedy, much good will
   7     come, and future generations will have a service of
   8     excellence, which all caring mothers so desperately at
   9     the present moment are crying out for.
  10        I thank you for giving me this moment. I know
  11     I have gate-crashed your meeting. I have done it for
  12     a purpose. I did not want to involve anybody. I just
  13     think it is a token of the most wonderful gift in life,
  14     the life of a child, and it does not matter what your
  15     profession is or what your status is in life, the most
  16     wonderful thing in life is a child. I trust, Professor
  17     Kennedy, and all the other gentlemen whose names
  18     I cannot remember, I trust you will take this as a token
  19     of tremendous love from the one above, who I feel sure
  20     will give us all the strength to see this Inquiry
  21     through, and as I said, in the remembrance of all your
  22     thoughts. Thank you.
  23   THE CHAIRMAN: May I intrude on you simply by asking your
  24     name?
  25   MEMBER OF THE PUBLIC: My name is Joan Bye.

   1   THE CHAIRMAN: Thank you for coming and talking to us. You
   2     and I know each other from past conversations. I am
   3     grateful to you. You remind us quite properly of the
   4     degree of despair, frustration and to a sense, also
   5     hope, that something may come from this Inquiry. All
   6     I can assure you is that my colleagues and I will do our
   7     very, very best to ensure that something positive may
   8     come from this Inquiry. It will take some time, but we
   9     will do our very best. Please, now, come and sit down,
  10     and then I will just say one other thing. It is that we
  11     shall take a break now. Thank you, Mrs Bye. We shall
  12     take a break now and the break will be for 45 minutes.
  13     We shall reconvene at 1.30 and when I say the break will
  14     be 45 minutes, it will be 45 minutes and we will
  15     reconvene at 1.30. Our first witness then we shall hear
  16     will be Mrs Tracey Clarke. Thank you, and I will see
  17     you again at 1.30.
  18   (12.45 pm)
  19               (A short break)
  20   (1.30 pm)
  21   THE CHAIRMAN: It is now 1.30, and I do wish to begin if
  22     I may.
  23        May I briefly, before we go on, refer to the
  24     closing of this morning's session? I thought it
  25     appropriate in the circumstances to allow the short

   1     speech. I would not, however, expect it to happen
   2     again. I recognise the depth of feelings that were
   3     aroused, and I offer my sympathy.
   4        Now let us move on. Mr Langstaff?
   5   MR LANGSTAFF: Mr Chairman, may we call Tracey Clarke,
   6     please?
   7   MR LANGSTAFF: Mrs Clarke, in a moment or two I am going to
   8     ask you to take the oath, which all witnesses will be
   9     asked. Because you are the first, let me explain the
  10     procedure. If you would not mind standing for the oath
  11     and then sitting for your evidence, or standing as you
  12     feel fit.
  13            MRS TRACEY CLARKE (Sworn):
  14            Examined by MR LANGSTAFF:
  15   Q. You are Mrs Clarke?
  16   A. Yes.
  17   Q. And you prefer to be known as Tracey?
  18   A. Yes.
  19   Q. You are, I think, 36 years of age?
  20   A. Yes.
  21   Q. And married, and you have two children?
  22   A. Yes.
  23   Q. That is a son, and I do not suppose that -- you remember
  24     his date of birth?
  25   A. I can: 28.9.88.

   1   Q. And you have a daughter, I think, Charlotte?
   2   A. Yes.
   3   Q. When was she born?
   4   A. She was born on 9.9.92.
   5   Q. What I am going to ask you about, Mrs Clarke, is a third
   6     child, who would have been your second. She was called
   7     Melissa?
   8   A. Yes.
   9   Q. Was she born at the Tiverton District Hospital?
  10   A. Yes.
  11   Q. That was on 9th November, 1990?
  12   A. Yes.
  13   Q. As far as you recall, you had a normal pregnancy and
  14     a normal delivery?
  15   A. Yes, everything was fine.
  16   Q. She was born about 8.30 in the morning?
  17   A. Yes.
  18   Q. And everything seemed well at first?
  19   A. It was fine for about an hour.
  20   Q. Perhaps, Tracey, you can tell us when you first realised
  21     that something might not be all right?
  22   A. The midwife took her to give her a bath and I think she
  23     realised, as she was bathing her, that something was not
  24     right. She was crying the same as a lot of other
  25     babies, and she noticed the difference in the babies.

   1     Instead of going bright red as babies do when they cry,
   2     she was turning blue, so she called out the Exeter crash
   3     team to come and investigate, to see if there was
   4     something wrong with her.
   5   Q. So let us just go back over that. This is not something
   6     which you saw yourself as you went over there --
   7   A. No, I was told. This is what she told us.
   8   Q. Was the first thing you knew that the crash team
   9     arrived?
  10   A. Yes. The first thing I knew was, after I had been
  11     sorted out and I was just about to get into a bed on the
  12     ward, they came over and said there was a problem with
  13     Melissa and would we go and sit and wait for the crash
  14     team, and they came very shortly afterwards.
  15   Q. Did you ever get to your bed in the ward?
  16   A. No, I did not.
  17   Q. How long did it take for the crash team to arrive?
  18   A. From when I knew about it, it was very shortly. It was
  19     within 10 minutes of me finding out, they were there.
  20   Q. How long after the birth of that baby, roughly?
  21   A. I would say about an hour and a half to two hours from
  22     the time of the birth to when they arrived.
  23   Q. Did you see what the crash team did when they came?
  24   A. Not really. I know they put her in an incubator.
  25   Q. Because you have been told that?

   1   A. No, I saw her in the incubator. They just put her in an
   2     incubator, to take her straight to Exeter.
   3   Q. Did you go with her to Exeter?
   4   A. No. They took her in an ambulance, I went up to my
   5     parents and they then drove us into Exeter.
   6   Q. So you knew where she was going and what had happened?
   7   A. Yes.
   8   Q. Did you go with Melissa?
   9   A. No, because at the time it would have left my husband on
  10     his own and I did not want to leave him on his own, so
  11     we travelled together.
  12   Q. You were worried, I am sure?
  13   A. Yes.
  14   Q. Your son Lewis?
  15   A. He was with my parents at that time.
  16   Q. So you went to Exeter?
  17   A. Yes.
  18   Q. And what did you find when you got there?
  19   A. She had been put in the intensive care unit and we went
  20     in to see her, and then we were put on a ward and just
  21     left.
  22   Q. You were put on the ward and just left?
  23   A. I was told "That is your bed", and we were just left
  24     sitting there. The doctor did come in and said that
  25     they did not think there was much wrong with her; she

   1     had what they call a shunt and that shunt was closed,
   2     they thought she would be fine.
   3   Q. Can you tell us anything about the doctor? You knew it
   4     was a doctor?
   5   A. Well, I assumed it was a doctor.
   6   Q. So it might not have been?
   7   A. It was somebody who came to tell me about Melissa.
   8     I just assumed it was a doctor.
   9   Q. So you just relied on whatever it was you were told by
  10     whoever was telling you?
  11   A. Yes.
  12   Q. And the doctor was a woman?
  13   A. Yes.
  14   Q. That reassured you, did it?
  15   A. Yes, well, I thought "That is fine. She is going to be
  16     okay. There is nothing seriously wrong", because in
  17     Tiverton I had not been told there was anything
  18     seriously wrong, they just wanted to make sure. When
  19     she said "Everything is going to be fine", then
  20     I thought, "Well, that is great", you know, "We will be
  21     able to take her home soon".
  22   Q. How long had you had to wait before the doctor came to
  23     talk to you?
  24   A. I do not know. About half an hour, an hour, they came,
  25     and then she went and I was just left, then, I did not

   1     see anybody. Nobody came to see me or check on me at
   2     all.
   3   Q. Did they know you had just given birth?
   4   A. Yes, well, I mean the they knew Melissa was only
   5     a few hours old.
   6   Q. Did Melissa come home with you that night, or was she
   7     kept in?
   8   A. No, she was kept in. I was eventually seen to, and
   9     admitted properly, and checked up on, on the ward.
  10   Q. How long after your arrival was that?
  11   A. About four hours after we got there, three or four hours
  12     after we got there.
  13   Q. Where you were was in the maternity ward, was it?
  14   A. Yes. It was not very far from the Intensive Care Unit.
  15     You have the corridor and it was just up and next to
  16     that. It was straight down -- it was only a few metres,
  17     really, around the corner down to the Intensive Care
  18     Unit.
  19   Q. Of course, we are talking about the Exeter Hospital
  20     here, not about Bristol Hospital?
  21   A. That is right.
  22   Q. I want to deal with how Melissa came from Exeter to come
  23     under the care of the Bristol hospitals. I think you
  24     had discussions, did you, with a doctor by the name of
  25     Penny Dyson?

   1   A. Yes.
   2   Q. And she gave you some information, did she, which rather
   3     frightened you?
   4   A. Yes. The morning after I had given birth, the next day,
   5     I went down to see Melissa, thinking that everything was
   6     going to be fine. When I walked in, there were several
   7     doctors around her, and Penny looked up and said that
   8     she thought there was a 50:50 chance of her surviving,
   9     which was a big shock to me, as I had been told the day
  10     before everything was going to be fine. So I just
  11     walked out and went into another room and sat there for
  12     a while, because I was on my own, my husband and that
  13     had gone home. Eventually a nurse came in to see me and
  14     said they were doing what they could for her, but she
  15     did not know what the outcome was going to be.
  16   Q. Can I just go back over that? This was the first you
  17     knew, was it, about the seriousness of the condition?
  18   A. Yes, this was the first I had been told.
  19   Q. You learned that on the ward from somebody you later
  20     realised --
  21   A. I got up in the morning, walked straight in to see
  22     Melissa. What greeted me was the doctors around her bed
  23     and them looking at me and saying she only had a 50:50
  24     chance, and that was the first I was told.
  25   Q. So Melissa stayed at the Heavitree Hospital, did she?

   1   A. Yes, she stayed there for a week, while they gave her
   2     about seven different drugs, because they did not have
   3     a clue what was wrong with her.
   4   Q. So far as you saw, or you can say, do you know whether
   5     they sought any help from outside the hospital?
   6   A. Not until, on the Monday, after -- she was born on the
   7     Friday. On the following Monday I was told that she
   8     would have to have this special scan, but they did not
   9     have the expert at Exeter to do the scan.
  10   Q. Just let me stop you there. This is three days after
  11     the birth?
  12   A. Yes, three days after the birth.
  13   Q. She was born at 8.30 in the morning on the Friday, and
  14     this is the Monday?
  15   A. I know over the weekend they sent off cultures and that,
  16     to see if they could --
  17   Q. Because you have been told that?
  18   A. Yes. On the Monday they said they needed an expert to
  19     look at the scan of her heart, to see if there was
  20     a heart problem. I was told that if there was a heart
  21     problem, they would send her to Bristol. If there was
  22     no heart problem, they would probably still send her to
  23     Bristol, because they would not know what was the matter
  24     and Bristol would probably find out better.
  25   Q. Let me take this stage by stage. You understood that

   1     she had to have some investigation to see whether there
   2     was a heart problem?
   3   A. Yes.
   4   Q. Who did you understand was to carry out that
   5     investigation?
   6   A. First of all they were going to get an expert in from,
   7     I think it was from Bristol to read the scan, but at
   8     Bristol they had a different scan which shows it more in
   9     depth which they do not have at Exeter, but they might
  10     have been able to see the problem with the other scanner
  11     that they had at Exeter.
  12   Q. So Exeter were telling you that they were not equipped
  13     to investigate properly?
  14   A. No. They did not have the equipment or the experts to
  15     do it.
  16   Q. But that Bristol would?
  17   A. Yes.
  18   Q. And when the doctor spoke to you about Bristol
  19     conducting the investigations, was it a him or a her
  20     that spoke to you about that?
  21   A. It was a him. The consultant was a him.
  22   Q. Did he say, "Well, would you prefer to have this dealt
  23     with in Bristol or Southampton"?
  24   A. No, I was just told they would have to get this expert
  25     in to look at her heart, and then decide what they were

   1     going to do.
   2   Q. The reason for it being Bristol was that that is where
   3     there were better facilities?
   4   A. Yes.
   5   Q. How long was it before the expert was available?
   6   A. Thursday, from the Monday.
   7   Q. So that is a further three days?
   8   A. Yes.
   9   Q. As you understood it at the time, was that an important
  10     delay, to you as her mother?
  11   A. It was. At that time I could not understand why they
  12     did not just send her to Bristol. If they were going to
  13     have to send her to Bristol whatever the outcome, if
  14     they found something wrong or if they did not find
  15     something wrong, even at that time, I could not
  16     understand why they did not just send her to Bristol, if
  17     that is where they had the better facilities to deal
  18     with her.
  19   Q. When she did go to Bristol, was that by ambulance?
  20   A. Yes.
  21   Q. That was on the Thursday, was it?
  22   A. That was on the Friday.
  23   Q. So the day after she was seen by the expert from
  24     Bristol?
  25   A. Yes, they sent her on Friday morning. She went straight

   1     up to Bristol.
   2   Q. As soon as the experts saw her, she was off to Bristol?
   3   A. Yes.
   4   Q. Do you have anything to say about whether that should
   5     have been earlier rather than later?
   6   A. Yes, I mean, they did her no good at all in Exeter. She
   7     had spent a week in Exeter without anything really being
   8     done for her, and if she had gone straight to Bristol,
   9     it would have been a lot better for her at that time.
  10   Q. When she went to Bristol, she went by ambulance. Did
  11     you go with her?
  12   A. We followed behind in our car.
  13   Q. Why was that? Was that for your convenience?
  14   A. Well, yes, plus we would have a car up there, and also,
  15     they had a lot of people sort of looking after her.
  16   Q. When you say "we", that was you and your husband Graham,
  17     was it?
  18   A. Yes.
  19   Q. So your child was still being cared for by his
  20     grandparents?
  21   A. Yes.
  22   Q. When she arrived on the Friday at Bristol, what
  23     happened?
  24   A. They took her straight into a room where a Dr Joffe did
  25     a scan on her, which -- you can see the colours of the

   1     blood on the scan, I am not sure of the name. Within 10
   2     minutes of her arriving at Bristol, he said what was
   3     wrong with her, said that she had what was called
   4     transposition of the greater arteries, that she would go
   5     up and have a small operation which was a balloon
   6     septostomy, and we would probably be able to take her
   7     home within a few days and in 9 months time she would
   8     come back for another operation.
   9   Q. What at that stage did you think about the degree of
  10     care?
  11   A. I was thrilled to bits from her being at Exeter and
  12     nearly dying and not knowing whether she was going to
  13     live, and being sent to Bristol and somebody saying "You
  14     can have this, you can take her home", I was really
  15     thrilled to bits.
  16   Q. From the description you have given of what I think is
  17     an echocardiogram, you actually saw the echocardiogram,
  18     did you, the picture?
  19   A. Yes.
  20   Q. Was that with Dr Joffe?
  21   A. Yes.
  22   Q. When you saw that picture with him, was any explanation
  23     given to you about what you were looking at?
  24   A. Yes. He told me that the arteries were the wrong way
  25     round, and instead of having red blood, oxygenated blood

   1     pumped around her body, she was having blue blood,
   2     unoxygenated blood, around her body.
   3   Q. I shall ask you this again, and other parts of your
   4     account to us, but obviously since everything happened
   5     with Melissa, you have had a lot of time to think about
   6     matters?
   7   A. Yes.
   8   Q. I think that it is no secret that you are contemplating
   9     issuing legal proceedings in the near future in respect
  10     of her death?
  11   A. Yes.
  12   Q. Dealing with your memories of what Dr Joffe said to you
  13     at Bristol, are you, do you think, reading into your
  14     memories words which you are now familiar with, like
  15     balloon septostomy?
  16   A. No, I knew it was a balloon. He specifically said
  17     "balloon". That is why I remember that. That is
  18     something I have always remembered, from that time.
  19   Q. What about the septostomy?
  20   A. No -- the septostomy, he actually said the balloon
  21     septostomy was what ...
  22   Q. You remembered that at the time?
  23   A. Yes, I think I did.
  24   Q. I think later on, when you came to deal with matters
  25     with the GMC, you called it an "osotomy". But it was

   1     a balloon, anyway?
   2   A. Yes, it was near enough. I missed off the "sep", but
   3     I knew it was --
   4   Q. The picture you had was that it was a balloon?
   5   A. Yes.
   6   Q. What was the balloon going to do?
   7   A. It was going to open up the hole in her heart that
   8     Exeter had said was the problem in the first place to
   9     make sure she had enough oxygen going around her body to
  10     keep her going until she could go for a proper
  11     operation.
  12   Q. That is the understanding Dr Joffe gave you at the time?
  13   A. Yes.
  14   Q. It is not something you learned afterwards?
  15   A. No, that is what he told me at the time.
  16   Q. If he told you when she was about 9 months old she
  17     needed to go for a bigger operation, that would make her
  18     about 9 months of age when she would have the operation?
  19   A. Yes.
  20   Q. She was by now just over a week old?
  21   A. Yes.
  22   Q. Did he say anything about the nature of that later
  23     operation?
  24   A. Not that I can recall at that time, no. No.
  25   Q. So on the Friday Dr Joffe operated, did he, and

   1     performed the balloon septostomy?
   2   A. Yes.
   3   Q. And Melissa and you came home, what, after a couple of
   4     days?
   5   A. No, she had to stay up there for another week.
   6   Q. When you went to pick her up, did you see anyone?
   7   A. No. We saw Dr Martin on the Wednesday. We stayed there
   8     for the weekend, and went home on the Sunday, and then
   9     we went back up on the Wednesday, where they had taken
  10     her for ventilation. We saw Dr Martin then.
  11   Q. What was Dr Martin, as you understood it?
  12   A. At that time, I did not really know who Dr Martin was.
  13     I assumed he was somebody who did the operation. I am
  14     not sure. The way he spoke to us, it sounded like he
  15     was somebody who did the operation. At that time,
  16     I must admit, I was not sure who he was. I was just
  17     told he was somebody in charge of Melissa at that time.
  18   Q. Did you ask about Dr Joffe and where he was?
  19   A. No, I did not.
  20   Q. Do you remember how the conversation went with
  21     Dr Martin?
  22   A. Dr Martin told us that she was going to have an
  23     operation. He showed us diagrams of the operation
  24     which, to me, looked like -- it said "switch" -- it did
  25     not look to me like a switch because I did not know what

   1     switch was, but it had "switch" written on the
   2     diagrams. He told me at the time there was a 95 per
   3     cent success rate with that, and he told me that he or
   4     they could do the operation well.
   5   Q. I want to ask you about each of those. The diagrams
   6     that he showed you: the way you described that suggests
   7     they were diagrams which were ready and prepared?
   8   A. It was, yes.
   9   Q. So they were in colour, were they?
  10   A. No, like a sort of blue, like a sort of blue ink.
  11   Q. But he did not draw them for you, in front of you?
  12   A. No, he did not draw them himself. It had "transposition
  13     of the greater arteries" and then diagrams of the heart
  14     and the operation.
  15   Q. And you remember the word "switch"?
  16   A. Yes.
  17   Q. Where was that, on the page?
  18   A. I do not know whether it was on the page or whether he
  19     said it, but that is the first time I had heard about
  20     that operation.
  21   Q. So he may have said it, or it may have been on the page?
  22   A. Yes. I cannot say I am sure about either.
  23   Q. Did you understand what needed to be switched?
  24   A. Yes. I had been told that the arteries were the wrong
  25     way round and they had to be switched back to where they

   1     should be.
   2   Q. Was it the arteries or the veins?
   3   A. Arteries. I have arteries in my mind and that is what
   4     I always thought: arteries.
   5   Q. You recall that Dr Martin said he or they would do the
   6     operation?
   7   A. Yes. At that time, I thought it sounded like Dr Martin
   8     was the one who was going to do the operation. It was
   9     not until a while later I found out he was not the
  10     surgeon.
  11   Q. You know now he is a cardiologist?
  12   A. Yes. I found that out at that time, before I realised
  13     the difference. At that time I had never dealt with
  14     hospitals or heart operations or surgeons or anything,
  15     so I did not really know at that time who was what.
  16   Q. But you accept that he may have said either he or they
  17     would have done the operation?
  18   A. Yes.
  19   Q. So to that extent, your memory of the conversation is
  20     a bit shaky?
  21   A. Yes.
  22   Q. I expect your main concern was simply to know that
  23     Melissa was going to come home?
  24   A. That is right, yes. All I wanted to know was when she
  25     was coming home and if she was going to be okay when she

   1     came home.
   2   Q. I suspect you would want to know she was going to be
   3     well-treated later on?
   4   A. At that time, he told me that the operation they were
   5     going to do was the switch, and that it was a 95 per
   6     cent success rate, and I thought "Fine, she is going to
   7     be fine". I mean, at that time I had no reason to doubt
   8     Bristol, and I just assumed she was in the best hands
   9     she could have been.
  10   Q. So what was important to you?
  11   A. That she was going to be okay; that the operation she
  12     was going to have, which was a while in the future, was
  13     okay, was a routine operation, I thought at that time,
  14     and that she was going to live; and that I could take
  15     her home at that time. It had only been just over
  16     a week since I had given birth, and I just wanted to get
  17     her home.
  18   Q. It would be fair to say that those were your main
  19     concerns?
  20   A. Yes.
  21   Q. And you were not perhaps so much concerned about the
  22     actual technique of the operation?
  23   A. Not at that time, no, probably not.
  24   Q. When you took Melissa home, were you given any
  25     instructions as to the care she was to have?

   1   A. She was first sent back to Exeter. She was sent back
   2     there on the Friday. We went in to see her the Friday
   3     night and we were told we could take her home on the
   4     Saturday. When we went back in on the Saturday, I was
   5     given a medicine, Frusemide, which I was told to give
   6     her, I cannot remember now, three times a day or
   7     something, with her food, and it stops heart failure.
   8   Q. The Frusemide was in liquid form?
   9   A. Yes. You give it to her in like a syringe.
  10   Q. And you fill the syringe and put it in her mouth?
  11   A. Yes.
  12   Q. Were there check-ups after that?
  13   A. Yes. I had one check-up at Heavitree, the maternity
  14     hospital in Exeter, and then following on from that she
  15     had like monthly check-ups in Exeter, mostly with Penny
  16     Dyson.
  17   Q. At the Royal Exeter Hospital?
  18   A. Yes. I saw Dr Martin about four months later.
  19   Q. Your next contact was to see Dr Martin four months
  20     later?
  21   A. Yes.
  22   Q. That puts us what, about March?
  23   A. Yes.
  24   Q. Of the next year, 1991? Did anything which surprised
  25     you happen when you saw Dr Martin on that occasion?

   1   A. Yes. When I went in to see Dr Martin, he asked me if
   2     she was on any medication. I said "Yes, she is on
   3     Frusemide". He asked me who prescribed it for her.
   4     I told him that she was given it at Exeter Hospital, and
   5     I had assumed that he had prescribed it for her. He
   6     just looked up and said, "Well, I do not think she needs
   7     this any more, just do not give it to her any more".
   8   Q. Did anything happen which you put down at any rate to
   9     that advice to stop taking the Frusemide?
  10   A. Yes, as soon as she came off that medicine -- before
  11     that, for about four months, she was crying and she
  12     would not sleep, she was very restless; she was very
  13     awkward to feed. She was just a very difficult baby to
  14     look after. As soon as I took her off that medicine,
  15     she was a completely different child. She was happy,
  16     smiling, slept through the night, fed easily, and was
  17     like a normal happy child.
  18   Q. Although you were having regular check-ups, did you
  19     notice anything untoward about Melissa over the next few
  20     months?
  21   A. No.
  22   Q. So she just seemed to be a normal, happy, bouncing baby?
  23   A. Yes.
  24   Q. When was your next contact with anyone from Bristol?
  25   A. She went up for a -- what I now know they call an

   1     emergency cardiology, up at Bristol, in June.
   2   Q. Emergency?
   3   A. That is what I now know. At that time, I did not -- it
   4     says "emergency" on the thing. At that time I was just
   5     told she was going up for a check-up, to make sure
   6     everything was okay.
   7   Q. Just so everyone knows, you are looking at a sheet of
   8     paper. Is that your statement?
   9   A. Yes.
  10   Q. So far as you were concerned, was there an emergency?
  11   A. No, not that I knew of, no.
  12   Q. Had the appointment at Bristol been arranged in advance?
  13   A. Yes, Penny Dyson had made the appointment for me to go
  14     up. I just thought it was something that they did at
  15     that time.
  16   Q. When she went to Bristol, was that 4th July 1991?
  17   A. No, it was --
  18   Q. No, June, I am sorry. It is my fault entirely, I am
  19     sorry.
  20   A. Yes, it was in June.
  21   Q. What happened to her at Bristol on that occasion?
  22   A. She went up and we left her there, or I left her there
  23     for the night, they admitted her, she stayed for the
  24     night and we picked her up the next day. I think they
  25     enlarged the balloon that was inside her.

   1   Q. So your understanding about the operation was what?
   2     What would you call it, from memory?
   3   A. That they enlarged the balloon.
   4   Q. That is what it was?
   5   A. Yes, that is what it was.
   6   Q. That is the way it was described to you, was it?
   7   A. Yes.
   8   Q. Who told you about what they were going to do with the
   9     operation?
  10   A. I do not know. I cannot remember. No, I do not know.
  11     I know we went off, I can see her in the hospital, but
  12     I honestly could not tell you. Penny obviously told me
  13     she was going up for this operation, but I honestly
  14     cannot say.
  15   Q. You went with her?
  16   A. Yes, I went with her and we left her there for the night
  17     and picked her up the next day.
  18   Q. You went all the way home and came back the next
  19     morning?
  20   A. Yes.
  21   Q. So something fairly significant, so far as she was
  22     concerned --
  23   A. I did not think it was fairly significant.
  24   Q. You did not?
  25   A. No, I just thought she was going for an ordinary

   1     check-up. I was not told that it was significant or ...
   2   Q. Any consent forms that you had to sign?
   3   A. I cannot remember. I cannot remember signing anything.
   4   Q. So this particular procedure is something which really
   5     is very vague in your memory?
   6   A. Yes. I know she went up and she stayed overnight and
   7     I brought her home.
   8   Q. The next contact that you had with Exeter: when was
   9     that?
  10   A. She went monthly for check-ups.
  11   Q. So that would be July?
  12   A. Yes.
  13   Q. What about Bristol?
  14   A. Bristol, we went up to see Mr Dhasmana in July.
  15   Q. Had you met him before?
  16   A. No, it was the first time I met him.
  17   Q. What was the purpose of your going?
  18   A. To discuss the operation, for him to see Melissa.
  19   Q. So you went up with Melissa?
  20   A. Yes.
  21   Q. To Bristol?
  22   A. Yes.
  23   Q. This was the first time I think you had met Mr Dhasmana?
  24   A. Yes.
  25   Q. How long did you spend with him?

   1   A. About an hour, from what I can remember.
   2   Q. Anyone else there?
   3   A. My husband.
   4   Q. How did the hour go?
   5   A. Fine. He looked at Melissa, explained to us that there
   6     were two operations that he could do. He said that one
   7     was an operation that was an easier operation, but it
   8     was a two-part operation, she would have to go back when
   9     she was about 14 or 15 and have another operation. The
  10     other operation involved switching the arteries around,
  11     which he thought, it was a harder operation to do, but
  12     he thought it was a better operation.
  13   Q. That is a very short summary of something which you told
  14     us took 45 minutes to an hour?
  15   A. Well, I said he checked on, he looked over Melissa
  16     first.
  17   Q. How long did that take?
  18   A. Probably about a quarter of an hour, and he drew
  19     diagrams. I mean, he explained more about the
  20     operation; he drew diagrams of the operations on
  21     a notepad.
  22   Q. "Operations" in the plural?
  23   A. Yes, he showed me two operations, one which he said was
  24     an easier operation to do, when she was about 14 or 15
  25     years old, she would have to go back and have another

   1     operation, if she had that one.
   2        The other one which he told us was a better
   3     operation involved switching the arteries around. It
   4     put the heart back to how it should have been when she
   5     was born. It was a harder operation to undertake, but
   6     he thought it was a better operation because he thought
   7     she would live and have a better life with that
   8     operation.
   9   Q. So the differences between these operations were drawn
  10     on two separate sheets of paper, were they?
  11   A. Yes, I think so. He drew ...
  12   Q. Can you remember how the drawing looked, what the
  13     difference was in the diagrams?
  14   A. No, I cannot.
  15   Q. So you can't picture those?
  16   A. No.
  17   Q. What you can remember is some description that was given
  18     to you by Mr Dhasmana about those operations?
  19   A. About the operations. I can remember the verbal
  20     descriptions he gave.
  21   Q. With the more difficult operation, was there going to be
  22     any further procedure later in life?
  23   A. No. That would be it. It was a one-off operation and
  24     that would be it, and she should lead a long and healthy
  25     life with that operation.

   1   Q. If that operation put the arteries back in the way they
   2     should have been, if she had been born normal, what did
   3     the other operation do, as you understood it?
   4   A. I do not know. I cannot remember it. I cannot remember
   5     him going into detail about the other operation. That
   6     is why the switch operation has always been so much in
   7     our minds, because that is the one that I can remember
   8     him showing us, drawing us and explaining to us.
   9   Q. Since that day back in July 1991, you, I think, have
  10     found out the difference between a Sennings procedure
  11     and an arterial switch operation?
  12   A. No. I found out that a Sennings operation was
  13     a different operation to the switch. I am still not
  14     absolutely sure what a Sennings operation is.
  15   Q. You have not investigated the background?
  16   A. I have been told, but I mean, from an expert I have
  17     spoken to, he has described a Sennings, but I am still
  18     not really sure about the technicalities of the
  19     Sennings.
  20   Q. The Sennings involves, in your understanding, does it,
  21     a switch of veins rather than arteries?
  22   A. I honestly -- I know it is a different operation; I am
  23     not absolutely sure about a Sennings, I mean, it was
  24     only when the GMC started that I found out she had
  25     a Sennings. It was really the first time that

   1     a Sennings, the word Sennings was in my mind, when
   2     I found she had that, I was not even sure about what
   3     a Sennings was at all.
   4   Q. What did you understand the purpose was of Mr Dhasmana
   5     saying there is this operation or that operation? What
   6     were you supposed to do about it?
   7   A. He was saying that he was going to do the best
   8     operation. That there was another operation, "but we
   9     will not do that because I do not think that is a very
  10     good operation". I think this is the best operation,
  11     and that is the operation that I can remember him
  12     explaining to us.
  13   Q. So he was not putting the two operations to you and
  14     saying, "Which do you choose"?
  15   A. No.
  16   Q. He was saying "There are two possible operations"?
  17   A. That is right.
  18   Q. "I am going to tell you all about this one, but that is
  19     the one I am not going to do"?
  20   A. Yes, "This is the one I am going to do".
  21   Q. Are you sure?
  22   A. I am absolutely positive, yes.
  23   Q. So it would follow that his mind appeared to be made up,
  24     that he was going to do the more difficult but better
  25     operation?

   1   A. At that time, his mind was made up on that operation.
   2   Q. And yet he still spent some 15 minutes talking about the
   3     other?
   4   A. Not long. He just explained there was this other
   5     operation which was an easier operation to do, but he
   6     did not think it was so good as the switch operation.
   7   Q. You have always maintained, I think, that what happened
   8     was that Melissa was going to have a switch operation?
   9   A. I always did, yes.
  10   Q. The first time you heard the name Sennings was when, at
  11     the General Medical Council?
  12   A. Yes.
  13   Q. I wonder if you could just have a look, on my screen
  14     first of all, please, at medical record 1753/48?
  15        What I hope you have in front of you is
  16     a handwritten medical record. It is dated 10th July
  17     1991, the date of your meeting Mr Dhasmana, and it
  18     records the weight of Melissa?
  19   A. Yes.
  20   Q. Her size. "TGA", we will be told I think in due course
  21     stands for transposition of the greater arteries, and
  22     with "intact septum", the division between the two sides
  23     of the heart?
  24   A. Yes.
  25   Q. And then the next words "for Senning repair on list."

   1        If this record was made at the time, it might
   2     appear that what the author of it, probably Mr Dhasmana,
   3     had in mind was a Senning operation?
   4   A. Yes, it does look like that there.
   5   Q. I wonder if we may just have a look, on my screen first
   6     of all, please, at 1752 at 1752/45. Just moving
   7     forward, when the operation itself was done, you signed
   8     a consent form?
   9   A. No, I did not sign it.
  10   Q. So your husband did?
  11   A. He did.
  12   Q. Were you there?
  13   A. Yes, I was there.
  14   Q. Would you take a look, please, at the document,
  15     1752/45. Is that your husband's signature at the
  16     bottom?
  17   A. Yes.
  18   Q. We see "Type of operation", "Investigation or treatment"
  19     in the middle, "Senning repair of the TGA". It is
  20     difficult to read the next few lines, but it is on the
  21     screen. Do not worry about that.
  22   PROFESSOR JARMAN: It is "ligation of patent ductus
  23     arteriosus".
  24   MR LANGSTAFF: I am very grateful. So the word "Senning"
  25     was obviously in the doctor's mind?

   1   A. At that time, I do not think -- my husband looked at
   2     that. When we were given the consent form to sign,
   3     because I signed everything else, I said "You can sign
   4     this one, I am not signing it", so he signed it. I know
   5     what my husband is like at signing things. At that time
   6     we thought we knew what operation she was having. We
   7     thought she was in the best place possible. We did not
   8     even take it, we signed it, there was no way we were
   9     going to read through documents and say, "No, she is not
  10     having that, I am taking her home". We had taken her
  11     there for them to make her better and that is all we
  12     wanted, to hand over our child for them to make better.
  13   Q. So what you are saying is that it was not a legal
  14     document as you saw it, it was a document you had to
  15     sign to get the operation?
  16   A. Yes, for them to do the operation.
  17   Q. And the operation, as you understood it, would be --
  18   A. The switch. We always thought she was having the
  19     switch.
  20   Q. May I please have on my screen 1752/39? This, I hope,
  21     will be on your screen. This is something I suspect you
  22     did not know anything about and you may have seen
  23     subsequently. This is --
  24   A. Yes, I have seen this since.
  25   Q. It is a letter signed by Mr Dhasmana, consultant cardiac

   1     surgeon, and it is dated Monday, 10th June 1991 at the
   2     top?
   3   A. Yes.
   4   Q. So it is before you saw Mr Dhasmana?
   5   A. I have been through these documents. I went to my GP
   6     and asked him for any documents. I have seen this, but
   7     all I know is what I can remember of the meeting I had
   8     with Dhasmana and what I have always thought ever since
   9     she died, because when she died, I wished she had had
  10     the easier operation, because I thought she would still
  11     be alive today if she had had the easier operation.
  12     Then I found out she did have the easier operation and
  13     she still died. I can remember in my mind him telling
  14     us he was going to give her the switch.
  15   Q. What I am going to say is what you have probably been
  16     told before: when you looked at this document, which was
  17     before the conversation with Mr Dhasmana, when you look
  18     at his record of the conversation that you had in July,
  19     when you look at what was in his mind at any rate when
  20     he gave your husband the consent form to sign, it would
  21     seem that he, for his part, had always had in mind that
  22     a Sennings operation would be done?
  23   A. Yes. That is what it looks like from all the
  24     documents. All I can go on is what I can remember and
  25     after that meeting I went back and told all my friends

   1     and families that she was having this operation, it was
   2     a one-off operation, she would not have to go back for
   3     any more treatment, it was the switching of the arteries
   4     and it was the best operation she could have. That is
   5     what I told everybody when I left his office that day.
   6   Q. Just remind us, I am not sure you have told us yet,
   7     whether you were quoted any success rate for the
   8     operation?
   9   A. He quoted 90 per cent at that time.
  10   Q. So he had said 90 per cent?
  11   A. Yes.
  12   Q. We know from your statement and what you have already
  13     said, Dr Martin had earlier quoted 95 per cent?
  14   A. Yes.
  15   Q. If that was the success rate for the more difficult of
  16     the two operations, did he quote you a success rate for
  17     the easier one?
  18   A. No. He did not dwell on the easier one. All I can
  19     remember is the success rate for that operation.
  20   Q. We may hear later in the evidence that the success rate
  21     at least as it was understood by the surgeons at the
  22     time was very much lower. I do not want to put a figure
  23     on it, but very much lower than 90 per cent for the
  24     arterial switch, the transposition of the arteries by
  25     operation. Suppose that a figure had been quoted to you

   1     of, let us say, 40 per cent chance of death at the
   2     operation, or 60 per cent success rate, putting it
   3     around that way. Suppose you had been told that Melissa
   4     had a 60 per cent chance of success in the more
   5     difficult operation, but it would be better for her and
   6     she might live longer, rather than the 90 per cent with
   7     the chance of having to have a further operation at the
   8     age of 15. Do you know what you would have decided?
   9   A. No. I honestly, it is a difficult -- I would not have
  10     liked the idea of her going back for another one, of
  11     having her for 14 or 15 years and having to live through
  12     14 or 15 years and having her go back for another
  13     operation, and thinking that that could go wrong, and
  14     also she would know what was happening to her, and she
  15     would have had that worry as well.
  16   Q. While I am dealing with the questions which arise as to
  17     the nature of the operation, one of your big complaints
  18     is you thought she had had the switch, and in fact she
  19     had had the Sennings?
  20   A. Yes.
  21   Q. I wonder if I could look at 1752/118, on my screen
  22     first, please. Is that up on your screen?
  23   A. Yes.
  24   Q. This is a nursing assessment chart?
  25   A. Yes.

   1   Q. It has various details about your baby. What I wanted
   2     to ask you about is right down the very bottom of the
   3     page, where whoever it was that made this record, one of
   4     the nursing staff, I think, has written:
   5        "Parents have experience of intensive care in the
   6     past."
   7        Is that right?
   8   A. Well, in Exeter.
   9   Q. "But appeared to be quite vague at present of the type
  10     of surgery Melissa is having."
  11   A. Yes.
  12   Q. Would that have been a fair description when she went in
  13     before the operation?
  14   A. We just knew that the arteries were going to be swapped
  15     over. At that time, like I said, we just wanted her to
  16     be taken and made better, and we just knew that the
  17     operation was called a switch and that the arteries were
  18     going to be swapped over and that is about it.
  19   Q. Can we come back, I am not going to waste any more time
  20     with this, but you knew, of course, what was wrong with
  21     Melissa was that the arteries were the wrong way round?
  22   A. Yes.
  23   Q. So naturally, you assumed that the surgery would put
  24     that right?
  25   A. Yes.

   1   Q. Do you think that with the passage of time you might
   2     have confused the idea of switching veins with switching
   3     arteries?
   4   A. No, I do not. I honestly, what I can remember, I have
   5     always thought of this: the fact that he told us not so
   6     much that it was the switching of arteries, but the fact
   7     that there were two operations, one was easier than the
   8     other, and he was going to do the most difficult one,
   9     the one that he thought was the best and the one that
  10     would put her heart back to the way it should be. That
  11     is why I can remember it.
  12   Q. Can I move on.
  13   A. Yes, please.
  14   Q. We come to the operation itself. In fact, before that,
  15     was there any delay in having the operation arranged?
  16   A. We were told by Dr Joffe right at the start that she
  17     would have to have the operation by 9 months and
  18     Mr Dhasmana told us that she would have to have the
  19     operation by 12 months. As time got on and she was
  20     getting older, we thought that she should be put in for
  21     the operation, so we went to our GP and said would he
  22     write a letter saying that she was getting worse, so
  23     that she could get in and have the operation done before
  24     12 months.
  25   Q. So you were worried that you had no follow-up from

   1     Bristol?
   2   A. Yes. We were not hearing. We were going to Exeter for
   3     her check-ups, but nothing from Bristol about the
   4     operation.
   5   Q. And it was not until you made enquiries about it that
   6     you heard that Melissa was on the operating list for
   7     October?
   8   A. Yes, the 15th.
   9   Q. So she was very nearly at the end of that 9/12 month
  10     period?
  11   A. Yes.
  12   Q. You went to the Bristol Royal Infirmary on 15th October?
  13   A. Yes.
  14   Q. Was she admitted to the Infirmary, or to the Children's
  15     Hospital?
  16   A. To the Infirmary.
  17   Q. Ward 5?
  18   A. Yes.
  19   Q. That was 15th October, but you understood the operation
  20     was going to be the 17th?
  21   A. Yes.
  22   Q. So what was going to happen in the two days, as you
  23     understood it?
  24   A. As I understood it, they were going to make sure she was
  25     fit and healthy enough to have the operation, do tests,

   1     and just generally make sure everything was fine.
   2   Q. You saw Mr Dhasmana again, did you?
   3   A. On the night before the operation, yes. When we arrived
   4     on the 15th, I was told that --
   5   Q. That is something which may or may not have been the
   6     case. You did not see him at any rate the night before
   7     the operation?
   8   A. No.
   9   Q. Did he tell you again the details of the operation, or
  10     not?
  11   A. Not that I can remember, no. He told us that he was
  12     still quite happy about doing the operation that he had
  13     told us he was going to do, and everything was going
  14     fine.
  15   Q. That is when the consent form was signed?
  16   A. That is when the consent form was signed, yes.
  17   Q. So you are relying on your knowledge of what was going
  18     to happen to Melissa on the conversation back in July?
  19   A. Back in July.
  20   Q. Did he say anything on that occasion -- this is the
  21     night before the operation -- as to the chances of
  22     success or failure?
  23   A. Yes. He repeated the 90 per cent success rate.
  24   Q. What did he say about the timing of the operation?
  25   A. He said they were going to take her down at 8 o'clock

   1     and that she would probably be finished about 3, give or
   2     take, and we could ring during the following day to find
   3     out when she was coming out, or to make sure everything
   4     was okay.
   5   Q. So by saying you were going to ring, or could ring, he
   6     did not obviously expect you to be there on the ward
   7     first thing in the morning?
   8   A. No, we could have gone down on the ward first thing in
   9     the morning, but as we did not leave her that night
  10     until about 11 and as they were taking her early, we
  11     decided we would not go down at that time to see her
  12     going down to the operating theatre.
  13   Q. Where were you staying?
  14   A. In a hostel up the road.
  15   Q. Arranged by the hospital?
  16   A. Yes.
  17   Q. And were there other parents at the hostel?
  18   A. Yes.
  19   Q. So the next day what did you do while Melissa was having
  20     her operation, as you thought?
  21   A. We wandered around Bristol, I rang up a few times.
  22   Q. I think one of your complaints is that you were not in
  23     fact told she would not be going down to the theatre
  24     until 11 o'clock?
  25   A. When I rang up, I expected her to be coming out and they

   1     said she has not been down there very long. If I had
   2     known it was later, we could have stayed with her before
   3     she had gone down to the operating theatre.
   4   Q. But you understood you could have phoned in to find out
   5     at any stage, and indeed you did?
   6   A. Yes.
   7   Q. Before you saw her again, had you had a conversation
   8     with anyone as to what you might expect when you saw her
   9     in intensive care?
  10   A. No, because we said we had seen her in intensive care at
  11     Bristol after she had the septostomy, and also we had
  12     been through a great deal in Exeter, we knew what to
  13     expect in the Intensive Care Unit.
  14   Q. So it was not going to shock you at all?
  15   A. No, we knew what she was going to be like.
  16   Q. When you did see her, did you see anybody else at about
  17     the same time?
  18   A. Yes, Mr Dhasmana was with her. He told us how pleased
  19     he was. You could see it on his face. He was thrilled
  20     to bits the operation had gone well and he was happy
  21     with how she was.
  22   Q. How did she look?
  23   A. Lovely: pink, all the blue tinge had completely gone.
  24     She was on all the paraphernalia, the tubes and that,
  25     but other than that, she looked lovely.

   1   Q. So were you reassured?
   2   A. Yes. I thought everything was fine.
   3   Q. That was the 17th?
   4   A. Yes.
   5   Q. Which was a Thursday?
   6   A. That is right, yes.
   7   Q. What happened on the Friday?
   8   A. The Friday we went down to see her in the morning, and
   9     we were told everything was still okay, so we decided to
  10     go home, get a change of clothes, see our son and tell
  11     our parents how everything was, and just go home for the
  12     night and come back the next day.
  13   Q. So that is what you did?
  14   A. That is what we did.
  15   Q. The Saturday?
  16   A. The Saturday, my parents drove us up, because it is so
  17     difficult to park in Bristol, so they drove us up and we
  18     all went into the intensive care unit to see Melissa.
  19     She still looked the same as she had when we left her on
  20     Thursday, or Friday morning, and then we went back to
  21     the hostel, gave the parents a cup of tea. They went
  22     home and we went back down to the intensive care unit.
  23   Q. What time was it that you went back, roughly?
  24   A. We went back in the afternoon some time, 3, 4, somewhere
  25     around there.

   1   Q. So almost exactly two days after she came out of
   2     surgery?
   3   A. Yes.
   4   Q. What did you see?
   5   A. There were several doctors and that all around us. They
   6     came over and said "Something has gone wrong", and sent
   7     us to the parents' room to wait for some information.
   8   Q. Just that: something has gone wrong and off you go to
   9     the parents room?
  10   A. Yes, would we go and wait and they would tell us as soon
  11     as they had sorted things out.
  12   Q. What did you feel about that?
  13   A. Very upset, that things were going wrong.
  14   Q. Was there anyone to talk to?
  15   A. No, we just sat in the room and waited until Mr Dhasmana
  16     came to see us.
  17   Q. Did you think of coming out of the parents' room and
  18     saying, "Look, what is going on?"
  19   A. No, we were told to go and sit and wait until somebody
  20     came to see us, and that is what we did.
  21   Q. Because you trusted the doctors?
  22   A. Yes, indeed, implicitly, yes.
  23   Q. Who did you see?
  24   A. Mr Dhasmana came down to see us.
  25   Q. What did he say?

   1   A. He said that there had been a problem, something to do
   2     with her heart beating too fast. I think he said that
   3     he put electric shocks on her heart, he had either said
   4     that or we had seen him doing it in the thing -- I know
   5     I have this thing about electric shocks being put to try
   6     and slow the heartbeat down, and that, but not to worry,
   7     there was still a 70 per cent chance of her pulling
   8     through this and that hopefully everything would be
   9     okay.
  10   Q. So it was the heart rate he was concerned about?
  11   A. Yes.
  12   Q. That is what he spoke to you about?
  13   A. Yes, that the heart was beating too fast.
  14   Q. May I just move forward for a moment in time? Can
  15     I ask, please, to have in front of me 1752/32?
  16     I would like you to blow up, please, the bottom half of
  17     this.
  18        "Clinical history", this is from the post-mortem
  19     report, so we have moved forward in time. I am
  20     anticipating what you are going to tell us.
  21        You do not know about the post-mortem because you
  22     were not there?
  23   A. No.
  24   Q. You can't, therefore, tell us what was told to the
  25     person who prepared this post-mortem report by others.

   1     One thing I want to ask you about. It says, if you look
   2     in the middle:
   3        "On 18th October 1991 at 0420 hours it was noted
   4     that Melissa was poorly oxygenated and this was
   5     associated with the low blood pressure and pulmonary
   6     oedema. Respiratory failure was partially due to
   7     mechanical difficulties in ventilating Melissa, but
   8     satisfactory oxygenation was achieved after
   9     several hours."
  10        We can have that screen off. When did you first
  11     hear any suggestion that there had been mechanical
  12     problems in the ICU?
  13   A. Not until after we found out there were problems at
  14     Bristol and we received notes from Bristol. It was not
  15     until quite recently that I knew about the ventilation
  16     problem.
  17   Q. Can we put a date on "quite recently"?
  18   A. Well, within the last couple of years I knew about the
  19     poor ventilation, if then.
  20   Q. You can't comment on whether there was or whether there
  21     was not, because you are not an expert?
  22   A. No, I had no knowledge at that time at all.
  23   Q. But someone at the hospital had plainly been told at the
  24     time in order to put that history down on paper.
  25        Let me simply ask you this: if there was any

   1     reference at any stage in the medical records of split
   2     tubing, was that something you ever knew about until you
   3     saw the records?
   4   A. No, not at all.
   5   Q. And certainly Mr Dhasmana, on your recollection, did not
   6     say anything about it?
   7   A. No. No, I did not know anything about that at all.
   8   Q. So he was hopeful, going back to the Saturday. Tell me
   9     what then happened.
  10   A. Not a lot until the Tuesday. I was back at the hostel
  11     when I was phoned up to say that they had to have
  12     a specialist because she was not urinating properly and
  13     they wanted to get a specialist to do something.
  14   Q. Again, let me just take you through: the Sunday, the
  15     Monday, to the Tuesday?
  16   A. We were sat by her bed and we were not told anything.
  17   Q. You stayed in the hostel?
  18   A. Yes.
  19   Q. Both of you by her bedside?
  20   A. Yes.
  21   Q. Did anyone talk to you about Melissa?
  22   A. No, not that I can recall, no, not at that time.
  23   Q. She was in intensive care; there would be nurses there?
  24   A. Yes. I was told by one of the nurses to get a shampoo
  25     and brush so they could wash her hair, but other than

   1     that, we were sat by her bed while they went through the
   2     routine of sucking her tubes out and what they do in
   3     medical care, but we were not told anything at all.
   4   Q. Would you say that the nurses appeared to be fairly
   5     efficient?
   6   A. Yes, at that time, fine.
   7   Q. On the Tuesday, you say you were told she was not
   8     urinating as she should have been?
   9   A. Yes. They had a kidney specialist there.
  10   Q. On the next day?
  11   A. No, that night. They rang me to tell me that night that
  12     they were getting --
  13   Q. I am sorry, I wanted to move forward to the Wednesday?
  14   A. On the Wednesday we were sat back by her bed and
  15     a doctor came in -- I do not know who he was -- and he
  16     said that I was not looking very good and that I should
  17     go home because it would be no good if I got myself ill
  18     for when she came home, and that I should be home, go
  19     home, resting with my son, so I was okay for when she
  20     came home. So we went home that afternoon. My
  21     brother-in-law came and picked us up and took us home.
  22   Q. So it was good advice that you accepted, as you saw it
  23     at the time?
  24   A. Yes, we decided to go and see our son.
  25   Q. On the Thursday, the 24th?

   1   A. On the Thursday we stayed home. I rang twice, once
   2     Thursday afternoon. I was not happy with what I was
   3     being told. I rang Thursday night about 10, half past
   4     10, and I was told by a doctor -- I do not know who he
   5     was -- that everything was going as planned. I can
   6     remember those words, they are ingrained in my mind,
   7     that everything was going as planned.
   8   Q. This is the Thursday, the 24th?
   9   A. Yes.
  10   Q. On the Friday?
  11   A. On the Friday, early in the morning, 9, half 8,
  12     9 o'clock, I had a phone call from Helen Strachan to
  13     say, would we please immediately go back up to Bristol.
  14   Q. You say Helen Strachan?
  15   A. Yes.
  16   Q. As in the Scottish Strachan?
  17   A. Yes.
  18   Q. I think it may be Helen Stratton. You knew Helen,
  19     anyway?
  20   A. Yes.
  21   Q. So she had come to see you before, made herself known?
  22   A. Yes.
  23   Q. What was her job, as you understood it?
  24   A. I do not know. She was liaison.
  25   Q. A friendly face?

   1   A. Yes, just somebody who was there that would call us.
   2     She spoke to us up there and called us up, and asked us
   3     to go straight back up.
   4   Q. So she was someone that the Trust had got to be the
   5     point of contact, had she?
   6   A. I do not know that we had an awful lot of contact before
   7     that day. I mean, I think she might have told me that
   8     morning who she was. She was there when we got to
   9     Bristol, to meet us.
  10   Q. Had you met her before?
  11   A. I do not recall. I do not know. I do not recall
  12     meeting her before. I think we might have -- yes,
  13     I think we might have when we first arrived on Ward 5,
  14     before Melissa had the operation, being introduced to
  15     her.
  16   Q. But you had not seen her between then and the time we
  17     are now talking about?
  18   A. No.
  19   Q. So you go into Bristol?
  20   A. Yes. We got our parents to drive us up to Bristol.
  21   Q. What happened?
  22   A. We walked into the hospital. We walked into the
  23     Intensive Care Unit to see Melissa, and all the nurses
  24     turned their backs on us.
  25   Q. Literally?

   1   A. I will not say -- they completely ignored us. The one
   2     that was looking after Melissa disappeared completely
   3     when we got to her bed. She walked off somewhere, and
   4     nobody came over and spoke to us at all until Helen came
   5     in and said that Dr Bolsin, who wanted to see us, was
   6     operating at that time and would we wait in the parent's
   7     room -- would we go and wait for him in the parent's
   8     room.
   9   Q. I want to ask you a bit more about the nurses and how
  10     they reacted. On the Saturday, Sunday, Monday, Tuesday,
  11     the last three days you had been at the bedside, you
  12     must have become quite familiar with the identity of the
  13     nurses who were caring for Melissa?
  14   A. Yes, the one who was looking after Melissa.
  15   Q. Just the one?
  16   A. I could not tell you her name. I remember I have one
  17     sort of -- I mean, they seemed fine. She was quite
  18     friendly. Like I said, she told me to go up and get
  19     shampoo and stuff so she could wash Melissa's hair and
  20     keep her looking nice.
  21   Q. So how had she changed?
  22   A. I do not recall seeing her. All I know is when we got
  23     into Bristol, when we walked into intensive care, I did
  24     not see any nurses. They all just seemed to melt away.
  25     Nobody came up to see us at all.

   1   Q. What happened next? You told us you went to see --
   2   A. Helen came up to see us and said that Dr Bolsin (who had
   3     called for us to go up there, whom I did not know at
   4     that time at all, I had never met him before) was
   5     operating at that time when we got there, and would we
   6     wait in the parent's room; he would be there as soon as
   7     he could.
   8   Q. Roughly how long did you wait?
   9   A. From what I can remember, about two, two and
  10     a half hours.
  11   Q. In your statement, just so there is no puzzle about it,
  12     the words "three hours" appear in italics?
  13   A. Well, it seemed an awful long time.
  14   Q. But something, two, three hour-ish?
  15   A. Yes, that is right.
  16   Q. Had you ever met Dr Bolsin before?
  17   A. Not that I can recall, no.
  18   Q. What did he have to tell you?
  19   A. He said that things were grim; that there were problems
  20     with her. He spoke about managing -- they would have to
  21     think of ways to manage the baby. I remember saying
  22     I did not want her managed if she was that bad. My
  23     mother pushed and pushed for him to say it, and I kept
  24     saying -- he said she had had a scan on her brain and it
  25     looked serious, and I remember saying, "Are you telling

   1     me she is dead?" He said, "Well, it looks serious."
   2     In the end, my mother pushed and pushed and in the end
   3     he finally admitted she was brainstem dead.
   4   Q. When you say "pushed and pushed" ...
   5   A. She kept on and on to him, saying, "What, is she dead?",
   6     "Are you telling us she is brain-damaged?" "Is there
   7     any hope?" Finally, he did admit there was no hope and
   8     that she was brainstem dead. We had to force it out of
   9     him. He was very, very reluctant to tell us the
  10     whole -- he wanted to tell us things were bad, but he
  11     was very reluctant to tell us the whole thing.
  12   Q. How long was this conversation, roughly?
  13   A. About 20 minutes, half an hour. I was in a bit of
  14     a state by that time.
  15   Q. Where was Helen Stratton?
  16   A. She was with us at that time.
  17   Q. So there was you, your mother, Helen Stratton,
  18     Dr Bolsin, anybody else?
  19   A. My husband and my father.
  20   Q. After Dr Bolsin had told you what he had to tell you,
  21     did he stay or leave?
  22   A. No, he left.
  23   Q. What about Helen?
  24   A. No, she stayed for a while. I remember we went in to
  25     see Melissa. I asked if I could take her off the

   1     ventilator and hold her. I was told we could not do
   2     anything because Mr Dhasmana was on a day off and
   3     I would have to wait until he came back to authorise.
   4   Q. Did anyone other than Helen speak to you?
   5   A. No, not that I can recall.
   6   Q. So what did you do?
   7   A. We stood outside in the corridor, after we had been in
   8     and seen Melissa, to say our goodbyes. My parents had
   9     driven us up. My father did not want to leave us at the
  10     hostel overnight, just to wait for Melissa to be turned
  11     off, for the ventilator to be turned off. We went back
  12     to the hostel, gathered our things and went home.
  13     We were in a bit of a state. I do not think we really
  14     knew what we were doing.
  15   Q. Do you remember any very odd thing that happened?
  16   A. Yes. As we were coming out of the Intensive Care Unit,
  17     a nurse went up to my husband and just thrust an
  18     envelope at him. Later -- I do not know whether it was
  19     downstairs or when we got home -- we opened it. There
  20     was œ30 in it, and I assumed it was for expenses, I do
  21     not know. I do not really know what it was for.
  22   Q. No note?
  23   A. No, nothing.
  24   Q. Just an envelope?
  25   A. Just £30 in a white envelope.

   1   Q. And nothing said?
   2   A. No.
   3   Q. Can you tell me how it ended?
   4   A. The next day, I rang the hospital when we got up and
   5     said, "Is she still alive?" They said, "Oh yes, she is
   6     still alive." I said, "Don't you think she should be
   7     taken off the ventilator, as she is dead?" They said,
   8     "We will see. We will look into it."
   9        I put the phone down and half an hour later I had
  10     a call to say she had died in the nurse's arms.
  11   Q. Would you like some water? Would you like a moment?
  12   THE CHAIRMAN: Would you like to take a pause.
  13   MRS CLARKE: No, I will be all right in a minute.
  14   MR LANGSTAFF: Some months later, did you hear something
  15     which really --
  16   A. Yes, about six months later, before we had gone to
  17     Bristol, Exeter had made an appointment for Melissa to
  18     go back for a six-monthly check up at Exeter for the
  19     operation. In the April, six months later, I had
  20     a telephone call from Exeter Hospital asking why I had
  21     not taken Melissa back for a check-up.
  22   Q. I wonder if we could have 1752/40, please.
  23        You probably have not seen this letter, but it
  24     supports what you have said. It is a letter which
  25     perhaps others may have to deal with at a later stage in

   1     the Inquiry. It is addressed to Mr Martin. It is from
   2     Mr Tripp, Senior Lecturer in Child Health, Department of
   3     Child Health, in, we believe, Exeter. It says:
   4        "We discovered about Melissa Clarke's death when
   5     Outpatients rang to discover why she had not kept an
   6     appointment".
   7        So there we have Exeter Hospital following up the
   8     death?
   9   A. Yes.
  10   Q. Your understanding of what appears to have happened is
  11     that after Melissa died, Bristol did not tell anyone?
  12   A. No.
  13   Q. On another occasion, you made the point that when
  14     Bristol had an investigation into deaths and Mr De Laval
  15     prepared a report, he recorded that between 1990 and
  16     1995, there had been 33 Sennings operations and none had
  17     died?
  18   A. Yes.
  19   Q. That plainly is not the case, if Melissa had a Sennings
  20     operation?
  21   A. No.
  22   Q. You have made a number of complaints in your statement
  23     about the care which Melissa was given. Can I deal with
  24     it in this way: the complaints which you make -- pages
  25     13 and 14 of your statement, and others can read it in

   1     due course -- are all complaints about the medical care
   2     that Melissa had. You are not a doctor.
   3   A. No.
   4   Q. I am sure, Tracey, you would be the first to accept that
   5     whether things went right or whether things went wrong
   6     is really a matter for doctors and experts to
   7     investigate?
   8   A. Yes.
   9   Q. This is obviously what you had been told, but it may or
  10     may not be right. You are happy with that?
  11   A. Yes.
  12   Q. What you can tell us about is the way in which the staff
  13     and you and your husband dealt with each other. You
  14     have a number of complaints to make there, I think.
  15     Your understanding, whether it is right or whether it is
  16     wrong, is that Melissa died in terms of brain death on
  17     either 21st or 23rd October. Is that your present
  18     understanding?
  19   A. Yes.
  20   Q. So having been operated on on the Thursday, the 17th,
  21     that would have been either the Sunday or the Tuesday?
  22   A. According to the letter, after Melissa died, he wrote to
  23     our GP and said that the events had happened that caused
  24     that cause of death 48 hours after the operation.
  25   Q. For future reference, may I say, I think we may find

   1     some reference to that in the medical records. Shall we
   2     look, please, at my screen only for a moment, 1752/32?
   3     That, I think, is the screen that we have already seen,
   4     talking about mechanical difficulties in ventilation and
   5     satisfactory oxygenation being achieved several hours
   6     later. Can we look at 1752/41? This is a document to
   7     which you have made reference before. If we can focus
   8     halfway through the second paragraph, what was reported
   9     by the hospital was:
  10        "After 48 hours of the episode in the morning of
  11     21st October, it was noted that her pupils were dilated
  12     and not reacting."
  13        48 hours afterwards would give you either the 23rd
  14     or the 21st, depending on when the 48 hours begin,
  15     before or after. Thank you.
  16        You had seen and spoken to doctors after the
  17     Tuesday; it was not until, as you told us, the following
  18     weekend, that Melissa died. The first you knew of that
  19     was Dr Bolsin?
  20   A. Yes.
  21   Q. May I ask simply what you think ought to have happened?
  22   A. I think we should have been told as soon as they knew
  23     about the problems that she was -- well, that it looked
  24     like her brain was damaged and that she was not reacting
  25     to light and there were serious problems. They had been

   1     telling us all through the week that things were fine
   2     when they knew that there were very serious problems.
   3   Q. You have criticised what happened when you were asked to
   4     come in to speak to Dr Bolsin, and you would conclude,
   5     I suppose, at this stage, the hospital or staff in the
   6     hospital knew what position was, which is why they had
   7     asked you to come and see Dr Bolsin?
   8   A. Yes. Dr Bolsin, I think, had personally asked to see
   9     us. He called us without Mr Dhasmana being there, so we
  10     were told she was dead but there was nothing we could do
  11     at that time.
  12   Q. What do you say about the way that was handled?
  13   A. I just don't -- I have never been able to understand why
  14     Dr Bolsin called us up at that time. He knew
  15     Mr Dhasmana was on a day off, yet he still called us
  16     up. He knew he could not turn the ventilator off until
  17     Mr Dhasmana was there, and yet he still called us up to
  18     tell us himself that things were going badly, and it
  19     just seems very funny, why he called us up when
  20     Mr Dhasmana was on a day off and he knew he could not do
  21     anything, and they had already known before that there
  22     were problems.
  23   Q. Can I just ask you a little bit more about that, because
  24     you said a moment ago was that it was important to know
  25     as soon as possible about Melissa's condition.

   1   A. Yes, as soon as possible and we should have been told
   2     when Mr Dhasmana was there. He was on a day off on the
   3     Friday.
   4   Q. Suppose it is discovered by the hospital that
   5     Mr Dhasmana has not told you? What should the hospital
   6     do? Should they wait for another day until he comes
   7     back or should they try and tell you straight away, do
   8     you think?
   9   A. I think we should have been told before that Friday.
  10     I think we should have been told when Mr Dhasmana was
  11     there. They knew before that Friday. I had rung up
  12     twice on the Thursday and was told Thursday night
  13     everything was going as planned. Then all of a sudden,
  14     on Friday morning, we were called to go back up -- on
  15     Friday morning! -- to be told she was dead, and yet
  16     everything was going as planned on Thursday night.
  17   Q. The other criticism that you make in respect of
  18     Dr Bolsin on this occasion is you say that he did not
  19     give you any reason for the problems?
  20   A. No. He just told us -- like I said, we had to force it
  21     out of him -- that she was brainstem dead, but he did
  22     not tell us why. I mean, I know we were all in a bit of
  23     a state about it, but he certainly did not give us any
  24     explanation as to what had happened.
  25   Q. Dr Bolsin you did not know, but Helen Stratton you may

   1     have met before. She had introduced herself. You
   2     described her, I think earlier on, as perhaps a friendly
   3     face?
   4   A. Yes.
   5   Q. Did you ask her to find out what had happened?
   6   A. No. At that time we were in too much of a state to
   7     think about anything. We had just been told our
   8     daughter was dead.
   9   Q. Was there any contact by anyone after that from the
  10     hospital?
  11   A. No. I did have a letter from Helen, a condolence card
  12     from her, and that is the only correspondence I had from
  13     the hospital.
  14   Q. You wanted to know what had happened to Melissa?
  15   A. I do not know. At that time I think we were all in such
  16     a state that she was dead and nothing was going to bring
  17     her back, and we thought that the best had been done for
  18     her that could have been done for her; and that things
  19     just did not go as they should have done. We were not
  20     offered any explanation and I did not think about
  21     ringing up the hospital to ask to meet Mr Dhasmana, and
  22     we were not offered to meet Mr Dhasmana, so it was just
  23     left at that.
  24   Q. I suppose what you are saying is that when you got to
  25     know of the press concerns about Bristol and the

   1     operations was when you really wanted to know what had
   2     happened to Melissa?
   3   A. That is when we decided to find out if things had been
   4     done the best for her, as we thought at that time.
   5   Q. Before that, you had not wanted particularly to know?
   6   A. No, no, I cannot say I had. I read the letter he had
   7     written to the GP, but that was it.
   8   Q. So it follows that the criticism that you make about not
   9     having any explanation --
  10   A. We were not offered any explanation. I mean, at that
  11     time, like I say, we were very upset, obviously. I did
  12     not think about ringing the hospital for an explanation;
  13     I thought things had just, you know, not worked out, but
  14     I think if we had offered to go up and see Mr Dhasmana
  15     for an explanation, I think we would probably have taken
  16     it at that time.
  17   Q. This is something you were worried about and complained
  18     about really in the light of recent events and recent
  19     knowledge, is it?
  20   A. No, I think we should have -- no, I think -- I have
  21     always been annoyed at the way we were treated up
  22     there. I mean, I have always thought Melissa was
  23     treated fine, you know. I thought they did the best for
  24     her. I have never been happy with the way we were
  25     treated ourselves, but that was by-the-bye, you know.

   1     That was as long as they did the best for Melissa, you
   2     know, you could accept the way we were treated. I have
   3     never been happy about the way we were called up to
   4     speak to Dr Bolsin and without Mr Dhasmana being there,
   5     and at that time we were all in such a state that as
   6     time went past, we thought it was too late to be able to
   7     sort of speak to anybody up there.
   8   MR LANGSTAFF: Tracey, that is all that I am going to ask
   9     you. I think there may be some questions from the
  10     members of the panel. There may be perhaps some
  11     questions from Mr Lissack, who is your representative,
  12     as you know. I do not know, sir, do you want to give
  13     Tracey a break before she answers your questions?
  14   THE CHAIRMAN: Would you like a break?
  15   MRS CLARKE: No, carry on.
  16             EXAMINED BY THE PANEL:
  17   PROFESSOR JARMAN: I just wonder whether you felt there was
  18     any problem with the ventilator?
  19   A. I did not at that time, no. No, I did not know anything
  20     about that at all.
  21   Q. Subsequent to that?
  22   A. It is only since I have seen documents and that that
  23     I have realised that there was, but at that time when
  24     she was in hospital, no, I did not know anything about
  25     it at all.

   1   PROFESSOR JARMAN: Thank you.
   2   THE CHAIRMAN: Is there any re-examination?
   3   MR LISSACK: One matter, please.
   4            RE-EXAMINED by MR LISSACK:
   5   MR LISSACK: May I say, when I re-examine any witness,
   6     I propose to give the panel the issue in the List of
   7     Issues to which the question I ask refers, so you may
   8     know some thought has gone into it, and also, where
   9     appropriate, to give a paragraph number in the witness's
  10     statement to which this question is directed.
  11   THE CHAIRMAN: That would be very helpful, I am much
  12     obliged.
  13   MR LISSACK: Having said that, may I tell you there is only
  14     one matter I wish to ask about: issue J4 on page 18 of
  15     the List of Issues. There is no paragraph reference in
  16     the statement because Tracey does not deal with it at
  17     all. May I ask a few questions about it, please?
  18   Q. As we know, Melissa died on Saturday, 21st October
  19     1991. Thereafter, again, as we know, a post-mortem was
  20     carried out. After the post-mortem, her body was
  21     returned to you?
  22   A. Yes.
  23   Q. And did you have her cremated or was she buried?
  24   A. Cremated.
  25   Q. When were you first aware that your daughter's heart had

   1     been retained by the hospital?
   2   A. About three weeks ago.
   3   Q. Coming as that did over eight years after her death and
   4     her cremation, what impact did that piece of information
   5     have on you?
   6   A. It was very upsetting to hear it. It brought everything
   7     really back to the fore again. I mean, obviously, it is
   8     in the fore with all this anyway, but it really did have
   9     a big impact; it was very upsetting to hear it at that
  10     time.
  11   Q. Have you subsequently learned what happened to Melissa's
  12     heart?
  13   A. Yes. They disposed of it less than two months after
  14     they took it.
  15   Q. So disposed of in December 1991?
  16   A. Yes.
  17   Q. Can we just deal with this because it may inform the
  18     Inquiry and assist, as to, if you had been asked in 1991
  19     for permission for Melissa's heart to be taken and kept
  20     for research, what would your reaction have been?
  21   A. I would have agreed to it.
  22   MR LISSACK: I have nothing else to ask, thank you very
  23     much.
  24   THE CHAIRMAN: Thank you. Mr Lissack, you will forgive me
  25     if I say, perhaps those questions could have come

   1     through Mr Langstaff and could do in the future. Thank
   2     you.
   3        Mrs Clarke, thank you very much for coming to give
   4     evidence. We are all extremely grateful to you. Please
   5     do not assume that this is the only opportunity you will
   6     have to assist us. If anything else comes to your mind,
   7     if you would like to get in touch with us in any way,
   8     please feel free to contact one of the Inquiry team.
   9     This is an ongoing process and we are always happy to
  10     hear if you have anything else to say. Thank you very
  11     much indeed for coming.
  12            (The witness withdrew)
  13   MR LANGSTAFF: Mr Chairman, before everyone breaks up for
  14     the afternoon, may I say that Mr Lissack was kind enough
  15     to indicate to me before this afternoon's proceedings
  16     began that he would have an application to make in
  17     respect of something which I think he might like to say
  18     tomorrow morning, rather than now, given the hour.
  19   THE CHAIRMAN: I am grateful. Thank you. We will hear it
  20     tomorrow morning. We have not kept to our time-schedule
  21     today because today has been our opening day. We will
  22     revert to the hours that we have announced from tomorrow
  23     onwards. That means that we will convene at 9.30 and
  24     end at approximately 2.15, depending on the state of how
  25     we proceed with the witnesses. Thank you all for

   1     assisting us on what has been a difficult opening day.
   2     We will reconvene tomorrow, thank you.
   3   (3.04 pm)
   4     (Hearing adjourned until 9.30 am on Wednesday,
   5     17th March 1999)
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   1                I N D E X
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   4     OPENING STATEMENT BY THE CHAIRMAN..................... 1
   5
   6     OPENING BY MR LANGSTAFF............................... 5
   7
   8     MRS TRACEY CLARKE (Sworn):
   9
  10        Examined by MR LANGSTAFF....................... 60
  11
  12        Examined by THE PANEL ........................ 119
  13
  14        Re-examined by MR LISSACK..................... 120
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Published by the Bristol Royal Infirmary Inquiry, July 2001
© Crown Copyright 2001