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Daily transcripts
Hearing summary
17th May 1999
Professor David Baum, President of the Royal College of Paediatrics and Child Health
(RCPCH) and Professor of Child Health at the University of Bristol, came to give evidence
today. Professor Baum described the evolution of the RCPCH from the British Paediatric
Association to its establishment in 1996 saying that its aims were a child centred service
which would provide seamless co-ordinated delivery and planning of healthcare for
children. He outlined major developments which had taken place over the period in terms of
standard setting and monitoring and continuing medical education for senior clinicians. He
was questioned about referrals from GP to paediatrician, from paediatrician to
cardiologist and on to paediatric cardiac surgeon. He said that several factors would be
taken into account in deciding where to make a referral: geography, professional
diagnostic skills, family circumstances and rarity of service. He said that he would have
felt that if a unit was designated to provide a service, it should mean that the service
was of an acceptable standard. He went on to say that it would be useful for physicians to
have a database of hospital performance, but that this was not available during the
Inquiry’s terms of reference. The issue of the facilities at Bristol was discussed,
and he said that the location of the paediatric cardiac services being split between two
sites was not ideal, but not unique to Bristol. As a member of clinical staff at the
Bristol Children’s Hospital he said that he had never heard any criticism of the
paediatric cardiac service on the hospital ‘grapevine’. On the contrary, he said
he had heard positive comments about the Children’s Heart Circle and the appointment
of a counsellor and excitement about the proposed concentration of the paediatric cardiac
surgical services on one site.
Today the Inquiry concluded the evidence from Sir Terence English, former President of
the Royal College of Surgeons of England (RCSE) and member of the Supra Regional Services
Advisory Group (SRSAG) 1990 – 1992. Sir Terence told the Inquiry last week that he
had received a request from Dr Norman Halliday, Medical Secretary of SRSAG in July 1991 to
arrange a RCSE review of the infant and neonatal cardiac service, asking for
recommendations about whether, firstly, some surgical procedures could be omitted from
supra-regional status and secondly if some units should be de-designated. He said the
report recommended that the number of designated units be reduced, de-designating
Harefield and Guy’s and designating Leicester. In between receiving the report and
the July meeting of the SRSAG, Sir Terence confirmed that he had received a letter from Dr
John Zorab, Medical Director at Frenchay Hospital, forwarded to him by Professor Norman
Browse, the new President of the RCSE. He said the letter expressed serious concerns about
the quality of paediatric cardiac surgery at Bristol. Sir Terence said that he revisited
the RCSE report and was concerned both by the emerging trend that activity figures were
falling, and that mortality figures for Bristol were high. He said he discussed amending
the report to include Bristol amongst the units to be de-designated with the Chairman of
the Review Group Professor David Hamilton, who agreed to the change. He said he then
advised Dr Norman Halliday of the revised recommendation and asked him to convey it to the
next SRSAG meeting, for which Sir Terence had to send his apologies due to an annual
holiday. Subsequently, Sir Terence told the Inquiry today, that Professor Hamilton further
discussed the change with other colleagues from the Royal College and decided to reverse
his decision and to leave Bristol as a designated unit, he went on to inform Dr Halliday
of this decision by telephone before the SRSAG meeting. Sir Terence confirmed that SRSAG
in his absence decided to de-designate the entire service and to ignore the
recommendations of the RCSE report. He said he attended the September SRSAG meeting with
the hope of being able to change this outcome, but was unsuccessful in this. This was his
last attendance at a SRSAG meeting. Sir Terence confirmed he had not passed on his
concerns about mortality at Bristol to the Department of Health or Regional Health
Authority, assuming instead that Dr Halliday, to whom he had expressed his concerns, would
take the matter further. In 1995, Sir Terence said he wrote to Dr Roylance, the former
Chief Executive of the United Bristol Healthcare Trust (UBHT) expressing his concern that
Dr Dhasmana, consultant Cardiothoracic Surgeon, had been restricted from undertaking
paediatric work following the internal inquiry commissioned by the UBHT. He said that the
internal inquiry had identified no problems with Mr Dhasmana’s competence. He
concluded by affirming that comparative data for surgical success would be helpful to
surgeons, especially when assessing their own performance.
In order to complete the evidence of Sir Terence English today, the Inquiry hearings
sat until past 5.00p.m. Therefore the transcript will be published on the Inquiry website
tomorrow morning.
|
FULL TRANSCRIPT
1 Day 18, 17th May 1999
2 (10.08 am)
3 THE CHAIRMAN: Mr Langstaff, perhaps I should begin by
4 apologising; we are 10 minutes late and we do seek to
5 adhere to our timetable, but sometimes there is a need
6 for last minute conversations outside between various
7 lawyers and parties. I understand this, but I would be
8 anxious if we can, to the best of our ability, adhere to
9 our timetable
10 ADDRESS TO THE PANEL by MR LANGSTAFF:
11 MR LANGSTAFF: Sir, if I may, for my part, begin the week on
12 a note of impertinence: I hope that at some stage we may
13 manage between and us the computers to ensure that all
14 our watches are on the same time. We do not make it
15 quite 10 minutes, if I can put it that way!
16 Sir, I wonder if I may just pick up two or three
17 issues which arose at the end of last week? In part,
18 arising from that which Mr Lissack was telling the
19 Inquiry on Thursday evening.
20 May I, for my part, pay tribute to the way in
21 which the Bristol Heart Children's Action Group has
22 co-operated. Indeed, I am glad to hear that Mr Lissack
23 and the Group feel the same about the assistance that
24 they have had from counsel, as do Counsel to the Inquiry
25 in response. But one may have perhaps detected from
0001
1 what he was saying some underlying feeling that the
2 parents whom he represents, and no doubt others whom he
3 does not, may feel that they have had their say in this
4 Inquiry already; nothing, as you know, is further from
5 the truth.
6 The Inquiry works principally on written material,
7 written statements which are presented to it. The oral
8 evidence is a supplement to it -- important, but
9 a supplement. It is vital to the work of this Inquiry
10 that we go on receiving statements from those who can
11 assist.
12 What we have in mind, those of us who present the
13 evidence to you, the Panel, is that we would hope to
14 call parents, not only when we come towards the end of
15 the Inquiry, Blocks 5 and 6, when we explore the
16 concerns that were raised in respect of the Bristol
17 surgery in the 1990s, but earlier, in June, next month,
18 when we hope to explore the issues relating to the split
19 site, about which we anticipate many parents, both from
20 the Heart Action Group and from the Surgeons' Support
21 Group, and those several others who are members of
22 neither, may have something to say. Secondly, the
23 highly emotive issue of retention of tissue, which we
24 hope to explore at the moment in July, is the tentative
25 timetabling for that.
0002
1 As of this morning, the Inquiry has had 16
2 statements from the Heart Action Group and 19 statements
3 from the Surgeons' Support Group, but that, I suspect,
4 is only the tip of what I hope I do not wrongly describe
5 as an "iceberg", because we know from questionnaires
6 already submitted to the Inquiry that a further 97
7 members of the Heart Action Group have indicated they
8 are prepared to give statements, as are a further 20 of
9 the Surgeons' Support Group. We have in addition
10 received questionnaires from 94 parents who apparently
11 are members of neither group, and yet who are willing to
12 give statements.
13 The Inquiry has written to all of those parents
14 asking them to state whether they wish their statement
15 to be taken by the legal teams or the Heart Action Group
16 or the Surgeons' Support Group by their own solicitor or
17 by the legal team from the Inquiry. We are awaiting
18 replies to some of those letters. Some are coming in,
19 and I shall report the outcome in due course.
20 Can I just take this opportunity to encourage,
21 publicly, through the electronic means we have at our
22 disposal, anyone who wishes to formalise their
23 questionnaire, or indeed, who wishes to make a statement
24 who has not yet been in contact, to do so, because the
25 Inquiry is keen to go on receiving as much information
0003
1 as possible.
2 Can I, with that said, turn in something of the
3 same vein to the first of two allegations which were
4 made in the course of Mr Lissack's address on Thursday
5 last, when he told the Inquiry that the Secretary of
6 State had been told at a meeting in April 1998 by his
7 clients that they strongly suspected a cover-up
8 involving the Royal College of Surgeons of England, the
9 Department of Health and the Bristol Royal Infirmary,
10 and he indicated that that remained their view.
11 In the spirit of co-operation which has
12 characterised the relationship between the lawyers for
13 all parties and Counsel to the Inquiry, I have asked him
14 whether there is any evidence which he had which had not
15 been sent to the Inquiry. There is not, so far as I can
16 gather, but what I would like to say is this: that
17 plainly the allegation is a serious one; it comes from
18 a responsible and respectable source and deserves to be
19 treated seriously, so can I take this moment to ask
20 again, through the electronic media we have at our
21 disposal, that anyone, whether in the Department of
22 Health, whether in the Royal College of Surgeons,
23 whether in the Trust or elsewhere, who has any
24 information which will enable the Inquiry to determine
25 whether there may or may not have been a cover-up such
0004
1 as is alleged, to come forward and to let us, at the
2 Inquiry, have that information. If that individual is
3 not happy to speak directly to the Inquiry, then I would
4 encourage that person to speak to his or her solicitor
5 and his or her solicitor will no doubt, as one would
6 expect, forward the information on to the Inquiry. But
7 we are keen to hear, because we, for our part, take
8 seriously the promise that no stone will be left
9 unturned.
10 I would hope that any information provided will
11 condescend to details of who, when and how, but I have
12 to leave that, of course, for the individual concerned.
13 Secondly, an allegation -- I am not sure if it was
14 an allegation; that may be too strong a word -- but the
15 complaint was made by Mr Lissack that there had been
16 correspondence with the Secretariat of the Inquiry about
17 the possibility that there might be cross-examination,
18 and he told you, sir, that he had seen correspondence to
19 and from the Inquiry which states that you have been
20 aware of the specific detailed, reasoned and written
21 concerns over cross-examination since last October.
22 I am told by him that the letters to which he
23 refers are dated respectively 26th and 29th October.
24 I have asked that they be looked out, and they consist
25 of a letter of 26th October(page 1, 2, 3), written by Tozers,
0005
1 solicitors, addressed to Miss Charlotte Martin, the
2 Assistant Solicitor to the Inquiry, and her reply that
3 I have dated, 30th October, in response.(page 1, 2)
4 What I propose to do, what arrangements will be
5 made to do, is to put those on the Internet because in
6 essence they will speak for themselves and the public
7 are entitled to see what the position was and is in
8 respect of those concerns, so that we, in the Inquiry,
9 deal with things in it without putting a spin upon it,
10 so those who may wish to know may see the raw material
11 for themselves.
12 Can I confirm that it is right that he, on behalf
13 of his clients, advanced a protocol as to
14 cross-examination and when cross-examination might be
15 permitted. This was in March of this year. There were
16 discussions about it which we, for our part, thought had
17 been resolved -- resolved in the sense that the protocol
18 was acknowledged, but it was asking for more than the
19 Inquiry were prepared to give, because it went beyond
20 that which you said in your opening statement last
21 October.
22 That is the history of the matter. As to the
23 principles, it is not my position to address the Inquiry
24 because it is for the Inquiry to make its position clear
25 if it wishes to do so. Sir, it may be helpful if you,
0006
1 on behalf of the Panel, were to make a short statement
2 as to the principles that inform the view that was taken
3 as to cross-examination.
4 May I, as part of my function as Counsel to the
5 Inquiry, advise that nothing should be said which in any
6 sense should be seen to prejudge or predetermine, or
7 prejudice, any application which Mr Lissack may yet make
8 to cross-examine Sir Terence English, or others, because
9 they must plainly be dealt with on their own merits, so
10 it is only to the general question that you may wish to
11 address some remarks
12 CHAIRMAN'S STATEMENT:
13 THE CHAIRMAN: Mr Langstaff, thank you. I crave the
14 indulgence of our first witness, because I am going to
15 speak for a few minutes, I am not sure how long. I hope
16 you will forgive me for doing so and not calling -- I am
17 now addressing the witness who is sitting here --
18 forgive me if we do this and it causes you to wait
19 a little while.
20 As you say, Mr Langstaff, I do want to make some
21 general remarks in the hope that they may be of some
22 help. Though they be specifically initially addressed
23 to Mr Lissack, because it was he who raised a number of
24 questions, of course, to the extent that they are
25 helpful or relevant to others, I would ask others to
0007
1 give them appropriate attention.
2 The Panel, I and my colleagues, think, Mr Lissack
3 in particular, that it may be helpful in view of the
4 intervention on Thursday to share some of our thoughts
5 again concerning the shape and the form of this
6 Inquiry. You, for your part, shared with us on Thursday
7 what you described as some "dissatisfaction" amongst
8 your clients. We recognise that there are many strong
9 feelings and high emotions about the matters we are
10 looking into, for the Panel as well as for others, and
11 they are always there. Every time we walk into this
12 hearing chamber, we are reminded again of the tragedy
13 which brings us here. We acknowledged this on the first
14 day of the public hearings back in October, and it is
15 with us every day as we sit, as we read and as we sift
16 evidence.
17 But you will also remember that by our very use of
18 the word "tragedy" on that day in October, we were
19 accused of bias, of having prejudged matters. Of
20 course, we did no such thing. We defy anyone, as
21 Mr Langstaff said in his opening address back in March,
22 to deny that the death of or injury to a child, however
23 it is caused, can be anything other than a tragedy. We
24 cannot take a view on what may have led to those deaths
25 and injury, that is in part what we are here to
0008
1 discover, but we can and do acknowledge the tragedy.
2 Equally, it is a tragedy that after 10 or 15 years
3 we are in this room, still trying to understand what
4 went on, such that so many people cannot get on with
5 their lives.
6 Thus, there was no bias in October, but equally,
7 not everyone may accept this. This is because, and it
8 is a trite observation is but no less true, different
9 people hold different views.
10 We ask, therefore, that everyone appreciates the
11 Panel's dilemma. We do not forget for a moment the
12 grief, the pain, the frustration and, yes, the anger of
13 your clients. But once the Inquiry has begun, we must
14 be even-handed and fair to everyone who gives evidence.
15 We must assume, as a starting point, that each witness
16 deserves the same respect. We cannot set out to subject
17 a particular witness to, as it were, the third degree.
18 Leaving aside the fact that such an approach usually
19 produces more heat than light, it is plainly unfair. It
20 assumes in advance both that there has been wrong-doing
21 and that this witness is a wrong-doer. The Panel makes
22 no such assumptions; we cannot. We began this Inquiry
23 with a clean sheet. We will read and hear the evidence
24 in as impartial and fair a manner as we can.
25 Conclusions are to be drawn at the end.
0009
1 So we ask again that you understand our position,
2 just as you ask us to understand yours. To proceed as
3 we do does not diminish for a moment our sense of
4 tragedy, but it is the only way to deal fairly with all
5 who appear before us.
6 We say this directly to you, Mr Lissack, and
7 through you to your clients. Whatever its history, this
8 Inquiry now belongs to the public. We cannot defer to
9 any individual or group. All who appear before us are
10 entitled to and will receive a fair hearing.
11 Of course, we on the Panel recognise we are asking
12 from you and your clients, just as we are asking from
13 everyone else, for two things that are probably the
14 hardest to give: trust and patience; trust that we will
15 see things through, and keep our promise to get to the
16 bottom of things.
17 As for patience in such a complex Inquiry as this,
18 understanding takes time. We will be hearing evidence
19 in this room until December. Of course this may be too
20 slow for some, particularly those who are impatient for
21 us to reach a particular view, but we must read and
22 listen carefully and this takes time.
23 So we ask for patience. We will do our duty in as
24 timely a manner as we can.
25 Finally, in the, as it were, 'conversation'
0010
1 between you and me, a request for guidance on
2 cross-examination was, as Mr Langstaff said, made before
3 Easter. We did not then believe that it would be
4 helpful to issue the requested protocol. The criteria
5 had been set out in October and any application could
6 then be made. We were, and remain, anxious that the
7 procedure which we believe is proper for this Inquiry
8 should not become lost in ever denser legal thickets.
9 That said, we are now persuaded that some guidance
10 as to the process to be followed may be of some use and
11 for that reason, we, the Panel, will issue guidance
12 today.
13 Having offered these general observations, may
14 I go on to say something about cross-examination, and
15 again, I crave your indulgence. Clearly any decision,
16 as Mr Langstaff properly reminded us, must await both an
17 application and the Panel's consideration of it. But we
18 thought it might be helpful if we set out the context in
19 which applications will be considered.
20 We have to consider any application for
21 cross-examination against the background of the
22 procedure we announced in October, and have reaffirmed
23 on a number of occasions. We, the Panel, recognise our
24 procedure may cause concerns to some; indeed,
25 Mr Lissack, you and I crossed swords early on concerning
0011
1 re-examination, when I was anxious to make clear at the
2 outset that we intended to follow our declared
3 procedure. As I said at the time, I meant no offence.
4 If I was too zealous or too harsh in affirming my
5 remarks, I regret that and I am sorry.
6 Now the issue is not re-examination; it is
7 cross-examination. There are some, including perhaps,
8 and especially, perhaps, legal representatives, who may
9 feel that we can never get to the bottom of things
10 unless we allow the legal representatives of all those
11 who are interested in this Inquiry to bring their
12 forensic skills to bear in exposing witnesses to
13 cross-examination. After all, this is what happens in
14 courts, and we have grown familiar with it elsewhere,
15 too.
16 Well, we have said many times, this is not a court
17 and we are not judges. We have been chosen for our
18 expertise in other fields: in medicine, in nursing, in
19 management, in university research and in health, law,
20 ethics and policy.
21 So we do things our way, within the general
22 framework of the law, of course. We are conducting
23 a Public Inquiry, an Inquiry which is hugely complex,
24 which is not concerned with a single event but spreads
25 over 12 years and hundreds and hundreds of events, and
0012
1 which is concerned as much with policy and culture as it
2 is with practice.
3 Our duty is to serve that public interest, not the
4 interests of any particular section. Our brief is,
5 quite frankly, humbling, ranging from the events at
6 Bristol to making recommendations for securing the
7 highest quality of care across the NHS, and to do all of
8 this in a timely fashion.
9 We were convinced in the outset and remain
10 convinced that the only proper way to fulfil our public
11 duty is to adopt an inquisitorial procedure. We were
12 and are convinced that the adoption of adversarial
13 positions will not ordinarily help us in our tasks. We
14 venture to believe that the story of Bristol and of the
15 NHS in the 1980s and 1990s will emerge more fully and
16 clearly if we are able to avoid the confrontations and
17 the often illusory black and white clarity which
18 adversariness tends to bring.
19 There are a couple of other factors to bear in
20 mind: first our procedure relying on written statements
21 and comments means that matters calling for
22 clarification can be clarified by further written
23 submissions. It is eminently flexible. Secondly, the
24 fact that this phase of the Inquiry will take many
25 months means that there is less need, indeed, little
0013
1 need, for instant comment and response; a feature,
2 indeed, some may say the feature, of cross-examination.
3 As I said on Thursday, let no-one fear that
4 because something which warrants challenge is not
5 challenged at that very moment, it will remain
6 unchallenged.
7 Much of the work in this Inquiry is in reading
8 that which has been written. What has been written is
9 not limited to the evidence; it includes comment.
10 Indeed, the Surgeons' Support Group has already
11 submitted a lengthy comment on the conclusions which we
12 should draw from Block 1 of our evidence. We regard
13 this as most helpful, whatever view we may take
14 ultimately of its content.
15 It is equally open to any participant in the
16 Inquiry to submit to us similar comments on any block,
17 or on what any witness has said, or for that matter, has
18 not said. We can assure you that whatever is submitted
19 will be read and will be considered fully, and of course
20 it will be published.
21 It is sometimes said that cross-examination is
22 comment dressed up as questions. To the extent that
23 there is any truth in that, such comment can be made in
24 writing.
25 Thus, even if one door, that leading to
0014
1 cross-examination, may on any particular occasion be
2 closed, we hope we are being constructive in reminding
3 legal representatives that there are other doors which
4 are always open.
5 We realise our general approach may disappoint
6 some. Indeed, there are some who may understandably see
7 this Inquiry as, at last, the opportunity to bring
8 someone to account and that cross-examination is a vital
9 tool in that process.
10 Well, the Inquiry does provide that opportunity
11 where it is proper to do so, to bring people to account,
12 but we do not see adversariness as a necessary tool to
13 achieving this. It does not mean that our examination
14 will not be rigorous or thorough. The Inquiry's
15 counsel, helpfully, if I may pay tribute again, aided by
16 other legal representatives has demonstrated this.
17 Further, as I repeated on Thursday, let no-one think
18 that because we set our face largely against an
19 adversarial approach, we are inevitably committed to
20 writing a report which in some way will lack force or
21 bite. Let no-one be in doubt that when we come to write
22 our report, if tough things have to be said, they will
23 be said. We read, we listen, we build up our
24 understanding, and we strive to treat all who appear
25 before us with equal fairness.
0015
1 Finally, let no-one think that our procedure, as
2 I repeat it again, and as Mr Langstaff made clear in
3 March, makes legal representatives redundant; far from
4 it. They have a crucial role, but it may be one which
5 is largely behind the scenes, although no less important
6 for that.
7 Our repeated reminder that we are not a court, we
8 accept, we understand, may cause some to chafe. They
9 may wish us to proceed by other perhaps more familiar
10 rules. We understand this, but we have set out our
11 procedure frequently. We first announced it in
12 October. It is not merely appropriate but essential if
13 we are to meet the obligations placed on us by the
14 Secretary of State in a proper and timely manner.
15 So it is against this background, and I thought it
16 important to rehearse it at some length, that we will
17 consider any application, but I remind all here that of
18 course any application that is made must and will be
19 considered on its particular merits.
20 Mr Langstaff, I have gone on perhaps rather longer
21 than I had hoped, but now may I defer to you?
22 MR LANGSTAFF: Sir, yes. I shall be short. Professor Baum,
23 would you come forward, please? Miss Grey will take his
24 evidence.
25 MISS GREY: Professor Baum, I am sorry you have been kept
0016
1 waiting, but I trust you will understand the need for
2 the debate we have just had. As you will also know, the
3 evidence in this Inquiry is taken on oath, so can
4 I invite you to stand and take the oath?
5 PROFESSOR DAVID BAUM (Sworn):
6 Examined by MISS GREY:
7 Q. Could we have, please, on the screen, WIT 36, page 1?
8 This is the title page of a statement which has been
9 written by you, but represents a consensus amongst
10 elected senior officers of the Royal College of
11 Paediatrics and Child Health; is that correct?
12 A. That is correct.
13 Q. You, of course, are the current President of that
14 college?
15 A. I am.
16 Q. Can I just ask you as a matter of record: are the
17 contents of the statement that we see there true?
18 A. The opening statement is true and it is the beginning of
19 the full statement, that is true.
20 Q. Professor Baum, you are firstly a Fellow of The Royal
21 College of Physicians of London?
22 A. Firstly, in chronological terms.
23 Q. And secondly, a Fellow of The Royal College of
24 Physicians of Edinburgh?
25 A. Correct.
0017
1 Q. Also, perhaps, in chronological terms?
2 A. Not quite, but let us not complicate matters.
3 Q. And thirdly, of course, you are a Fellow of The Royal
4 College of Paediatrics and Child Health?
5 A. I am.
6 Q. And its President. You are also, I think, the Professor
7 of Child Health at the University of Bristol?
8 A. I am.
9 Q. When did you take up that post?
10 A. On August 15th at 11.30, 1985.
11 Q. Is it right there that at the University of Bristol your
12 main concern has been to build up the University
13 department under your control and guidance?
14 A. It has been my main concern.
15 Q. And also to build up, to develop, an Institute of Child
16 Health?
17 A. That is so.
18 Q. But it is also right, is it not, that you are in fact
19 a clinician at the Bristol Children's Hospital, holding
20 a particular interest, a specialty in the field of
21 diabetes?
22 A. That is correct. I am a general paediatrician in
23 clinical practice with a special concern for childhood
24 diabetes.
25 Q. So you have some involvement and knowledge of the
0018
1 Children's Hospital at Bristol since 1985?
2 A. I have.
3 Q. And although you have come to speak to us on behalf of
4 the Royal College of Paediatrics and Child Health, it
5 may be that at odd times this morning your evidence will
6 also touch upon your knowledge of that hospital; is that
7 right?
8 A. That would seem to be a proper ...
9 Q. Thank you. Professor Baum, I think it is the case that
10 you may need to speak a little more loudly. I do not
11 know that the microphone needs to come any closer; it
12 does pick up sound from a distance of about 3 metres,
13 but it still needs a fairly clear statement before it
14 picks it up adequately.
15 A. Thank you.
16 Q. Turning back to the Royal College of Paediatrics and
17 Child Health, it is right that the College has been
18 a late arrival to the group of Royal Colleges and that
19 its charter was not awarded until 1996?
20 A. That is correct.
21 Q. It follows, therefore, simply as a matter of record,
22 that the College has not had responsibility for the
23 accreditation of hospital training posts in the field of
24 paediatrics during the period from 1984 to 1995?
25 A. That is correct.
0019
1 Q. You will appreciate, of course, that the period I have
2 just described is the period of our terms of reference
3 as an Inquiry.
4 A. That is so.
5 Q. It is of course the case that now that position has
6 changed and the College has taken up that function,
7 together with other associated functions such as such
8 aspects as continued education for its members and also
9 a role in the appointment of hospital consultants,
10 paediatricians?
11 A. That is so, but if I may just offer a gloss on that, of
12 course as you have read in our full statement, there was
13 a gestation before our birth and during the years,
14 indeed, the decades, and particularly the latter ten
15 years before the birth of the College, we were exerting
16 considerable influence, at least upon the ethos of
17 quality of clinical practice.
18 Q. Because the predecessor to the Royal College was of
19 course the British Paediatric Association, a membership
20 association that in some respects attained the status of
21 a college even prior to its recognition as such in 1986?
22 A. Exactly so.
23 Q. Could I ask you, however, Professor Baum, about the
24 status in which the profession of paediatrics and the
25 discipline of paediatrics was held during the period of
0020
1 1984 to 1995? Does the late recognition, if I may call
2 it so, of the Royal College of Paediatrics and Child
3 Health as such lead you to make any comment on the
4 general status of the profession of paediatrics during
5 the earlier period, that period?
6 A. It does. It is not of course unique to this country.
7 Across the world the independent voice of paediatrics
8 has been later than physicians and surgeons as an
9 identifying group in the world of medicine. In the
10 United States the separation of the American Academy of
11 Paediatrics was quite late in coming into existence, and
12 in this country, much later still was the separate
13 identity of our profession as deserving of a Royal
14 College of its own.
15 If one has to understand that, I think as you will
16 see from our document, it is really well put in the
17 context of the United Nations Convention on The Rights
18 of the Child. That itself did not come to the world
19 until 1989 and that was a recognition in the world in
20 a much broader sense: that children are a group without
21 a vote who are biologically heterogeneous, have rights,
22 are fully formed humans, albeit at an immature stage and
23 that there is this very broad case for recognising
24 children as a separate entity, and we, as physicians for
25 children, made our case that in this country that should
0021
1 be reflected by a separate voice on equal standing with
2 physicians, surgeons, anaesthetists and so forth.
3 Q. It is, I think, a comment made in the evidence of the
4 Royal College of Nursing that the UN Convention on The
5 Rights of the Child was ratified by this country in
6 1991. Would that fit into the general historical
7 pattern that you have just been describing?
8 A. I think the point on the graph is exactly well placed.
9 Q. If we turn from that statement to the Royal College of
10 Nursing, this is WIT 42. If I can invite you to put up
11 page 6, please. If we can just scroll down to the
12 bottom of that page, this is a historical perspective on
13 the development of health services for children, and if
14 I could just invite you to read paragraph 2.5 at the
15 bottom of the page:
16 "Advances in the knowledge of children's physical,
17 psychological and physiological needs took place during
18 the early decades of this century. However, government
19 acceptance of the separate needs of children who are ill
20 or have a major disability was only recognised for the
21 first time with the publication of the Platt report in
22 1959."
23 Would you agree with that paragraph?
24 A. I would, but would regard it as an understatement,
25 because -- if I may just divert for a moment, the early
0022
1 part of my career in the middle 1960s to middle 1970s
2 was the period when the even more separate identity,
3 physiologically, biologically, of the new-born baby was
4 being described, and those descriptions, that
5 developmental physiology in which many of us found our
6 early career, portrayed differences much greater than
7 the differences which were at that time recognised, at
8 the time of the Platt report. So whatever was stated
9 there, with which I would associate myself most
10 strongly, applies, and applied decade by decade, more so
11 with the uncovering of the huge biological differences
12 of the new-born and prematurely born.
13 Q. Would it be fair to say, therefore, that the insights
14 that the Platt report offered were overtaken by events,
15 and seen to recognise or to reflect a fairly limited
16 understanding of the separate needs of the child?
17 A. I would agree with that.
18 Q. If we could just turn over the page to page 7 and look
19 at the first paragraph, 2.6:
20 "There have been difficulties in establishing
21 a true recognition of the status and value of child
22 health professionals."
23 Then the statement goes on to talk about the
24 emphasis on adult nursing, meaning that children's
25 nursing has not been accorded equal professional status
0023
1 over the years.
2 It continues:
3 "The development of the professional status of
4 children's nursing which has been mirrored with medical
5 colleagues and paediatricians only achieved the status
6 of a Royal College in 1996, with the formation of the
7 Royal College of Paediatrics and Child Health."
8 Is the thrust of the argument set out in that
9 paragraph something you would endorse, or something you
10 would wish to disagree with in any shape or form?
11 A. No, I would endorse it. It is difficult to concisely
12 portray a view of what is behind it, but elements of
13 what is behind it, if I may look to the Panel, forgive
14 me for turning my back as I speak, are matters that in
15 the self-selection of what branch of medicine doctors
16 and nurses choose to go, there are, of course,
17 determining factors, and it would be the case that,
18 putting myself aside from what I am about to say, one
19 might consider that those choosing to go into the
20 medicine of children might have a gentler approach to
21 life, a more listening and sympathetic approach to life,
22 and prior to the physiological and scientific explosion
23 of the latter half of this century, that led to
24 a certain avuncular, sentimental at times, reputation,
25 and I think that, while appropriate to its subject,
0024
1 disadvantaged the separate professional strengths of the
2 professionals. It really has been with the development
3 of the scientific base of our subject that there has
4 been the necessary assertiveness to win the points in
5 paragraph 2.6.
6 Q. So in other words, the profession of paediatrics was
7 seen as being something of a softer option, if that is
8 not too crude, both intellectually and scientifically
9 until a relatively late stage?
10 A. No, I would not be able to agree with the way you put
11 it: might be and was regarded as a gentler subject, but
12 no less rigorous in its intellectual challenge. You may
13 read the works of Donald Winnicott and realise the
14 extraordinarily intellectual challenges that he
15 addressed in the 1940s and 1950s: no less a challenge,
16 but gentler in its approach at that time.
17 Q. But at what point was the fact of the intellectual
18 challenge that the profession demanded or required of
19 its participants generally recognised amongst other
20 medical disciplines and specialties?
21 A. It would be progressively in the 1950s, in the period
22 since the end of the Second World War.
23 Q. How would say, then, that the status of paediatricians
24 and of children's health services and professionals
25 compare to that of other branches of medicine now, at
0025
1 today's date?
2 A. I think there is yet a backdrop of that atmosphere
3 I have described over the first half of this century
4 which leaves us, without, I hope, diminishing one jot of
5 our compassionate care for children and their families,
6 to have to be rather more than less assertive to appear
7 politically as equals.
8 Q. If we push that back to the beginning of the period of
9 our terms of reference, 1984, would your answer be the
10 same or would you have to modify it in any way?
11 A. It would be the same. It was at the point on a rather
12 steep slope of the change in the professional standing,
13 both in nursing and in the medicine of children.
14 Q. If we push that answer down to the level of the
15 individual hospital, and in particular, a hospital,
16 a large hospital which has as a part of it a separate
17 Children's Hospital, how does the voice of those who are
18 managing and representing the Children's Hospital make
19 itself felt amongst the competing pressures of hospital
20 services as a whole?
21 A. If we were talking abstractly, and this was a children's
22 hospital within the greater building complex of an
23 all-specialty general hospital, then the normal
24 mechanism of representing views at the necessary
25 committees and the necessary presentation of documents
0026
1 and speaking to them and so forth would be equal among
2 equals. However, there was a tradition from which we
3 come that children's hospitals were in many places in
4 the world set up as castellated installations, separated
5 from the main, because it was recognised that the needs
6 of children were separate and required to be addressed
7 separately but that separatism has not historically
8 worked wholly to the best advantage of children.
9 Curiously, in Bristol itself, the very fact that the new
10 Children's Hospital is to be provided not on top of the
11 hill in grand isolation and in what was clean air, but
12 at the bottom of the hill, contiguous with the new
13 building, is I think a political statement that shows
14 that we wish to retain everything that is important and
15 separate about the health care of children, but we need
16 to be contiguous with the whole of medicine.
17 Q. Since you raised the example of Bristol and the
18 Children's Hospital, how does the new political
19 statement, as you have described it, compare with the
20 pre-existing situation where the Children's Hospital was
21 'up the hill' and therefore at least physically
22 separate from the remainder of the hospital?
23 A. It is still up the hill, and it does require an
24 additional effort to go down the hill to join the
25 necessary committee meetings and policy making groups
0027
1 and so forth to win an equal share of the discussion.
2 That requires an additional effort. That effort goes
3 on, but we hope that we will be able to represent the
4 case of the need of the health care of children that
5 much better when we are on the same side.
6 Q. Turning back to the question of the Royal College's
7 mission in this general area of the advance in the
8 interests of children, what do you see as the College's
9 mission in the next five years or so of its
10 development? Perhaps at this point it might be of
11 assistance if we turned up page 46 of your witness
12 statement, where the College's document, its Child
13 Health Strategy, is set out. That is of course just the
14 first page of it.
15 A. Might I just interrupt? On the front sheet is
16 a statement which, if I may turn to the Panel, we made
17 with serious intent, calling our strategy a "Children's
18 Health Service", since we believe that our
19 responsibility certainly includes setting and
20 maintaining the standards of paediatric practice. But
21 we see our responsibilities as being wider than that and
22 working with other agencies and pressing government that
23 we shall have a child-centred Health Service in the
24 country.
25 Q. So how does that differ, if at all, from the traditional
0028
1 mission of a Royal College?
2 A. It is not for me to find fault with other mission
3 statements, but we took great care, after long debate,
4 in naming our College not the Royal College of
5 Paediatricians but the Royal College of Paediatrics and
6 Child Health, so that our focus should be on the health
7 needs, curative for the child who is sick, paediatrics
8 and child health, the preventative and health promoting
9 aspects of our discipline, and that to achieve that end
10 were these matters of setting standards and maintaining
11 quality of clinical practice, but they being means to
12 the end, and the end is where we have our focus and that
13 is where we must be judged.
14 Q. That of the Child's Health Service. It is fair to say,
15 if one looks through the document, it recognises the
16 very broad aspects that are engaged in securing
17 children's health, because they encompass social and
18 educational issues as well as purely, if I might use
19 that term, medical issues?
20 A. Yes, I agree.
21 Q. If we turn briefly to the foreword of the document at
22 page 50, it is written by you. You talk there about the
23 document defining the strategy of the Royal College and
24 again, there is the reference to the United Nations
25 Convention on the Rights of the Child. The aim of the
0029
1 document and the College as you have just been
2 describing is perhaps very briefly summarised there.
3 It is apparent that the College is clear upon its
4 mission towards children, but of course it is also
5 setting standards for paediatricians which form its
6 basic membership.
7 Is there perhaps a tension between the aims of the
8 College to set out a blueprint and to aim to participate
9 in the development of a Health Service for children, and
10 its duties or its loyalties towards its membership of
11 paediatricians?
12 A. There must be tensions. The metaphor we use in the
13 College is, it is healthy tensions that keep the mast
14 upright and the sails in appropriate tension to sail the
15 ship. There have to be tensions, but they have to be
16 managed. We use the UN Convention as our anchor, so as
17 the debates unfold, the debate is always brought back in
18 the best interests of the child, how shall we resolve
19 these issues?
20 So there are issues about the configuration, the
21 shape of health services that we would wish to influence
22 to come, and how that will balance against the number of
23 consultant paediatricians that there are and the number
24 that we think there should be, and how we will manage
25 our work today and how we would wish to manage our work
0030
1 in five years time, in the best interests of the child.
2 If I can give an example there, which I think is
3 perhaps relevant to some of our discussion, there would
4 be modelling which would say in the best interests of
5 the child and family, they would want their health care
6 in their immediate neighbourhood. If we then look at
7 that from the professional point of view, to deliver the
8 best health care in the best interests of the child, if
9 this is an uncommon condition, the conclusion would be,
10 that cannot be delivered in every neighbourhood because
11 there has to be a certain quantum of work to maintain
12 the expertise of the practitioners. That leads one to
13 conclude that there has to be a configured tertiary
14 centre with sufficient throughput to justify that rare,
15 uncommon, perhaps highly technological work, which is
16 not in the family's backyard. And there is a tension.
17 But in the best interests of the child one would then
18 try and form a resolution to that and make that our
19 proposal.
20 Our conclusion in our consultations with families
21 is that if we professionally believe it is in the best
22 health outcome interests of the child to travel
23 a distance for the more highly experienced, highly
24 technological, rarer kind of care, then that is the wish
25 that we believe families would go with, even though it
0031
1 takes the care away from their home base.
2 Q. I would like to come back, if I may, to the issue of
3 tertiary services and the tension that may, on occasion,
4 be manifest between geographical location and the
5 development of expertise, but to return to the issue of
6 a possible conflict between developing children's
7 services and the interests of members. The crude point
8 that might be put against the College in its aspiration
9 to manage both of these things is the large dependence
10 which it will inevitably have for its funding upon
11 membership subscriptions and the support of its members,
12 both financially but also in more indirect fashions.
13 If we look, for instance, at page 151 of your
14 statement, this just by way of an example is the
15 College's last year's published accounts, and it is
16 obvious from there that the membership subscriptions
17 that year came to just under œ1 million, and represented
18 just under half of the College's total income.
19 It is also fair to say that you make the point in
20 your statement that in the coming year the dependence on
21 membership funding will go down to roughly one-third,
22 but what do you say about managing possible tensions
23 between these two loyalties in the context of quite
24 a major dependence upon members for funding and other
25 forms of support?
0032
1 A. I find your question original, in that I have never
2 encountered a tension in the way that you have put it.
3 It may be part of the newness of our College, but there
4 has not been, at any of our debates, at our very
5 powerful vocal Council meetings, a challenge that our
6 members will not buy into this. We are still
7 a vocationally driven specialty, and the importance of
8 our accounts is that we look to our Finance Committee to
9 keep us solvent. But the issue of, "Will we be able to
10 carry our members with us on such a recommendation?" for
11 example, if the recommendation was that to deliver the
12 Health Service in the best interests of children,
13 consultants should have to start living in hospital, we
14 would have quite a debate on our hands.
15 But I would not have considered, until you raised
16 the question, that anyone would have started to threaten
17 withdrawing their subscription. The atmosphere is not
18 set in this way.
19 Q. So, so far, does it follow from your answer that you
20 have managed to manage any tensions, or conflicts that
21 may exist between the interests of paediatricians and
22 the interests of the child without any real difficulty?
23 A. I think that is the key, and I think it is because --
24 I like to think it is, in my earlier remarks, there is
25 still a selective sorting of who goes into the health
0033
1 care of children, and they are people committed to the
2 health care of children. The tension is, "Which is the
3 better moral?" and then we will have a lively debate and
4 try to take our anchorage from the best interests of the
5 child.
6 Q. Does the College's endorsement or advocacy of a proposal
7 for the position of a national Children's Commissioner
8 have any part to play in this particular debate?
9 A. It is an aspiration of the College. It has been
10 discussed in our Council, which is a representative
11 Council, and is strongly supported by our Council and it
12 is something to which we are committed, and will
13 continue to work. And if I have to give some brief
14 justifications for that view, which I think is a view
15 that is shared by our colleagues in the Royal College of
16 Nursing, that it is one thing for us in the best
17 interests of the child to work out a policy, to have
18 a policy statement, to place it before Her Majesty's
19 government; it is another matter to ensure that it is
20 implemented, and it is our view that the office of
21 a Children's Commissioner, a children's rights
22 commissioner, an Ombudsman for children, looking
23 sideways at government, in the best interests of the
24 child without any question, for that would be the
25 purpose of the office, would be our best safeguard that
0034
1 recommendations, and in our work recommendations for the
2 health care of children, would have a body standing
3 which would say, "In the best interests of children,
4 that should be implemented; it has not been implemented,
5 Her Majesty's government must be answerable, why has it
6 not been implemented?"
7 Q. Thank you. You mention there the Royal College of
8 Nursing, and perhaps that is a point on which we could
9 pass to the general issue of the shortage of nurses
10 trained in paediatrics throughout the NHS during the
11 period again of our terms of reference, 1984 to 1995.
12 We have heard already a great deal of evidence of
13 the general shortage of such nurses, and of course the
14 British Paediatric Association, as it then was, did
15 a great deal to point that up through a number of its
16 reports and working party documents throughout our
17 period.
18 Can I ask you, however, that assuming that general
19 background as read, what impact do you think the absence
20 of a trained children's nurse upon a ward would make to
21 the care of that child?
22 A. I believe there would be, and is, a great impact flowing
23 from the presence or the absence of a children's nurse
24 trained presence on the ward, to prove that case is very
25 difficult. I would have initially to begin by restating
0035
1 the differences between children and adults, more
2 strikingly so younger children, more strikingly so the
3 new-born, to rehearse the difference in their
4 physiology, in their fluids, in their drug requirements,
5 in their physical signs, in the subtleties which would
6 lead a skilled, that is a trained nurse, in children's
7 health care to say "That child is not well", "That child
8 is blanching", "This child will anticipate pain from
9 this procedure", to be the guardian of the young child,
10 the baby.
11 I think those are substantial differences.
12 To prove it made a difference would be an
13 extraordinary long-term study which would require,
14 I suppose, the randomisation of children or children's
15 wards without such special care nursing, and it would be
16 a long and very expensive experiment and no doubt will
17 take some years to have outcomes, but I think it would
18 fall at the first ethical fence that I think sensible
19 people would judge, and you cannot do that experiment
20 because it is manifestly the case that children should
21 be looked after by children-trained staff.
22 Q. Does it follow from what you have said that if we were
23 to start searching through scientific journals in search
24 of such evidence we would not find it, but that the
25 evidence comes both from the basic theory of children's
0036
1 nursing plus possibly anecdotal evidence of the
2 importance of the interventions that particular nurses
3 have made on particular occasions?
4 A. Yes. I think that is the case. But I would not wish to
5 decry anecdotal evidence. I think qualitative
6 observation research has served mankind very well, and
7 should not be discarded because it is not a mega
8 randomised trial.
9 Q. So the term "qualitative evidence" rather than
10 "anecdotal evidence" may be preferable for that
11 reason?
12 A. It may, but I would not always give ground because
13 I would wish to win back the respectability of anecdotal
14 evidence. Sigmund Freud did not do too badly on
15 anecdotal evidence.
16 Q. On the question of availability of paediatric nurses,
17 are you able to help us from the point of view of your
18 own recollection of the position of the Children's
19 Hospital in Bristol during the period again 1984 to
20 1995?
21 A. I would make some observations. I cannot be tied to the
22 quantitative detail.
23 Q. I appreciate that I am asking you this question without
24 the benefit of any documents, purely on the basis of
25 your own recollection at this date.
0037
1 A. But it was, and indeed, is the case, that when
2 a hospital like our Children's Hospital talks in terms
3 of bed closure, insufficient beds, difficult in opening
4 beds at night and so forth, it is not of course the
5 structure of a bed; it is a sufficiency of trained
6 nurses to safely have a sick child in a bed. That
7 certainly was an issue, has been an issue ever since
8 I have been in Bristol; it has improved somewhat in the
9 last year or two, with some very imaginative management
10 of the budget and of the personnel at the Children's
11 Hospital, and I think we are well set to do this much
12 better with the new hospital, which would bring certain
13 additional advantages.
14 So there certainly were limitations, as my memory
15 goes, for the late 1980s and early 1990s.
16 Q. Can you help us by placing that answer in its national
17 context at the time, if we had been asking this question
18 of other children's hospitals, do you, in your own
19 experience, think that the answer would have been
20 substantially different?
21 A. No. I think this would be the national picture. If
22 I may have a minute just to enlarge on this to the
23 Panel, it is engraved on my mind, and other parts of my
24 anatomy, that in the early development of the intensive
25 care of babies, we made recommendations that to look
0038
1 after a high dependency baby in a Neonatal Intensive
2 Care Unit would require an establishment of 5 full-time
3 equivalent of nurses. We actually said 8, and people
4 threw up their hands, "This is ridiculous."
5 When we came down to a figure nearer to five,
6 there were counter arguments, but it is a very small
7 patient. Until we were able to make the needs -- it is
8 nothing to do with size, it is to do with the intensity
9 of care of a sick baby which requires the undivided
10 attentions of a nurse for a shift and even our dedicated
11 nurses are not able to work 24 hour shifts and they do
12 require some respite time and some study time. You
13 factor that up and you have an absolute of five
14 full-time equivalents.
15 So we have to break through barriers of small
16 people needing fewer staff to the understanding that
17 these are whole-time people, these children and babies,
18 who require whole-time staff and the sicker they are,
19 the more complex the health care techniques, the more
20 dedicated completely preoccupied attention from the
21 nursing staff attending, therefore the more are needed
22 in the whole staff of the hospital and that produces
23 tremendous difficulties, both in having the budget to
24 employ the staff, but downstream or upstream to have
25 enough nurses coming through that training.
0039
1 I am sorry it was a slightly long answer.
2 Q. Can I just take that a little bit further, because one
3 of the issues that then arose out of the recognition of
4 the special needs of children was the beginning of the
5 questioning of the adequacy of mixed adult and
6 paediatric wards in specialist services.
7 First, I think it is probably right to state for
8 the record that you yourself were not involved or had no
9 reason to be involved in the intensive cardiac ward in
10 the BRI?
11 A. That is right. I was at the Children's Hospital and the
12 Institute of Child Health on top of the hill.
13 Q. But if I can ask you more broadly to look back again to
14 1984 and to ask yourself and to assist the Panel on how
15 important it would have seemed to health care
16 professionals at the time to ensure that children were
17 not, when we are talking about such specialised
18 services, nursed on mixed adult and paediatric wards at
19 that time?
20 A. At that time, if one were looking at or were preparing
21 a policy document, I have no doubt that the conclusion
22 would have been very firmly, these should be separate
23 entities. That would apply if one was talking about the
24 mix from adolescents and adult, let alone younger
25 children and babies, let alone if they were profoundly
0040
1 ill.
2 In the 10 to 15 years since the time that you are
3 addressing, we have progressed somewhat, but it has only
4 been in the last two or three years that under the
5 heading of paediatric intensive care services, as you
6 know, the government has come down on the side of not
7 only having a policy, but actually implementing
8 a policy, so that in all parts of the land we are still
9 at the implementation phase, there should be a separate
10 fully equipped, fully staffed Paediatric Intensive Care
11 Unit. That has still not been totally achieved for the
12 nation in May 1999.
13 Q. But if the policy document would have looked the same at
14 the beginning of the decade as it would now, what were
15 the obstacles to realising that policy, again in the
16 earlier part of our period?
17 A. It would be multi-factorial. There would be a directive
18 from government down to implement such a policy. There
19 would be the --
20 Q. I am sorry, if you I stop you, do you mean the absence
21 of such a directive?
22 A. Yes. It would require a directive; it would require
23 a directive as powerful as the current directive, which
24 is, as I understand it, an absolute one, that there
25 would be no local choice over the matter, and it is
0041
1 only, as I say, in the last year, and currently, there
2 is no choice over the matter of having separate
3 paediatric intensive care units, so it would have
4 required a clear directive, which I believe there was
5 not; it would have required a local commitment which was
6 a matter then of discretion, and then, if it is a matter
7 of discretion, it is looking at the relative competition
8 of other priorities, financial issues, the tremendous
9 delay that is essential in reorganising a service, let
10 alone rebuilding physically a service, quite apart from
11 the staffing structures and so forth.
12 So even from the moment of recognition, even from
13 the moment of a government directive, there is
14 necessarily a lag-time.
15 Q. Can you help us as to what has changed to bring
16 something that was recognised as a matter of theory or
17 a matter of policy writing in 1984, right up to the top
18 of what one might call the hospital agenda at the end of
19 our period, so that it becomes not a matter of
20 discretion but something that requires to be
21 implemented?
22 A. I hope I will not be indiscreet. One element has been
23 a change in government to move away from the competition
24 in health care delivery to sensible planning and
25 collaboration. That has been a major factor in
0042
1 answering your question.
2 Under the spirit and heading of "collaboration"
3 has been this realisation that for some subjects we have
4 to have networks of specialist locations where things
5 can be done, specially because the number and the
6 intensity require a specialist centre going back to what
7 I said earlier, albeit a distance from the family home.
8 Then, most tragically, but so much of life and
9 history is like this, it required a high profile, huge
10 tragedy to make it inescapable in government terms. So
11 there was the poor child in the north of England who was
12 moved from pillar to post, as you know, and the death of
13 that child raised the political energy that this was at
14 flashpoint; it was no longer conscionable.
15 That, I suppose, is the nature of our species,
16 that we require these tragedies to make things happen.
17 Q. If you were being asked to describe the mind-set of,
18 say, a hospital manager in 1984 -- I appreciate of
19 course that you were not such -- but you are looking at
20 such a person, and in 1984 he is confronting the
21 problem -- because it would be recognised even then as
22 such -- of a mixed adult and paediatric intensive care
23 ward, how do you suppose he would view the priority of
24 the need to make changes in that service, when set
25 against all the other priorities and demands that might
0043
1 be set against his hospital's resources at that time?
2 A. He or she would have to face tough decisions. There
3 would be repeating priorities, depending on who was
4 making the case locally, which documents and which
5 authority were being placed on his or her disk. But no
6 doubt there would be entirely practical elements of, "If
7 we separate them, where will they go?" "If it will
8 require additional budget, where will I get the budget
9 from ?" "It requires this development, but by making
10 this my priority, I will have to put that on
11 a backburner", facing up to the political fallout of
12 that decision.
13 Q. What I detected in some of your answers is a general
14 concern about the danger of judging this issue with the
15 benefit of hindsight. Is that a fair observation?
16 A. It is a fair observation, because on this point we are
17 just discussing, even now, in 1999, there are in the
18 country children being cared for on adult intensive care
19 units. The matter is not totally yet sorted. It will
20 be, I hope, within the 12 months.
21 With hindsight, it is such a difficult task you
22 have. In my reflections before we came in to you, I had
23 at the bottom of my paper, "chimney sweeps". Well, it
24 was obvious perhaps to Charles Dickens that that was
25 a bad idea, but it was not obvious to our Victorian
0044
1 ancestors. It was not obvious to me in the middle 1960s
2 that babies should be delivered in the same physical
3 configuration as the Neonatal Intensive Care Unit.
4 I spent many of my formative years running at another
5 hospital across a car park and through a tennis court
6 with a sick baby in my arms to go from the delivery ward
7 to the Neonatal Intensive Care Unit. It was becoming
8 apparent that this was a bad arrangement. It took
9 several years to have the budget and the will to
10 rearrange that so they were cheek-by-jowl. It is very
11 difficult to get it right in the historical context.
12 Q. Could I ask you to look, please, briefly at the
13 Department of Health standards in 1991 in the Welfare of
14 Children? That is at HOME 2. The document starts at
15 page 1, but if I could take you directly to page 13,
16 please. This is, as I say, from the Department of
17 Health standards in 1991 and it recognises there the
18 desirability of caring for all children within
19 a children's department or children's hospital, and
20 grouping of children together obviously facilitates
21 a number of aims.
22 But the first mention there is that it enables
23 a children's physician or surgeon, i.e. a paediatric
24 specialist, to participate in the general management of
25 and professional oversight of a department, even though
0045
1 responsibility for the individual child's medical care
2 may rest with consultants in specialties other than
3 paediatrics.
4 Can I ask what would be the understanding of the
5 importance of a paediatric oversight or input into even
6 mixed adult and paediatric wards within a hospital
7 during the period with which we are concerned?
8 A. I would interpret the notion in bullet point 1 to mean
9 that the conductor of the orchestra has to be
10 a paediatrician in order to integrate the specialist
11 care of, let us say, an ear, nose and throat surgeon,
12 together with the necessary ear, nose and throat
13 nursing, but orchestrated into that the health care
14 needs of that particular child in their stage of growth
15 and development, their particular physiological needs
16 which might be very different from an adult approach to
17 fluids, to electrolytes, to drugs, taking into account
18 their position in the family, the health care of the
19 parents, other siblings, educational needs, the social
20 setting, and so on. It is a very big orchestra to be
21 held together, but sometimes one has to let the bassoons
22 play so low.
23 Q. How does the general idea of orchestrating a child's
24 care through the media of a paediatrician play when the
25 child is being cared for on a mixed adult and paediatric
0046
1 ward in a separate part of the hospital that does not
2 form part of the Children's Hospital?
3 A. I think your question is very powerful and well put. It
4 is extremely difficult at another hospital which is not
5 on my normal beaten track where I am an occasional
6 visitor trying to orchestrate something at a distance.
7 It was not designed to work well. That is, of course,
8 the whole argument for bringing things together within
9 the polarity of a children's hospital.
10 Q. If we perhaps move on to the general issue of how the
11 changes in the organisation of the NHS in around 1991
12 affected the delivery of children's services, we might
13 briefly have a look, please, at the Audit Commission's
14 report of 1993, "Children First", at HOME 1/132.
15 I think we will find that is just the title page, to
16 give us the reference.
17 Then, if we move on, please, to page 195, the
18 Commission there talked about strategic commissioning
19 for children's services, and it set out the need for
20 a clear and consistent strategy for commissioning
21 services for children, as being important. The DHAs at
22 that time were the main commissioning authorities, and
23 they needed to set a framework in which the providers
24 operated.
25 If we scroll down a little bit, it talked about
0047
1 the problems of lack of commissioning strategies, poor
2 specification of services in contracts, inadequate links
3 between commissioning authorities and providers, and
4 lack of attention to the need for change.
5 In particular, if we look at paragraph 144, it
6 talks about the fact that it was new, this role, for
7 DHAs, and that very few had firm plans for developing
8 a strategy. The assessment of needs for children was
9 very much in its infancy, and, in the last sentence:
10 "Some DHAs do not even classify children's
11 services as a separate entity, but group them with adult
12 services, particularly in contracts for surgery."
13 Do you have any experience or did you encounter
14 the issue of how children's services were managed as
15 a contracting issue after the introduction of the NHS
16 reforms in 1991?
17 A. Not personally.
18 Q. Are you able to comment, therefore, on whether or not
19 the DHAs, the Commissioners of Children's Services,
20 generally rose to the challenge of commissioning or
21 providing a strategic cause for children's services?
22 A. On that I may comment. I think I am right that only in
23 one DHA in the land was there a designated Children's
24 Commissioner. I think that has been in Oxford. In very
25 few of the DHAs -- I put it in the past tense since
0048
1 I believe we are moving into the Primary Care
2 Commission, which may produce even more difficulties
3 until we get it right, that it was a minority of DHAs
4 that had anyone with a designated portfolio, let alone
5 a totally designated children's health commissioner.
6 I think that what is said in paragraph 144 was not
7 enacted, was not implemented, and to a worrying degree,
8 still applies.
9 Q. So that if the Audit Commission noted that children's
10 services were often grouped with adult services,
11 particularly in contracts for surgery, that is something
12 which you would agree with?
13 A. I would agree with.
14 Q. Who, in general, would you have regarded as being
15 responsible for identifying the need for children's
16 services?
17 A. We cannot be innocent in this as a profession. If
18 I were to take the view that it will be the District
19 Health Authority that must place the contract for the
20 services, I have my job to represent the need for that
21 contracting to the DHA, and there the thing goes in
22 a circle. The vigour and efficiency with which we make
23 our case will, to some extent, affect the strategy of
24 the DHA.
25 Q. What about the Regional Health Authority and the
0049
1 national role of, say, the NHS Management Executive or
2 the Department of Health? What part do they play in
3 this jigsaw?
4 A. I think you just made a case for a Royal College of
5 Paediatrics and Child Health.
6 Q. If we look at that role, then, we can look at page 46 of
7 your statement once more, where we had the beginning of
8 the College's strategy for the next five years. In your
9 statement in general, you talk about the many functions
10 of the Royal College. One of them has obviously been to
11 provide advice and assistance to its members.
12 Could I just take you briefly, as a commentary on
13 that particular part, to page 56, where you talk about,
14 or the College talks about the general need for
15 a co-ordinated child-centred Health Service which
16 serves the needs of the child and the family, and there
17 the agenda for action is set out. Perhaps we could just
18 scroll briefly through that.
19 Does that strategy there arise out of what we have
20 just been discussing, the need for co-ordination in the
21 area of commissioning children's health services?
22 A. Yes, very much so. I would like just to enlarge on one
23 point within it, which is, if you like, it begins with
24 a philosophical position, or a slogan, that an admission
25 of a child to hospital is a failure and that we look
0050
1 towards our strategy and the commissioning to be
2 a unified service, paediatrics, child health from the
3 hospital intensive care bed to the consultation with the
4 family doctor and that that seamless, co-ordinated
5 delivery and planning of health care for children is
6 part of the strategy embedded in this page.
7 Q. Professor Baum, I would like, if I may, to turn to the
8 area of the maintenance of standards. However, it may
9 be that it would be appropriate at this moment to take
10 a short break, for perhaps 10 minutes, before resuming,
11 if that is acceptable to you, Chair?
12 THE CHAIRMAN: Yes, shall we do that, take 10 minutes and
13 therefore reconvene at -- I am now nervous because
14 Mr Langstaff reminded us no clock shows the same time.
15 May I suggest a quarter to? Would that be more or less
16 accurate?
17 MISS GREY: Thank you.
18 (11.30 am)
19 (A short break)
20 (11.47 am)
21 MISS GREY: Sir, I am extremely sorry we should have been
22 late. I blame on this occasion Mr Langstaff's watch
23 which is still clearly badly co-ordinated. I apologise
24 both to you and Professor Baum.
25 THE CHAIRMAN: Just let me say, although we can smile, it is
0051
1 important that we do get it right, so perhaps we will
2 talk about synchronising our timepieces in due course.
3 MISS GREY: If I smiled, it was not through any want of
4 contrition.
5 Professor Baum, if I can turn to the question of
6 maintenance of standards by the College, generally, if
7 one looks at your statement, it underlines the changes
8 in this area from the point of view of the College,
9 which underlie or derive from the move from being
10 a professional association, the British Paediatric
11 Association, to being a full Royal College.
12 I am looking at page 23 of your statement; where
13 at the end you emphasise the difference in the
14 standard-setting mechanisms which are now available to
15 the College in contrast with the relative paucity of
16 mechanisms that would have been available to the British
17 Paediatric Association at the beginning of the period of
18 our terms of reference.
19 Could I ask, then, please, if we look now at
20 page 10 of your statement and paragraph 1.21, where
21 there you talk about the increasing greater regulatory
22 and disciplinary powers and responsibilities available
23 to the College, and you distinguish there between the
24 GMC and the College by saying:
25 "To reduce the distinction to its simplest terms,
0052
1 the College sets professional standards: the GMC
2 enforces them."
3 You add that "The BMA as the doctors' trade union
4 has an active interest in both, but is ultimately
5 responsible for neither."
6 May I ask, how does the College see the balance in
7 responsibilities between firstly the College; secondly
8 the GMC; and thirdly that of a local employer or
9 Hospital Trust, since that might perhaps be said to be
10 the element in the picture that is missing from that
11 particular paragraph of your statement?
12 A. I would find it easiest to construct my answer if
13 I could see the flow diagram relating to good standing.
14 Can that come up on the screen?
15 Q. If you can help me as to where it can be found, yes.
16 A. It was one of the annexes.
17 MRS HOWARD: Miss Grey, if I can help you, it is WIT 36/60.
18 MISS GREY: Thank you very much. Can we have page 60 up,
19 please?
20 A. That is it, thank you. Forgive me asking, it just gives
21 me a structure which with I can answer your important
22 question. The important part of your question was about
23 the Trust's role in the management and quality of
24 practice, but to run up to that, this diagram
25 illustrates our opportunities for controlling the
0053
1 quality of training and then of achieved standards by
2 those who are deemed to have reached consultant
3 standing.
4 So from the entry point at the top, we have the
5 Senior House Officers who are themselves of course
6 graduates, they are bright, dedicated, hard-working
7 people, but they are in good standing to take the first
8 exam, the MRCPH, they require to have references from
9 their consultants to say "These are suitable people to
10 go on in training".
11 They then face the ordeal of the professional
12 exams, and I will not go into that in detail. If they
13 pass through that exam, they are then deemed to be
14 a member in good standing. They are so far in good
15 standing having had their consultant's references and
16 passed the professional exam.
17 Q. Can I stop you there by asking what percentage would
18 generally pass and what percentage would fail?
19 A. We are still in the process of inheriting the total
20 control of the exam from the Royal College of Physicians
21 and it is in the order of two-thirds passing.
22 Q. Thank you.
23 A. However, we look to a day when it will be 95 per cent
24 passing, not through a drop in standards, but through
25 appropriate training, so exit from a university, one
0054
1 does not expect half to fail, one expects the majority,
2 90 per cent, to have reached the required training and
3 standards.
4 They then face a competition to enter into higher
5 training. This requires further satisfying of
6 a committee that they have the appropriate attributes,
7 in addition to what they already have, to go into higher
8 training.
9 They then spend five years in higher training,
10 which are no longer meandering, dipping in and out of
11 experience, but a highly stratified episode of training
12 in which there is appraisal at every step and an annual
13 appraisal with the Regional Adviser of the College and
14 the Post-graduate Dean. So it is quite closely
15 regulated to make sure they are progressing
16 satisfactorily. At the end of that time, there is no
17 exam but there is a summation of their progress and look
18 at their portfolio, and one does not expect people to
19 fail at that time, but may expect to find along the way
20 somebody who needs a little more of this, that or the
21 other or somehow their manner or style needs correction,
22 and we hope the antennae will be sensitive enough to
23 adjust that.
24 They then will be judged to have completed their
25 training and we then, as the standard setter, will
0055
1 recommend to the specialist training authority, which in
2 that very brief note you showed me perhaps naughtily
3 I assumed the GMC is a proxy for that as well, but
4 specialist training authority independent of the GMC,
5 answering to European legislation, will accept our
6 recommendation because they have scrutinised our whole
7 process of training regulation. If we will provide the
8 necessary documents -- and it is quite a dossier of
9 documents -- to support and recommend somebody receives
10 their certificate of specialist training, then they are
11 so given it. Then they recommend to the GMC that the
12 name goes on the specialist register.
13 We then invite them to take the College oath and
14 all this is contemporaneous history. We have only just
15 entered into this phase in our development, but the
16 first Fellows have taken the College oath and that is
17 a very serious issue: that they are signing up to X
18 number of paragraphs which commit them to certain
19 components of their professional life.
20 They will then go on as a Fellow of The College in
21 good standing, so far, and then we enter into very much
22 contemporaneous history, the proposed ideas for
23 revalidation, which, even were it to be the case,
24 I think, that the General Medical Council did not impose
25 cyclical revalidation, we are sufficiently committed to
0056
1 it that we believe we will proceed and are on the way to
2 proceeding down this path, which I believe, knowing the
3 sad origins of these discussions, and I must remember to
4 tell the families concerned that, as paediatricians, we
5 naturally feel for them deeply; it is our professional
6 business to be alongside them in such difficulties and
7 tragedies. But nevertheless, there is a positive
8 outcome in that I think it has brought to focus this
9 particular development of, there was not in place
10 a process for periodically reviewing the standards of
11 practice of established consultants. I think that is
12 a very important world-leading development which our
13 College is committed to deliver, even if we are not
14 required to. Our image of it at the moment is that
15 perhaps five-yearly we will ask each of us to take stock
16 what has been the audit, the quality of our clinical
17 care over the last five years, what is our plan for the
18 next five years and that is what is captured in these
19 letters, CME/CPD.
20 Q. If we look further at the gap you have identified, the
21 absence of the periodic review of the established
22 practitioner, what would have been the mechanism for
23 dealing with the situation in which a number of
24 individuals, whether they were local colleagues of
25 a paediatrician or whether they were people whom he or
0057
1 she had encountered on the professional circuit or
2 something, and from one of the pieces of conversation or
3 so, began to have concerns about the quality of the
4 practice of that individual, how would that have been
5 addressed during that period?
6 A. This is a most important key question, bearing in mind
7 I still have not addressed your question about the
8 managerial Trust input, which I will come back to.
9 It was not all bad. Although there was no formal
10 mechanism as set out in this flow diagram, what was in
11 its place was the tradition -- tradition is not always
12 good, but I reckon this was a good tradition -- of
13 working in firms in that these are the consultants,
14 these are the training staff, these are our beds, these
15 are the nurses who are with us, and a certain 'tribal'
16 grouping, if you like, of people who hang together and
17 did this kind of work.
18 Within that format, there was, and I reflect back
19 very well upon this in my early career, many checks and
20 balances within that system of finding things which were
21 going astray and bringing them back, or taking remedial
22 action, not in a formal sense but in the group sense of
23 "this group hangs together by the strength of all its
24 links".
25 That has been eroded and lost over the last
0058
1 20 years because of more efficient use of hospitals, so
2 there is no longer a ward where Professor Baum goes to
3 see his patients, I will have one on ward 36, two on
4 ward 31, five on ward 37, because that is more
5 efficient. Of course with the civilising reduction in
6 the working hours of the junior staff, there is no
7 longer my SHO, who has been on all week, it will be
8 a series of people working shifts.
9 Putting all that together, we have lost
10 a coherence that did still apply in the late 1980s/early
11 1990s which was itself a check and balance on the system
12 and within that framework, in my belief, there would be
13 a resonance of "something is going wrong" which would
14 have either been addressed or would have been made known
15 to the managerial committees. That was the check and
16 balance.
17 Q. Why do you say that it would have been addressed in that
18 situation, because the danger of the scenario that you
19 paint is that it was a hierarchical model with
20 a particular consultant at its head, and that such
21 a system might be good at dealing with problems in
22 performance or competence of a more junior member of the
23 team, but might have difficulties in coping with
24 a person who had flaws who was at the apex of that
25 structure?
0059
1 A. A most important and well put question. I cannot sweep
2 it aside or gainsay it in any absolute way, but my
3 belief is that by virtue of the firm being
4 multidisciplinary, most particularly looking to our
5 nursing colleagues who, in my experience, have been the
6 fighting champions for the child, that the system did
7 have sufficient checks and balances that a rogue
8 consultant would not have been able to conduct her or
9 his work outside bounds of acceptability. I think there
10 were sufficient checks within the overall system that it
11 was not only rooting out difficulties in juniors.
12 Q. So the route would be to discuss, to try and deal with
13 difficulties within the firm, and if that failed, you
14 suggested, I think, a minute ago, that a problem might
15 be taken outside it to hospital management; is that
16 correct?
17 A. That is right, yes.
18 Q. Would it be a managerial route that was sought to
19 resolve a problem like this, or would it be something
20 that remained amongst clinicians for rather longer by
21 appealing, as it were, up the clinician structure rather
22 than the management structure?
23 A. Yes. At that time, probably, you are right that it
24 would have been first addressed among other senior
25 clinicians, and it is my belief that they would not have
0060
1 ducked the responsibility if something was going amiss
2 and it needs to be addressed.
3 Q. So at what point, if at all, does it become a hospital
4 management responsibility?
5 A. I think I am ducking this question because I do not see
6 the lines of demarcation clearly enough as they were in
7 1989/1993. If I can guess at it, depending on the
8 nature of the problem, it would have either gone to the
9 senior medical staff committee which, of course, would
10 be a Joint Committee with management, but other species
11 of the problem might have looked to its Royal College
12 with the "three wise person" mechanism and taking it up
13 to that route, or there might have been a sufficiently
14 clear view that the matter would have been taken
15 straight to the GMC.
16 Q. If it is difficult to answer the question, is that
17 because we are talking at a level which is too abstract
18 and it depends on the nature of the problem, or is it
19 because there were changes and flux in the balance of
20 responsibilities of managers and clinicians during the
21 period we are talking of?
22 A. I think it is because Professor Baum was never involved
23 with those structures, and was never an active
24 participant in hospital management, senior medical staff
25 committees, at that time, so I actually do not have
0061
1 a clear memory or even at the time, I do not think I had
2 a clear image of how it might be handled.
3 Q. Could I ask you to go back, then, to the question where
4 we started, which was to ask you to outline how you
5 would see the balance of responsibilities between the
6 College and, I think, realistically, if we are pushing
7 it into the back -- because in a sense one is talking
8 about the Royal College of Physicians rather than the
9 Royal College of Paediatrics and Child Health, but the
10 Royal College, the GMC and the local Hospital Trust or
11 management.
12 A. One reason why we are so enthusiastic about what is the
13 outcome of this Inquiry -- one of the outcomes -- is
14 that under these words "CPD", continuing professional
15 development, the model we are working towards is that if
16 I am now preparing for my next year's quinquennial
17 review, where I will be putting together a summary, an
18 audit of my clinical practice over the last five years,
19 I would be doing that in all likelihood with hospital
20 management staff to agree how many clinics I have done,
21 what number of patients had not attended, what I had
22 done about non-attending patients, and so forth, and
23 most certainly, setting out my five years work to come.
24 That can only have validity if the hospital, my
25 employer, is willing to employ me in those terms. So if
0062
1 I were narrowing my work that I am now only going to see
2 14 year-olds with diabetes and no other patients, they
3 may say that is not a sufficient contribution to the
4 work plan that will give you a contract, with that kind
5 of job description. I think it is in that future
6 planning of a quinquennial piece of work, where an
7 individual consultant, the Royal College, the GMC,
8 Trust, employer, University, would come together to say,
9 "Yes, that is something we will all sign up to as
10 a very sensible portrayal of how you spend your next
11 five years".
12 Q. What you are describing there is a system which is
13 proactive in developing professional standards so as to
14 avoid, one would hope, ever having to confront the
15 problem of the failing practitioner. If the College
16 succeeds that will not arise, but if one is talking
17 about a situation where somebody does appear on
18 anecdotal evidence to be presenting a problem to his or
19 her colleagues, and yet the five-year audit of the
20 College is still two or three years down the future,
21 what does the College do in that situation? Or what do
22 the other players do?
23 A. As you will see in our document, there is mention made
24 of our Professional Standards Group, and the notion
25 here -- and it is still on the brink of being a fact --
0063
1 that we are encouraging all our Fellows to think in
2 terms of, "if any part of your work is providing
3 difficulties, or any of your colleagues to your opinion
4 are getting into difficulties, come and talk to us about
5 it, and let us consider things like retreading your
6 skills, or reflecting that if you are in a highly
7 technical part of your work and you are finding your
8 dexterity is not what it was, then let us consider how
9 best to use all your life experience". This might be
10 the time to say, "I will now have a brief Sabbatical and
11 move out of the hands-on technical care and do some
12 other related branch of my subject, which I can do but
13 without my dextral skills". I think it does depend on
14 winning the Trust of our Fellows, that we would like to
15 help everyone adjust and help their careers develop, but
16 occasionally statistically it must happen that somebody
17 will be failing in their competence and will not take
18 the path that we are offering them, and then we have
19 entered a new culture where this will not be tolerated
20 by colleagues because we will hold our College Fellows
21 responsible, if knowingly they were not alerting us to
22 a failing in standards.
23 Q. So the corollary of that is what action would follow?
24 A. And then we would ask a colleague to meet with our
25 Professional Standards Group and make our own
0064
1 "enquiries" is perhaps too powerful a word, to have
2 a discussion, and if as a result of that we are agreeing
3 there were remedial pathways to take, we would recommend
4 them and hope we would put in place the checks and
5 balances to make sure they would follow through, if it
6 was outwith that kind of corrective programme, then we
7 would openly say "This is a matter we must refer to the
8 General Medical Council".
9 Q. That is the stance the College has arrived at now. Is
10 that an understanding of how the problem should have
11 been approached that would hold true for the period 1984
12 to 1995, or has the answer changed more recently?
13 A. I think the detail has changed beyond recognition. If
14 I can back to my previous model of the firm, I think the
15 firm would have contained, would have encouraged,
16 remedial action, if this was not sufficient, would have
17 taken it to the medical staff committee and so forth.
18 It probably would have meant, at that time, that
19 somebody's performance or behaviour was three standard
20 deviations from the norm before somebody said "This is
21 just intolerable", and it would be a more exaggerated
22 point that would go to the GMC, whereas I hope today we
23 would be at a much more blurred margin so there was much
24 more corrective work rather than disciplinary work.
25 Q. But ultimately, does it follow from that answer that if
0065
1 a college -- I am talking now of the medical colleges --
2 discovered that there was reason to be concerned about
3 the performance of a particular practitioner, and that
4 there seemed to be no signs that the firm or the local
5 structures were dealing with that situation, that
6 ultimately it would have an obligation to refer to the
7 GMC if no other corrective mechanism seemed to be in
8 play?
9 A. Yes, that is right.
10 Q. Just a point of detail about the membership of the Royal
11 College of Paediatrics. We have been speaking this
12 morning about paediatricians. What about the position
13 of paediatric cardiologists? Where would they be likely
14 to find their home these days?
15 A. Ours is a medical Royal College, and 99 per cent of our
16 Members and Fellows are medically qualified. We have
17 some 15 specialty groups, supra or subspecialty groups,
18 to cover the various 'ologies -- nephrology,
19 gastroenterology, neurology and so forth. It happens
20 that the paediatric cardiologists, in the evolution of
21 our College, maintained largely their identity with the
22 College of Physicians, the Specialist Advisory Committee
23 on Cardiology, as the group to which it looked for
24 recommendations for training and subsequently for CCST,
25 and subsequently for their CME regulation.
0066
1 That is how it fell out. I am not sure at the
2 moment how it is going to work out. In preparation for
3 today, I tried to find some figures to illuminate this.
4 The best I can offer is that we do have a paediatric
5 cardiac group of our College and I think that there are
6 something like 44 members of that group, of which 6 are
7 medical scientists, not clinicians -- I think this is
8 about right -- and of that 38 who are clinician doctors,
9 paediatric cardiologists, four are currently looking for
10 their continuing medical education with our College,
11 which means the remainder are College of Physicians or
12 elsewhere.
13 I know Professor Alberti sent out a questionnaire
14 to find out where they are looking to for the CME, but
15 it is a historical event which is not entirely random.
16 Most paediatric cardiologists were, in the 1980s and
17 early 1990s, coming from training in cardiology, and
18 then specialising in paediatric cardiology, so they were
19 coming from physicians hanging out with cardiologists to
20 become paediatric cardiologists.
21 This is on the change, but across Europe, this is
22 not just this country, this subspecialty in paediatrics
23 which is separate from the confederation of specialties
24 is paediatric cardiology.
25 Q. With the development of continuing professional
0067
1 development and accreditation schemes, it is likely that
2 these particular subspecialties will have to choose one
3 home or the other, rather more definitively than they
4 have had to do so far; is that right?
5 A. I think so, unless, which I think would be a better
6 outcome, we have the administrative organisational
7 powers to have joint committees of supervision, which
8 would be a better outcome, but is administratively quite
9 a difficult thing to deliver.
10 Q. Could I ask for your assistance on the matter of
11 referrals from paediatricians to paediatric
12 cardiologists? If we look at the evidence of
13 Dr Reith -- I am looking at WIT 59/10 -- Dr Reith, as of
14 course you know, is the Honorary Secretary of the Royal
15 College of General Practitioners, and he very helpfully
16 assisted the Inquiry on the question of how GPs would
17 choose to refer a child who had, say, a suspected heart
18 murmur on wards. He makes the point at this part of his
19 statement that the majority of children with complex
20 cardiac conditions are likely to be picked up in
21 hospital at birth, and therefore a GP may not see them
22 until they have already come under the care of
23 paediatric cardiologists and possibly even surgeons.
24 We see in the bottom paragraph there that in fact
25 a GP is only likely to see a new patient with such a CHD
0068
1 about once every five years.
2 If we go on to page 12 of his statement, he picked
3 up some of the implications of that by pointing out that
4 the GP is likely to refer the child to a paediatrician,
5 and then, if we can scroll down, you will see, Professor
6 Baum, that in general the likely route of referral will
7 be to a general paediatrician rather than to
8 a paediatric cardiologist.
9 If we turn over to page 14 of the statement,
10 please, he says there that in effect the signals that
11 were being sent out when GPs were referring to Bristol
12 was that it was a major teaching hospital in the UK and
13 funded as such by the Department of Health, and that,
14 looking at 2.2.6, generally GPs would not have
15 information available to them at that time about the
16 performance of particular tertiary centres, but that
17 even if such information were available, it would be
18 difficult for an individual GP to interpret it, and that
19 a GP would therefore rely on the consultant
20 paediatrician for their interpretation of the case mix
21 and the severity of each case within it.
22 With that information as a background, can I ask
23 you, if we take the debate one level up, what
24 information would the paediatrician have, or be likely
25 to have, again, looking at the period from 1984 onwards,
0069
1 about the competence, performance or services offered,
2 to put it more broadly, by the paediatric cardiologist
3 to whom they were considering referring a child?
4 A. As I see it, there were four steps in the referral
5 process. I will address the heart of your question.
6 The first is -- perhaps there are five steps -- the
7 recognition that all is not well with the child in
8 a hospital, or perhaps after the baby has gone home;
9 being seen by the family doctor.
10 And at that point, just let me make this point:
11 mostly the family doctor will not see a baby saying
12 "I have a pain in my heart" or "I have a terrible heart
13 murmur"; what the general practitioner will see is what
14 the family is seeing: the child not right, vomiting,
15 sweating, not a good colour, these vague things. It
16 would be perfectly within the best of practice for the
17 GP to say, "There is something wrong with your baby,
18 I will send you to a paediatrician", or that might have
19 come, as you have said, directly from the maternity
20 hospital.
21 The paediatrician's job would have been to narrow
22 the problem: this is not a stenosis of the valve that
23 the baby is vomiting, the baby is in heart failure,
24 there is a heart problem. There would have been a time
25 when 20 years ago I would have had the responsibility to
0070
1 try and identify more exactly what the problem was, but
2 if I am working with cardiologists, I will ask my
3 colleague cardiologist, hopefully in the same hospital,
4 to say, "I have a baby who has poor colour, is vomiting
5 and sweating. There is a loud heart murmur and
6 a thrusting apex speed. I believe this to be
7 a cardiological problem, please will you take over the
8 care?" The cardiologist will then come in, take over
9 the care and make the necessary diagnostic work up and
10 will then form the next step to cardiac surgery with the
11 echos and the catheters in between, so it really is
12 a five stage process.
13 To take your question, what information on the
14 performance of my colleague cardiac surgeons would I be
15 looking at at that time --
16 Q. Well, or cardiologists, because I recognise there is
17 a step between the paediatrician and the cardiac surgeon
18 and it is in fact the cardiologist who is likely to make
19 the choice of referral to a particular surgeon.
20 A. Here is one of the great difficulties I have, and you
21 have, with this problem, of putting it in the context of
22 the time. My memory of the context of the time is that
23 this was not a culture -- which I think is a desirable
24 culture, but it was not the culture -- of, "This has
25 been the quality of my clinical performance with these
0071
1 outcome measures for the last five years, those are my
2 cards, do you like them or do you want somebody else's
3 cards?" It was very much more broadly an atmospheric
4 of, "This is a good guy, this is not such a good guy".
5 But within that has to be titrated the urgency of
6 the matter, so if the matter was urgent or were urgent
7 tomorrow, there would be the other consideration of, "Is
8 it on my patch or am I going to look at the cards to
9 such a degree I am going to send the patient to another
10 patch?"
11 So, to answer your specific question, in
12 1990/1994, as a paediatrician, if I feel this child is
13 unwell and there is a cardiological problem of some
14 severity, it would not, I believe, have entered my
15 consciousness to think, "What is the quality, outcome,
16 performance, audit, of my colleague cardiologists?"
17 I would say, "There are competent consultant-trained
18 cardiologists on this corridor who are my colleagues who
19 I trust through their training and I trust them as
20 individuals, that I will refer the care of the baby".
21 Q. Would your answer have been any different if you had
22 been a paediatrician in a district general hospital who
23 had to refer onwards to a different hospital to reach
24 the services of a paediatric cardiologist, rather than
25 someone who obviously was able to work in close
0072
1 proximity to colleagues based at the same hospital?
2 A. An excellent question. It might have been. No, it
3 would have been different, but the difference would have
4 still hung on an atmospheric of quality of service,
5 rather than on any published measured audit of accuracy
6 of diagnostic skills.
7 Q. So when you say it is based on a general atmospheric
8 judgment of "This person is a good guy; this person is
9 not such a good guy", what information actually lies
10 behind those judgments?
11 A. Many strands. They would include a reputation of
12 diagnostic skills. And how does that reputation get
13 about? Well, there are the value of clinical meetings,
14 the value of first- and second-hand discussions, the
15 gossip network. So there would be diagnostic skills;
16 there would be matters of professional courtesy; again,
17 the gossip vine of how they are with parents who are
18 worried about their sick child; how they are in terms of
19 their relationship with their firm, with their juniors,
20 as trainers, with their colleagues.
21 There would be an element of their efficiency
22 professionally, of how quickly they could accommodate
23 what I am saying, 'This is an emergency', and how far
24 they will put themselves out to come to see the child in
25 my clinic in the DGH or to arrange transport and so
0073
1 forth, and many other elements. So it is professional
2 diagnostic skills and other elements of professionalism.
3 Q. Can you help us by factoring into your calculations as
4 to where you are going to send the child, assuming we
5 are now still based in the district hospital rather than
6 in the unit which already has the tertiary services
7 centred within it; what importance you would place on
8 the factor of proximity or the need for transport to
9 another centre?
10 A. An extremely difficult but very important question. The
11 proximity factor becomes more important, in my opinion,
12 the more urgent the referral. That is one issue.
13 The second issue would be matters of family
14 judgment, of how close they want to be to the scene of
15 action when their sick child is undergoing investigation
16 and surgery; and a third point would be that it becomes
17 sort of nonsensical if all patients with this condition
18 have to go to the Mayo clinic or have to go to
19 Edinburgh.
20 Q. Because the "best", in inverted commas, assuming one
21 could identify such a thing, could not possibly cope
22 with every case?
23 A. Could not possibly.
24 Q. Can I take you back to the first strand in that: the
25 more urgent the case, the more proximity mattered. Can
0074
1 you explain why that should be so?
2 A. Maybe not terribly well, but there are considerations
3 like, "How long will it take me, whether I am the family
4 or the general practitioner or the paediatrician, to
5 find out where is a 'better', in inverted commas,
6 centre and by what criteria will I find out that they
7 are better", since much of my atmospheric is built on
8 the network of gossip and the group behaviour of our
9 region, of our Deanery, of how well we know people, and
10 I have a much better feeling of who is who in my
11 locality -- and this might be the South West in this
12 example -- than to have any real understanding of what
13 is the "quality", inverted commas, of the service in the
14 North West of England.
15 Q. I had thought you might be referring in your answer to
16 the issue about the availability of specialist retrieval
17 services and the fact that if a child is particularly
18 sick and therefore the referral is urgent, that might be
19 an important consideration?
20 A. It would be an important consideration, although it is
21 still not well put together now, historically, even for
22 paediatric intensive care, to return to that very clear
23 development, with the government directive there is not
24 in place paediatric intensive care retrieval systems,
25 transport systems, throughout the country.
0075
1 If we take it back to 1990 to 1994, for paediatric
2 cardiology, it was not all neatly in place.
3 Q. If one then looks at the second strand in your answer,
4 which is the question of how the family will manage the
5 child's absence, keeping contact, communication with it,
6 how important is that as a factor for the child's
7 recovery?
8 A. I regard it as an extremely important matter for the
9 child and the family. The child, depending on the age,
10 will have their own input into it. A 14 year old versus
11 a 14 day old; a 14 day old that has been breast fed
12 versus formula fed; a 14 day old in a family where it is
13 an only child with two parents, or a family where there
14 are two old older siblings under the age of three, and
15 two parents one of whom is unwell, there is a real life
16 scene here which would come into the equation. Some
17 would say, "We just cannot manage to hold the family
18 together and go up to Birmingham every day, but we can
19 manage to hold the family together and go from Taunton
20 to Bristol every day".
21 Those become real considerations which I think in
22 the whole balance of the best quality of delivery of
23 health care for children is a real and important issue,
24 because, if, please God, the child survives, life goes
25 on a very long time and these differences make a whole
0076
1 difference to the whole family dynamics for years to
2 come.
3 Q. Is that answer based on the, as it were, social dynamics
4 of a family, or does it also represent a clinical
5 judgment on what is needed to enable the child to
6 recover best?
7 A. It really is both. I do not wish to over-separate
8 them. It sounds perhaps far-fetched to say the psyche
9 on the soma when it is a surgeon's knife cutting a blood
10 vessel, but in the overall global health the influence
11 of social factors, psychic factors, the now and the next
12 year and the next decade are very powerful;
13 underestimate them not. But if it is purely on the
14 technological skill of that moment, then of course they
15 are separate.
16 Q. If we look again at paragraph 2.2.6 of Dr Reith's
17 statement, he makes the point there that if information
18 about outcomes were available, performance, about
19 particular tertiary units, it would be difficult for an
20 individual GP to interpret. What information, if any at
21 all, would be of assistance to a paediatrician in
22 interpreting factors about hospital performance?
23 A. If I were able, at the push of a button, to put on to
24 the screen -- let me take it to a completely different
25 field. Let us say it is a teenager with an acute bowel
0077
1 problem, and if I am told by the gastroenterologist,
2 "This needs a particular kind of operation but does not
3 have to be done today; we have got plenty of time", then
4 with the advice of the gastroenterologist, perhaps with
5 the general practitioner, scroll through the screen and
6 see who is doing the operation, what are their waiting
7 times, what is the transport like, and as the patient,
8 family, client, weigh this up and see what might be the
9 best outcome. If it has to be done tomorrow, I might
10 take the view, if it is available at my local teaching
11 hospital, because it is a sufficient specialty, it will
12 not be in my local district hospital, then I will trust
13 the system, the people on staff there appointed to those
14 jobs, who are sufficiently well trained that they are
15 able to do that job. This is an emergency and,
16 everything taken into account, let us not be fancy; we
17 will go there because it will take us a long time to get
18 a balanced view of what is right.
19 Q. Because it takes too long to develop the expertise to
20 make any other judgment?
21 A. The other judgments, even with as much information as
22 there might be on this screen, will be human judgments.
23 If I have the time, I would like to go and meet Dr X,
24 Mr Y, Professor Z to see, you know, is it going to suit
25 us? If this has to be done tomorrow, then taking into
0078
1 account, to model down again, my other three children
2 under 3 and everything else, then I must, as a user of
3 the Health Service, trust and believe doctors and the
4 systems of the Health Service and believe that, which
5 I do believe, now and in 1990, and 1980 that we had the
6 safest and best Health Service in Europe.
7 Q. But if you are speaking not as a patient but as
8 a paediatrician, who has not a great deal of leisure but
9 nevertheless has the benefit of building up experience
10 from day-to-day, would you not be able to make
11 a judgment on the performance, the relative performance,
12 of various tertiary centres, over time, which could then
13 be used to enable a patient to make even an emergency
14 choice by the availability of such information as we
15 have discussed?
16 A. Members of the Panel, this, I think, is such an
17 important and well put question, I hope I can match it
18 with a decent answer.
19 If I put up on my screen the performance of Dr X,
20 Mr Y, Professor Z in different parts of the country for
21 this procedure I might then have my league table.
22 I must then take the advice of my statistical colleagues
23 to say, "Does it mean anything?" You will know in your
24 papers that a recent and most important study was
25 published last year by William Tarn and Maudy, looking
0079
1 at the outcome of neonatal intensive care units, which
2 is much bigger business than anything which we are
3 calling today rare and specialised, and coming to the
4 conclusion that statistically the league tabling does
5 not make any scientific sense because the numbers are
6 not big enough for it to be meaningful.
7 So if I am looking at "This person has done this,
8 this person has done that", I might find,
9 scientifically, I cannot actually say "This is different
10 from that".
11 However, within this, there has to be a prevailing
12 of common sense, or uncommon sense, and you will know
13 that uncommonly sensibly, the Department of Health has,
14 in the last couple of weeks, decreed that liver
15 operations, the Kasei operation, shall only be done in
16 three centres in the country, for children. We, at our
17 College, looked at those results scientifically, I hope
18 I remember this correctly, you could not say there is
19 a line of demarcation because the numbers are not big
20 enough. But stand back and say, "But It just does not
21 make sense to have the whole machinery for this
22 complicated operation done in several units; let us
23 aggregate them and even though we know parents have to
24 travel, let there be three centres; it is better that
25 way".
0080
1 So there is a judgment element which is beyond the
2 statistics.
3 Returning to my position, I might have to use some
4 judgment, but it would not be simple enough to say
5 "This guy has been top of the league for the last two
6 years; he is better".
7 Q. I think nobody underestimates the difficulty of
8 interpreting data such as this. All I am seeking to
9 press you on is whether or not you think one can move
10 from the situation you described as being true of the
11 1980s and 1990s, where generally what one might call the
12 "professional grapevine" was the main source of
13 information on the performance of one's colleagues,
14 whether there are any additions that can be sensibly
15 made to that system, or whether, because of the
16 difficulties of interpreting data, one comes back to the
17 conclusion that really that system was about as good as
18 one could get?
19 A. I think we can do substantially better, and the
20 additional information -- that I am not decrying; I am
21 just saying it is not going to be just totally simple as
22 a look at a column and choose the green one --
23 additional information is bound to better inform the
24 choice, but eventually it will be a synthesis of all
25 these factors to say "For this family, even though the
0081
1 decision has to be made by tomorrow, it is better they
2 go to such-and-such a place".
3 Q. Thank you. Professor Baum, running through much of this
4 morning's evidence has been, obviously, your knowledge
5 of Bristol, informing your position also as President of
6 the Royal College of Paediatrics and Child Health. You
7 have already described how you did have a clinical role
8 at the Children's Hospital from 1985 onwards, but you
9 had no specific responsibility or involvement in cardiac
10 or cardiological services for children.
11 May I ask you, did you, throughout that period,
12 1984 to 1995, have any reason to suppose as a clinician
13 in a children's hospital that other people were or might
14 be asking questions about the performance of the cardiac
15 services branch of the children's services at Bristol?
16 A. If I may again turn to the Panel, because this again
17 must be a most important question, and I hope that I can
18 clearly say what is in my heart and mind to say.
19 Firstly, although my responsibilities were
20 predominantly academic, I was, through those years,
21 a figure recognised in the Children's Hospital, doing
22 clinics, taking patients, doing ward rounds, teaching
23 undergraduate students, so very much in the hospital and
24 very much in the hospital gossip circuits.
25 Furthermore, in 1988 we established the Institute
0082
1 of Child Health, of which the most important part, which
2 I personally designed, is the coffee shop, which serves
3 as the coffee shop; it is the place where people have
4 coffee and gossip.
5 If I can find my memory of the years 1985 to
6 1992/93 in cardiology, I have to say the thing that I am
7 remembering most is a great admiration for the
8 Children's Heart Circle, who seemed to be doing
9 something which, as far as I knew, and I think correctly
10 know, was unique in appointing a counsellor specifically
11 for children's cardiac surgical work, which seemed to me
12 a remarkable and imaginative step to take.
13 Throughout that, I did not perceive or detect
14 grumbles that "all is not well". What I do remember --
15 and this probably is in the years 1992 to 1994 -- is an
16 excitement that from the bad geographical arrangements
17 of the split site, there seemed the chance that we could
18 bring paediatric cardiac surgery and intensive care up
19 the hill.
20 But my memory of that was not things are
21 disastrous but that we would be able to do things more
22 efficiently and better.
23 So I have to say -- but of course I may have had
24 my head in the clouds and my feet not on the ground, but
25 as far as I remember, being part of the Children's
0083
1 Hospital community, my memories up to the middle of the
2 1990s are very much with a positive gloss of the Heart
3 Circle doing something special and the excitement that
4 we were going at last to have children's cardiac surgery
5 up the hill.
6 Q. But knowing what you know now about the concerns that
7 were at least being expressed by some individuals during
8 at least the later part of the period we have been
9 discussing, possibly earlier, does that say anything
10 about the nature of the hospital gossip circuit that you
11 have described yourself as having been on at that time?
12 A. It must do. I was not part of the Bristol Royal
13 Infirmary corridors -- quite a stranger there, for
14 special meetings, post-graduate occasions -- but the
15 cardiac surgeons and cardiologists were frequently to be
16 found in my coffee shop.
17 As soon as these matters were in the public
18 domain, then certainly, one knew about this and was
19 greatly concerned for where the truth lay, but at the
20 time, before it became a matter of public concern,
21 I have to say either I had a blind eye or the
22 atmospheric was not all the public, or it was all the
23 BRI, or that it was contained.
24 Q. What you do remember, I think, because we have discussed
25 it throughout this morning, is a general recognition
0084
1 that a split site was not an optimum or desirable
2 feature of the way the services were organised?
3 A. Absolutely. Just as it was not when I was doing
4 neonatal intensive care 20 years ago. It was very bad
5 to have a split, it took a long time to get it together.
6 Q. I wonder if you would like to look at page 164 of your
7 witness statement. I think this perhaps sums up, does
8 it not, what the College would see as the vital and
9 central duties of a paediatrician. It is, I think, the
10 College oath as it has now been developed; is that
11 right?
12 A. That is right.
13 Q. Would you like to take us through the key features of
14 that document?
15 A. If I was a new Fellow being asked to sign up to it, and
16 "Be careful to read it before you sign, because you are
17 going to be held to this", I would have said, "Well,
18 that sounds like good apple pie stuff", number 1.
19 Number 2 is the profound commitment that "I hereby
20 pledge to, throughout my professional life, as
21 a consultant, do everything I can to enhance and
22 maintain my skills and competence", and that, in the
23 terms I suppose of today's discussions, is the most
24 important, but it is framed deliberately second to there
25 being a rights issue of babies, toddlers, children,
0085
1 teenagers.
2 Then if I could scroll down, if I can use that
3 term, not too quickly or I will get a migraine, all the
4 points I would want to make special points of, but
5 I suppose it is the very last one which goes with the
6 standardising and maintenance to that, that skills and
7 competence are not sufficient. All paediatricians
8 should be courteous and compassionate in all their
9 professional dealings with children, parents, other
10 carers, placing the child's best interests at the centre
11 of all clinical considerations. I would hope that new
12 Fellows signing up to that might be affected by it in
13 addition to agreeing to abide by it.
14 Q. Thank you, Professor Baum. I have asked a number of
15 questions this morning. Before the Panel ask any
16 further questions, if they have any, is there anything
17 that you feel have not been adequately covered or which
18 you would like to add at this stage, remembering of
19 course, as you have heard earlier today, we will be here
20 until December, so of course if at any time the Royal
21 College wishes to add anything further, it is always
22 welcome to do so. For this morning, is there anything
23 you would like to add?
24 A. Two or three quick points. Firstly, to thank you for
25 your wonderful questioning. I thought you allowed me to
0086
1 go through the papers we had submitted and set them off,
2 I would say, to advantage.
3 Secondly, to thank who has ever designed the
4 format of the occasion and the chamber, since it seems
5 to me, apart from turning my back on yourselves, to be
6 most facilitative.
7 Finally, to use this rare occasion publicly to
8 express, on behalf of my colleagues, our sadness for
9 what the children and families have been through; to
10 know that, with the loss of a baby or the damage of
11 a baby, a whole family loses that child's childhood and
12 that is irreplaceable, but if corporately as
13 a profession, we were less skilled than we might be, for
14 that we should publicly apologise, but that it is my
15 most sincere belief, perhaps as portrayed in the words
16 used in the College oath, that the vast majority of
17 doctors, not just paediatricians, are and were and will
18 be driven by a vocation, a commitment, to doing the best
19 they can, but that what we have learned from this
20 Inquiry, albeit still with time to come, is that the
21 wish to do good is not sufficient and we have to put in
22 place the lifelong training and the checks and balances,
23 and that will be a memorial to these babies who died.
24 THE CHAIRMAN: Thank you, Professor Baum. There may be some
25 questions from the Panel.
0087
1 EXAMINED BY THE PANEL
2 MRS MACLEAN: Yes, thank you very much indeed for all you
3 have said this morning, Professor Baum, it is most
4 helpful.
5 I just have a small point, a supplementary to the
6 question Miss Grey put to you about the talk in your
7 excellent coffee shop. You described yourself as not
8 being aware of discussions about difficulties across the
9 road at the BRI. Were you aware of any discussion of --
10 not the referrals in but the removals out of BRI, the
11 transfers from the BRI to the Children's Hospital, as in
12 any way giving rise to discussion?
13 A. The discussions that I remember were about how greatly
14 advantaged it would be to have it all on one site; how
15 it was difficult to move sick children. I do not
16 remember problems that "there is trouble at mill", and
17 that the actual surgical performance was outwith what
18 might be expected.
19 MRS MACLEAN: Thank you.
20 MRS HOWARD: Professor Baum, just two questions: one you
21 have alluded to on several occasions this morning in
22 relation to site configuration with which you were faced
23 at the Children's Hospital.
24 What I would like to ask, for my personal clarity,
25 is what was the College's view as to the best
0088
1 configuration of Children's hospital services in the
2 best interests of the child?
3 A. I believe that they should be contained within a defined
4 children's unit, but contiguous with a general hospital,
5 and -- this is more difficult -- contiguous with the
6 health care for children in the community. It is that
7 which cannot be solved by bricks and mortar; it is the
8 more difficult to deliver, but equally important.
9 Q. Thank you, and perhaps leading quite nicely on to my
10 second question, you referred to the orchestra early on
11 and that your belief is that the leader of the orchestra
12 should be a paediatrician.
13 What is the issue in terms of influencing child
14 Health Service issues in, for example, a very large
15 trust, if the whole of the Trust is managed as one
16 entity? I am not sure if I have made my question
17 clear. I am talking about, how would leadership for
18 child health issues in that situation be delivered in
19 your view, in the best way?
20 A. I believe the best way would be a multidisciplinary
21 leadership of having sufficient agreement -- which
22 I would see no difficulty in getting people together --
23 between the specialists in children's doctoring,
24 children's nursing, children's social work, children's
25 therapies, to come together and agree their political
0089
1 representation.
2 MRS HOWARD: Thank you.
3 THE CHAIRMAN: Professor Jarman?
4 PROFESSOR JARMAN: Professor Baum, you mentioned early on
5 about the difficulty general practitioners have in
6 deciding where to go. Would you see in future any role
7 for primary care groups and primary care trusts in
8 collecting information about their local hospital?
9 A. I would hope that is part of the blueprint, because it
10 seems to me, even allowing what I said about numbers and
11 statistics and so on, that there were judgments to be
12 made. Even if they are judgments which lead the primary
13 care group not to say we are taking the business away,
14 but to say, explain why the standards are deviating from
15 where we would expect them to be. So I think it would
16 be a most healthy dialogue, let alone directly affect
17 the referral patterns.
18 Q. The second question, you mentioned about the difficulty
19 of intensive care and the lack of beds and so on. Would
20 you have any comment on the report which came from one
21 of the Royal College of Physicians inspections, that in
22 1992, at the BRI, the excessive workload probably at
23 times was so great as to affect the quality of patient
24 care?
25 A. I have not read that document and I come with some
0090
1 baggage of prejudice -- I am on the record, I cannot
2 take this off the record -- which is that I am not
3 over-affected by the ideas of workload. I think the
4 vocation of the subject and the vocation of the time
5 would lead me to believe that the job would have been
6 done effectively, although there might have been
7 a considerable fatigue level.
8 PROFESSOR JARMAN: Thank you.
9 THE CHAIRMAN: Professor Baum, I have one question that --
10 this is a very wide-ranging question. You talked about
11 the future and that the future might contemplate some
12 kind of quinquennial review, and you said, if I recall
13 correctly, that you would need to win the trust of your
14 colleagues for that to be a "runner".
15 Do you think that there is any chance of winning
16 the trust of another important constituency, namely, the
17 public, in the light of events over the last several
18 years in a number of contexts?
19 A. I have pointed out a point on my page which I had meant
20 to make, and thank you for this. We, like all the Royal
21 Colleges, are putting in place our patient advisory
22 mechanisms, not as a bit of tokenism, but in realisation
23 that -- and certainly in terms of our subject -- that
24 who is most well placed to represent the best interests
25 of the child, we would do well to put a child or
0091
1 a parent or a group to represent that interest.
2 It is part of our blueprint which is not
3 published, to gradually bring that into force, not only
4 to represent, I will call it "patient view", but it is
5 complicated because it varies between the opinion of the
6 child -- the child of 7 has an opinion; the child of
7 3 has an opinion, so it is everything that is in the UN
8 charter, together with the views of their family, in our
9 committee structure, in our regional structure, and it
10 is certainly part of our blueprint that in actually
11 finally developing the five-year plan, that the body
12 that would be reviewing that would include input from
13 a patient group.
14 THE CHAIRMAN: I am grateful. We have no more questions.
15 May I begin by thanking you for coming. May I apologise
16 for keeping you for a while when we had different
17 conversations. We have benefited greatly from what you
18 have been able to put in by way of written evidence and
19 by way of what you have been able to tell us. I echo
20 what I think Miss Grey said: if there are other matters
21 that you wish to bring to our attention, we are here for
22 some time and would be grateful to receive any further
23 observations, but for the moment, may I, on behalf of
24 all of us, thank you very much for coming.
25 THE WITNESS: Thank you for your courtesy.
0092
1 (The witness withdrew)
2 THE CHAIRMAN: Mr Langstaff?
3 MR LANGSTAFF: Sir, we are very much in your hands as to
4 timetabling this afternoon. What I would propose for
5 your consideration would be that Sir Terence, who is
6 here and has been here for a little while, recommences
7 his evidence now and we may take a break perhaps if the
8 shorthand writer is happy to do this, at about half
9 past 1, and then have, let us say, a late lunch, half
10 1 until 2, and then recommence in the expectation that
11 it will only be necessary then to have one short break
12 in the course of the afternoon?
13 THE CHAIRMAN: Thank you. We think that is an excellent
14 proposal, so why do we not do that? We will go on until
15 1.30, break for half an hour. I look to the
16 stenographer for her nod of approval, and I am happy to
17 receive it, because she is a very important part of this
18 exercise, and we do not express it very often, but we
19 need to say sometimes we are very grateful to you. Why
20 do we not break from half 1 until 2, and thereafter
21 proceed as we usually do in the afternoon. Thank you.
22 MR LANGSTAFF: Thank you. Sir Terence English, will you
23 come back on to the stand?
24 SIR TERENCE ENGLISH (Recalled):
25 EXAMINED BY MR LANGSTAFF (continued):
0093
1 Q. Sir Terence, since Thursday, you have kindly provided us
2 with typewritten copies of the handwritten notes which
3 you then provided. They have only just arrived and they
4 will be distributed by Mr Maclean to those behind me.
5 Can I thank you for that?
6 Could I ask you to have on your screen, please,
7 RCSE 2/33?
8 Can I remind you that you are, of course, still
9 under oath.
10 A. Correct.
11 Q. This is a paper we have looked at already, but we looked
12 at an edition which came from the Department of Health
13 files and this comes from the Royal College files.
14 If I can just go for a moment to page 36, and down
15 to the bottom, please, the handwriting. The difference
16 between this document and the other document is that
17 there is handwriting on it. Is that your handwriting?
18 A. Yes, it is.
19 Q. Can I go back, please, to page 33, the foot of it? This
20 paper was not in your authorship, I take it?
21 A. No.
22 Q. But the notes, as at the end, must be yours?
23 A. Yes, they are.
24 Q. You say, in respect of Bristol in 1990, at the end of
25 the page:
0094
1 "But encourage pro tem", and then, underlined, the
2 next words, "protect it". Was that in reference to
3 Bristol?
4 A. Yes, I assume it was.
5 Q. What did you mean, because we had a long discussion
6 about this on Thursday: what did you envisage to be the
7 content of encouragement?
8 A. I would have hoped that the encouragement would have
9 come predominantly from the hospital itself, the
10 hospital management, to try and increase the throughput,
11 achieve the sort of unit which would no longer need the
12 encouragement.
13 Q. But the wording "encourage" meant no action on your
14 part?
15 A. No direct action, certainly.
16 Q. What about the words which are underlined, "Protect
17 it". Who was going to do the protecting?
18 A. I am not sure. I presume that by that I meant that it
19 looked as if the Bristol unit should continue to be
20 designated as a supra-regional centre, and benefit from
21 what that would bring to it.
22 Q. Help us, please, as to your reasoning, because they are
23 your words. What would be the basis of seeking to
24 protect a unit which had had problems, in respect of
25 which the only two advantages were its geography and its
0095
1 potential; in respect of which the geography you told us
2 would not be enough on its own; and against the
3 background of a paragraph which indicates that the
4 potential is likely, if anything, to diminish with the
5 establishment of the Welsh Office in Cardiff?
6 A. I think, if you look a little bit higher up that
7 self-same paragraph, it says:
8 "The referral of patients has increased and the
9 centre appeared to be on a much stronger basis."
10 I am not sure where that came from, but this was
11 presumably what was in my mind at the time, that it was
12 worth protecting.
13 Q. I ought to ask you this. It has been suggested at
14 various times in various places that one of the factors
15 and features surrounding Bristol and its staff was
16 a possible influence of Freemasonry.
17 Are you or have you ever been yourself
18 a Freemason?
19 A. No.
20 Q. If we can turn over the page to 34, we see what you say
21 about Newcastle, your own thoughts:
22 "Keep under very careful review", and you
23 underline the word "very".
24 A. Yes, and ask for data, which presumably could not have
25 been provided.
0096
1 Q. I was going to ask you about that. You were looking for
2 data of throughput?
3 A. I think, just the fact that it had been brought to our
4 attention that Newcastle had not provided all the data
5 that was sought. I am not sure what it was, whether it
6 was relating to mortality statistics or activity.
7 Q. At the bottom of the page your conclusion:
8 "Needs to de-designate Harefield (a) --
9 A. It is "cf", referring to the original report.
10 Q. Can you read the next words?
11 A. "(b) Has been unable to work as a joint unit. Failed to
12 allow visit; failed to comply with CEPOD."
13 You will recall that the original reason for
14 designating Harefield was in the supposition that it
15 would become part of the Brompton unit, and that had
16 failed to happen.
17 Q. If we turn, then, back to page 36, the foot of the page,
18 "RX", that is recommendations, I take it?
19 A. Yes.
20 Q. "De-designate Harefield. Close watch on Guy's and
21 Newcastle and keep Leicester waiting"?
22 A. Correct. Those were my impressions at the time, as
23 I read the report.
24 Q. That report was, as we know, the middle of 1990 and that
25 was your thinking at that stage. I took you through, in
0097
1 the questions which I asked you on Thursday, to the
2 proposal which you made in the middle of 1991, to
3 develop a Working Group to consider procedures and units
4 which could or should be de-designated or designated
5 with a view to rationalising the system of
6 supra-regional services.
7 If we can look, please, at what followed your
8 response, which you will remember I asked you a number
9 of questions about as to the need to relate
10 supra-regional services designation to workload, can we
11 look, please, at UBHT 64/239?
12 Can we turn back a couple of pages, so we can see
13 what this is? The announcement by the Secretary of
14 State (UBHT 64/234) which is made each year in advance
15 of the forthcoming financial year. This is the
16 announcement in respect of the supra-regional services
17 for 1992 to 1993.
18 If we can go back, please, to where we were at the
19 start, the one I want to ask you about, down to
20 paragraph 31:
21 "In its recommendations last year, the Advisory
22 Group pointed out that there were effectively 10
23 designated centres, and some activity was taking place
24 in other units. This meant that the service must be
25 considered for de-designation. The group would,
0098
1 however, prefer in the interests of patients that the
2 service be rationalised into fewer designated units.
3 Discussions are taking place with professional bodies,
4 but unless these offer the prospect of early
5 rationalisation, designation will have to be withdrawn."
6 Can you help with the approximate date in the year
7 when the Secretary of State made the announcement as to
8 next year's funding?
9 A. I believe it was towards the end of the year, round
10 about the December time: in other words, after -- yes,
11 I think that is right. I am not absolutely sure.
12 Q. And the discussions then which are referred to are those
13 which were taking place between the Royal College of
14 Surgeons and perhaps others, and the Supra Regional
15 Services Advisory Group, were they?
16 A. I presume so, yes. I do not know when this document was
17 written.
18 Q. That is why I am asking you, really, for your best
19 recollection as to when this was normally produced.
20 Certainly, what is said in paragraph 31 would fit, would
21 it, with the discussions you had with Dr Halliday
22 towards the end of 1991, when he was asking you to
23 produce a recommendation, a Working Party, to look at
24 the possibility of de-designating a number of centres?
25 A. Yes, but what does not fit with timing is the fact that
0099
1 the Supra-regional Services Advisory Group first
2 considered the possibility of -- it first said that it
3 would like to de-designate the whole service, was at the
4 July meeting and that was confirmed finally at the
5 September meeting.
6 Q. You are ahead. You are in the year, I think.
7 A. I am one year out? Then I am all right. It was the
8 1992/93 bit that I did not understand.
9 Q. I hope I made it clear to you that my understanding is
10 that this was an announcement made in advance of the
11 financial year. The financial year would begin in
12 April.
13 A. So if this was the sort of end of 1991 position, then it
14 fits, yes. Thank you for clarifying that.
15 Q. Am I right in thinking, then, that there was active
16 discussion which was taking place between the Royal
17 College on the one hand and Dr Halliday and the Supra
18 Regional Services Advisory Group on the other, as to the
19 prospects for continued designation of the service?
20 A. The discussion had not been terribly active, because my
21 recollection is that -- perhaps it may have been after
22 the meeting in July 1990 that it was minuted that
23 Dr Halliday would have discussions with me to discuss
24 the future of the service. I do not think a lot
25 happened until 1991, July time, when I got a paper from
0100
1 him, I think.
2 Q. Can I help you with the timing of that? I think your
3 memory may be at fault and I imagine you have probably
4 seen a number of papers, documents, over time. Shall we
5 have a look at DOH 3/4?
6 This is from Dr Halliday to you. It is dated
7 20th December 1991.
8 A. Yes.
9 Q. It tells you that he is attaching a draft paper for your
10 consideration.
11 A. Yes.
12 Q. He wants any comments. It is for the next meeting of
13 the Supra Regional Services Advisory Group?
14 A. Correct.
15 Q. The last paragraph:
16 "I appreciate that the conclusions reached in this
17 paper are not ones that you will find easy to support.
18 I have, however, reviewed all the options with a number
19 of colleagues and it is difficult to refute the logic of
20 the conclusions given the problems of remaining within
21 the supra-regional criteria and continuing the
22 designation of the service."
23 Written to you as the President of the Royal
24 College?
25 A. Yes.
0101
1 Q. When you get papers such as this, which may have an
2 impact on the profession, was it your habit to discuss
3 them with others in the College?
4 A. No, not on an issue such as this, which I felt able to
5 handle. I was already a member of the group. I do
6 remember, however, feeling concerned that I had not been
7 in any way consulted about the paper which accompanied
8 that letter, and that there was a minute, I think made
9 in July 1991, that I would be and that we would jointly
10 bring forward proposals to the Supra Regional Services
11 Advisory Group.
12 Q. Just reviewing that for one moment, if --
13 A. I think if you turn to Dr Halliday's letter to me in
14 July, which I subsequently -- which you showed me
15 yesterday and which I replied to in September --
16 Q. It is RCSE 2/66?
17 A. At the bottom of that letter there was a suggestion that
18 he would discuss matters with me, I think.
19 Q. Can we have a look back at RCSE 2/66? This is the July
20 letter. It is looking for a Working Group. Can we turn
21 over the page? It is plainly anticipating that there
22 will be ongoing discussion, and then we see your
23 response in September 1991, which is DOH 3/3. You,
24 I think, suggest that it would not be easy to do what he
25 is asking you to do, but you do end by saying, in the
0102
1 very last paragraph:
2 "I look forward to discussing the possible ways
3 ahead with you at your convenience."
4 Was it that paragraph you had in mind?
5 A. Yes, because I think it is terribly important to get
6 this into context. The previous letter was asking to,
7 as I recall, convene a Working Party to look at the
8 possibility of accrediting certain operations so that
9 they would be taken out of designated centres, so that
10 one could reduce the number of designated centres, and
11 I think I felt that that was not appropriate or
12 workable, and I think I had said so.
13 Q. You did, in the letter, I think.
14 A. Yes. So I had hoped that we would be able to look at
15 some other way of proceeding at that time.
16 The next thing was the letter in December, as you
17 have shown me, which I responded to very fully after
18 having received it.
19 Q. Just so I understand the process, you were a member of
20 the Supra Regional Services Advisory Group; you were the
21 President of the Royal College of Surgeons of England.
22 Dr Halliday was considering options. You had offered to
23 discuss those options with him, but he never took the
24 offer up until, at any rate, after he sent you the paper
25 setting out the thoughts of him and his advisers?
0103
1 A. Yes.
2 Q. So you felt chafed by this?
3 A. I was concerned that the document that arrived with the
4 December letter, which I was asked to comment on, was so
5 at variance with what -- it was making a plea for the
6 fact that they could not continue to designate the
7 service, and I had never agreed with that.
8 Q. We have been told on a number of occasions by
9 Dr Halliday in the course of his evidence that he relied
10 for any clinical input upon the medical contacts which
11 he had and in particular, the Royal Colleges.
12 That seems to be rather belied by the fact, as you
13 have it, that there was no communication between
14 September and December, and no discussion about this
15 important change in policy?
16 A. We were one source of advice to the group. There were
17 others. He had been to the Society two years
18 previously, with the 1988 report and of course he had
19 his own information from the visits that he made and the
20 other Secretaries, to the designated units.
21 Q. Was the lack of communication between the College and
22 you as its President, and Dr Halliday, within that three
23 month period, from September to December, symptomatic of
24 what was usual, or was it by way of exception to the
25 general rule?
0104
1 A. I think it was exceptional, and I think it was
2 exceptional because I suspect, and I put it no stronger
3 than that, that Dr Halliday may have seen that the Royal
4 College of Surgeons in particular, had consistently
5 advocated that the service continue to be designated and
6 I believe that round about 1990/1991, the Department
7 began to feel uncomfortable with designation of the
8 service and probably wanted to see it de-designated, and
9 I think that in that circumstance there may have been an
10 exceptional lack of communication which might not have
11 taken place in another setting.
12 Q. Do you mean he did not ask for information which he did
13 not think would fit the bill?
14 A. I would not put it as strongly as that. I would simply
15 say he knew my position fairly well. I had expressed it
16 previously to the Supra Regional Services Advisory Group
17 on a number of occasions. My own view of the values of
18 continuing to designate the service, and the
19 professional view had been firmly behind that on two
20 previous occasions.
21 Q. If we look at the draft paper he sent, DOH 3/5, we see
22 a paper in which, if I may focus on the bottom of
23 paragraph 1, identifies the units most at risk as
24 Bristol, Newcastle, Guy's and Harefield. It is the
25 third line up from the bottom of the first paragraph.
0105
1 Paragraph 2:
2 "Members had previously considered a paper ...
3 which had provided more information on the units at
4 risk. Bristol and Newcastle were considered to be", and
5 then these words, "essential on geographical grounds,
6 but officials were asked to discuss ..."
7 Pausing there, can we have a look back at
8 DOH 2/203? It is paragraph 12. What you are looking at
9 here is paper SRS(90)15, and the words used are not
10 "Bristol and Newcastle are considered to be essential",
11 but "there is a strong case for Bristol and Newcastle".
12 It might appear to the English reader that there is
13 a difference in emphasis between the two?
14 A. I believe there is.
15 Q. Do you know how it came to be that what members had
16 thought became converted in one paper from "strong
17 case", to "essential" in a later paper?
18 A. I do not, sir, but I do know I expressed my view fairly
19 firmly when I saw that it was supposedly "essential",
20 that I did not agree with it.
21 Q. Can we go to split screen, as between DOH 3/5 on the one
22 hand and RCSE 2/81 on the other? You have to forgive
23 me, Sir Terence, if it is not as easy to read, because
24 we cannot, in this mode, highlight it.
25 If I can take the opportunity, although this
0106
1 mistake has been made, to pay tribute to those who
2 operate the machine, at how well they managed it, that
3 we should actually comment on this occasion.
4 The reason I put these side by side is that the
5 one on the right, the letter of 8th January 1992, is
6 your letter responding to the paper, is it not?
7 A. Correct.
8 Q. And we see that the response, the numbered paragraphs in
9 that letter, refer to the numbered paragraphs in the
10 paper.
11 A. Yes.
12 Q. Your response is first of all to say that you remain
13 convinced of the value of designation for the surgical
14 service, and then, in paragraph 2, you do not believe,
15 you say, that Bristol and Newcastle should be considered
16 essential on geographical grounds?
17 A. Yes.
18 Q. Going back to paragraph 2 in the left-hand side, it
19 would appear from what Dr Halliday and his advisers were
20 drafting for your consideration that the report,
21 following on from the discussion of SRS(90)15, was that
22 officials had been asked to discuss with units ways in
23 which the activity might be increased.
24 The use of that terminology would, would it,
25 support your view that this was for the officials rather
0107
1 than for the Royal College?
2 A. Absolutely, yes.
3 Q. Paragraph 3 -- here we get the words "strong case" in
4 terms of geographical spread, on the left-hand side?
5 A. Yes.
6 Q. "That it would be difficult, if not invidious, to
7 de-designate the centres in question on the basis of
8 surgical expertise."
9 Would I be right in thinking from that that there
10 may have been some discussion as to the relative
11 surgical expertise of the various centres at some stage?
12 A. I very much doubt it, apart from the information that
13 the group already had from the ATH report on mortality.
14 Q. So this was not a question of the grapevine, as
15 Professor Baum put it this morning, working to members
16 having an idea of where the weaker units were in terms
17 of expertise, and saying "We do not rely on that because
18 we do not know enough about it", or for whatever reason?
19 A. I do not believe so.
20 Q. In your reply, paragraph 3, you believe, you say, that
21 the Advisory Group should accept the possibility of
22 de-designating the centres on the basis either of no
23 referral patterns or inadequate staffing.
24 "Low referral patterns", that is numbers, is it?
25 A. Yes.
0108
1 Q. "Institutions and their reputation can change quite
2 quickly. Designation should not be regarded as fixed
3 and immutable, but should rather be dependent on regular
4 review of the activity and quality of output of
5 individual units."
6 So what were you saying, in that paragraph, as to
7 the significance of quality? Because if one looks at
8 the criteria you were suggesting, it appears to be
9 simply numbers, even though you do refer to quality in
10 the last line.
11 A. No, the quality of output was certainly there in my
12 mind, was mortality, because cardiac surgery is one of
13 the specialties where I think generally speaking
14 mortality is an indication of quality, in very general
15 terms, and here I was responding to paragraph 3 where
16 they were saying that it might be invidious to
17 de-designate centres on the basis of surgical expertise,
18 and doubted whether it was possible to do so.
19 My own view was that it would have been perfectly
20 proper to have analysed quality of output in terms of
21 mortality, and de-designate it if necessary.
22 Q. So it follows that you would have thought the
23 statistics, the data, was available if anyone were but
24 to ask?
25 A. I did not believe that the data was available in the way
0109
1 that it needed to be in terms of detail and risk
2 stratification, but I certainly felt that it should have
3 been.
4 Q. Forgive me. If what you are saying in the letter in
5 reply is that one was to de-designate on the basis of
6 quality, the immediate question is, how was quality to
7 be measured? Are you saying, "Well, we had measures but
8 they were not very good", or are you saying, "We had no
9 proper measure to deal with quality at this time"?
10 A. I think I am saying both: that we did have some measures
11 available to us at that time in terms of crude mortality
12 from some of the units, but we did not have any sort of
13 sophisticated analysis of operations, even by surgeons.
14 I mean, they were still coming through as unit returns,
15 completely disaggregated, completely non-risk
16 stratified.
17 Q. So what did you envisage as the process of looking at
18 quality? Would it have been a question of looking at
19 crude outcomes and then, if they suggested a problem,
20 investigating further?
21 A. Exactly. I think that the output of crude mortality is
22 there as a sort of warning, if you like, that if it
23 raises an issue, then you need to go in and do a much
24 more detailed and difficult analysis.
25 Q. So if the crude warning is there, one simply has to ask
0110
1 further questions?
2 A. Yes.
3 MR LANGSTAFF: Sir, would that be a convenient moment?
4 THE CHAIRMAN: Yes, thank you, Mr Langstaff. We will break
5 now for half an hour, and therefore reconvene at
6 2 o'clock. Thank you.
7 (1.30 pm)
8 (Adjourned until 2.00 pm)
9 (2.00 pm)
10 MR LANGSTAFF: Sir Terence, I wonder if we could have up on
11 the screen, the same split screen that we had before,
12 DOH 3/6 on one side, and RCSE 2/82 on the other.
13 7(i), the opening words: "The possibility of
14 de-designating the smaller units was reviewed in
15 1990..."
16 It goes on for the best part of a paragraph. The
17 very bottom of the page, the last line:
18 "The Advisory Group concluded, however, that it
19 would not be possible to simply de-designate the smaller
20 units."
21 Do you see that?
22 A. Yes.
23 Q. Your response to that, it is the left-hand side, 7(i),
24 because that is the paragraph of the draft report you
25 are looking at, "Did the Advisory Group ever conclude
0111
1 that it would not be possible to de-designate smaller
2 units? I rather doubt this."
3 A. That was my view.
4 Q. So you saw in 7(i) of the draft report some
5 mis-statement of the position as you understood it, and
6 you were keen to correct that?
7 A. Yes.
8 Q. Indeed the conclusion that your views would drive you to
9 would be that if the service had too many units in it,
10 as it did, then the route, the preferable route, would
11 be to de-designate some of the those units?
12 A. Yes.
13 Q. Can we look now, single screen will do, at RCSE 2/83?
14 It is going to be the last page of your letter.
15 A. Yes.
16 Q. You are suggesting that a Working Group should be
17 established with specific terms of reference being to
18 review the existing centres with a view to reducing the
19 total number to a maximum of 7?
20 A. Yes.
21 Q. And looking for the centres, which you mention, to
22 submit, we see, activity and mortality data?
23 A. Yes.
24 Q. Mortality data no doubt with a view to carrying out the
25 sort of exercise, albeit crude, that you described in
0112
1 the last couple of question and answers immediately
2 before lunch?
3 A. Correct.
4 Q. When Dr Halliday got that response from you, that
5 detailed response of 8th January, the draft report was
6 changed, I think, in some respects. Can we look,
7 please, at DOH 2/44, paragraph 2?
8 The wording has changed from "essential on
9 geographical grounds" to "important on geographical
10 grounds", so your first point was obviously accepted?
11 A. Yes.
12 Q. Paragraph 4 has been added. In another context we saw
13 this with another witness. The very last sentence:
14 "Mortality data from each of the designated units
15 will be tabled at the meeting."
16 A. Yes.
17 Q. This was looking to the first meeting in 1992?
18 A. Correct. February.
19 Q. And it would suggest, would it, that Dr Halliday or
20 those who wrote this note had access to mortality data?
21 A. Yes.
22 Q. Was mortality data in fact tabled?
23 A. I cannot be absolutely sure about this, but I do not
24 recall so.
25 Q. If it had been, and had revealed what you understood in
0113
1 July, later the same year, to be the position with the
2 crude mortality data in respect of Bristol, you, for
3 one, would have raised questions?
4 A. Yes. I hesitate because when we did get the table 1
5 from the 1992 report, which presumably we will look at
6 in a minute, which was the mortality data such as the
7 Working Party had been able to get, it was incomplete
8 and it was very crude data, and there were a number of
9 units which did not apparently perform very well --
10 three, I think, who had high mortality rates.
11 So the reality of it was that in fact it was the
12 stimulus of receiving Dr Zorab's letter, together with
13 the mortality figures, which made me subsequently take
14 the action which I did in July. I think that is an
15 important point to get across.
16 Q. I will come back to that, if I may.
17 A. If I could just add, if there had been a similar
18 stimulus about, say, Guy's or Harefield, in conjunction
19 with the raised mortality -- with the higher mortality
20 figures, then one would have wanted to look at that and
21 suggested that that was the right thing to do next.
22 Q. So I get this straight for when I come back to it, are
23 you telling me that one would not only need the crude
24 figures which were disturbing, but one would actually
25 need someone, some clinician, somewhere, complaining
0114
1 about them?
2 A. I think that is what actually, to my mind, determined
3 that this needed a closer look: the two together.
4 Q. What it suggests is that unless someone had been
5 prepared to complain, there would have been no closer
6 look?
7 A. Well, partly, but also what it suggests was the great
8 difficulty of making anything out of the mortality
9 statistics that were provided as they were. They were
10 very inadequate, incomplete, as I say,
11 un-risk-stratified, disaggregated, not coming from
12 individual surgeons.
13 Q. I will come back to that. The report then, which you
14 have, envisages the discussion which was going to take
15 place at the group, and if we go, please, to DOH 2/33,
16 we can see the meeting of the group, page 2/36, please.
17 It reports you saying:
18 "Most recent reports concluded that keeping 90 or
19 95 per cent of the neonatal and infant cardiac surgery
20 work concentrated in 6 or 8 patients was most beneficial
21 to patient care."
22 You set out three options and offer to set up
23 a Working Party.
24 4.2.4:
25 "After discussion, members agreed to Sir Terence's
0115
1 suggestion that he would set up a Working Group to
2 consider the", and one sees the terms of reference which
3 are rather different to those you said in your letter.
4 Overleaf:
5 " ... three options for the service. If that
6 group recommended that the number of designated units be
7 reduced, it would name the units to be de-designated",
8 I think it should read?
9 A. De-designated, yes.
10 Q. And the group would produce its findings in time for the
11 July meeting?
12 A. Yes.
13 Q. Pausing there, may we look at RCSE 2/95? Can we go
14 down, please. This is a footnote in your handwriting?
15 A. Yes.
16 Q. It is an annotated copy of the final report which went
17 before this committee?
18 A. Yes.
19 Q. Can I just go through it with you?
20 "What are we trying to achieve by designation?
21 Designation and the ...", please correct me if
22 I go wrong in trying to read your writing. In fact,
23 would you prefer to read it for us?
24 A. I am very happy for you to do so. I will correct you if
25 you go wrong.
0116
1 Q. " ... and the funding that would go with this would be
2 likely to concentrate plus or minus 90 per cent of the
3 activity in 5 to 7 major centres.
4 "This would be a better solution than
5 de-designating the whole service, because a small amount
6 of activity was going on in non-designated centres.
7 This, in any case, would be likely to decline in the
8 face of continued non-designation.
9 Then your comment in brackets: "(Make Magdi do his
10 work at the Brompton)."
11 A. Yes.
12 Q. That really is picking up what you had said in your own
13 handwritten annotations to the 1990 report saying
14 Harefield should not be a separate centre?
15 A. Yes.
16 Q. What you are looking for, then, is a concentration on
17 5 to 7 major centres?
18 A. Yes.
19 Q. Which, coming down from the 10 that you had, would mean
20 that 3 at least, and 5 at most, would have to go?
21 A. Yes.
22 Q. At this stage, at this meeting, you had had the view for
23 some time, you told us, that the only two arguments in
24 favour of Bristol were geography and potential, and this
25 is now 1992. The geography is not an essential reason,
0117
1 you say in your own letter, in January. Is it the case
2 that eight years experience had failed to recognise
3 whatever potential may once have existed?
4 A. Well, it certainly had not developed as well as many had
5 anticipated, or would have liked.
6 Q. So was there still potential even at this stage?
7 A. I think the answer has to be "Yes". It is very
8 difficult to consider neonatal and infant cardiac
9 surgery entirely on its own, without reference to the
10 paediatric cardiac surgery that goes on in slightly
11 older children. The activity in the latter regard with
12 respect to Bristol had been quite good. The numbers
13 were quite reasonable in comparison with national
14 standards, or national achievements.
15 Q. Is that the answer to the question, why it was that at
16 this meeting of the Supra Regional Services Advisory
17 Group you did not say, "Well, actually, Bristol ought to
18 be de-designated, in my view, but we will have a Working
19 Party to check that"?
20 A. I do not think there was nearly enough evidence at this
21 meeting, in February 1992, to consider or suggest that
22 Bristol should be de-designated at that stage. We
23 simply did not have the information.
24 Q. You were written a letter which I think we see at
25 DOH 3/12, following the meeting in February. Purely
0118
1 formal: you had been at the meeting, you knew what was
2 going to come and this is a formal recognition of the
3 terms of reference?
4 A. Yes.
5 Q. It really is asking the committee to choose between the
6 three options, and if it is the third option, no doubt
7 to give candidates what I have described as the "chop".
8 A. Yes. Here it says "to around 7".
9 Q. Yes. What then happens is that you establish a Working
10 Party, is it?
11 A. Yes.
12 Q. May we have a look at DOH 2/1? That is to identify the
13 document. Move to page 13.
14 This is a record in each year, the first of the
15 open and then of the closed operations, for 1990 to
16 1991, 1991 to 1992?
17 A. These are all under 1 year olds, I presume?
18 Q. They are. The box on the right-hand side is
19 catheterisations, 93/110 for Bristol.
20 A. Right.
21 Q. The workload there -- again, I just press you on the
22 point -- plainly the number of open heart operations is
23 very small.
24 A. Yes. You need to take it in comparison with, shall we
25 say, a very large institution like the Brompton where
0119
1 the numbers are larger but not hugely so, and certainly
2 of Southampton, likewise. And of course Harefield, very
3 low: much lower than Bristol.
4 Q. You are recommending Harefield for de-designation?
5 A. Well, I never felt that it should be de-designated --
6 well, I felt it should be amalgamated with the Brompton,
7 because Professor Yacoub was Professor at the Royal
8 Brompton Hospital. There was a paediatric cardiac unit
9 going there and it seemed logical to have all paediatric
10 cardiac surgery, not just neonatal and infant, but all
11 of it, at the Brompton.
12 Q. In any event, shall we have a look at the Working Party
13 report, when it was produced? It is RCSE 2/165.
14 If we can just skim through it, it sets out the
15 history of the Working Party in the beginning, the value
16 of the supra-regional designation and funding, which is
17 general, and then page 166 deals with the presentation
18 of data. It concentrates on tables 2, 3 and 4, which
19 give a breakdown of figures, 5, 6, 7 and 8.
20 The findings and recommendations, if we turn over
21 to 167, paragraph 4:
22 "We recommend that 9 centres now be recognised for
23 supra-regional designation and funding, viz table 7 (top
24 left-hand table) are: Great Ormond Street, Birmingham,
25 Liverpool, Leeds, Wessex, the Royal National and
0120
1 Brompton Hospital, Bristol, Newcastle and Leicester."
2 There is no separate discussion in the text, as
3 I follow it, about Bristol, or for that matter,
4 Newcastle?
5 A. I do not believe so, no. I think at Newcastle it had
6 been established previously that they had appointed
7 a new paediatric surgeon and that the throughput was by
8 then going up quite steadily, and there was, as you say,
9 no mention of Bristol.
10 Q. If we turn over to RCSE 2/170, the total of open and
11 closed cases for 1989, neonates and infants, and on the
12 far right-hand side one sees numbering going from 1 to
13 12?
14 A. Yes.
15 Q. That would be the league table ranking?
16 A. Well, it was really just ranking of combined activity of
17 open and closed, yes.
18 Q. And if we look down to see where Bristol ranked, for
19 open and closed of the under 1s, in 1989, seventh?
20 A. Yes.
21 Q. Only Guy's and Newcastle of the designated units, and
22 Harefield, the smaller?
23 A. Correct.
24 Q. If we turn over the page to 171, 1990, Bristol has now
25 dropped to eighth for total activity?
0121
1 A. Yes.
2 Q. If we turn over to 172, Bristol has now dropped to ninth
3 for overall activity?
4 A. Yes.
5 Q. The numbers done have gone down from 99 in 1989 to 84,
6 15 less in 1990; 74, 10 less again in 1991. If one were
7 to derive a trend, if it were sensible to do so, for
8 three years of data, the trend is undoubtedly for
9 a reduction in numbers of referrals, is it not?
10 A. In the way you present it, sir, that is correct, but
11 I think if you move on -- I am not sure what the table
12 number is, but look at the cumulative three-year
13 activity, both for all paediatric cardiac surgery and
14 for the under 1s, Bristol comes out at, is it sixth,
15 seventh or eighth, I am not sure. The table further on.
16 Q. I wondered if you might say that. To be fair, can we go
17 back to RCSE 2/170? What I have shown you thus far, of
18 course, is the neonatal and infant figures.
19 A. Yes.
20 Q. Because that was the specialty?
21 A. Yes.
22 Q. At the bottom of the page, these are the other
23 paediatric cases?
24 A. Yes.
25 Q. But not neonatal and infants. You might rightly draw
0122
1 attention to the fact that Bristol there is fourth in
2 size after Great Ormond Street, Birmingham and Liverpool
3 in terms of the numbers done?
4 A. Yes.
5 Q. If we turn over the page to 171, Bristol has dropped in
6 numbers from 151 down to 126, and dropped in the league
7 table to sixth.
8 If we turn over the page, 172, the numbers, let it
9 be said, remain constant, but the position is dropped
10 down to seventh?
11 A. Yes.
12 Q. So if one were to look at the trend in the over 1s, one
13 would have exactly the same picture?
14 A. Yes. I agree that you have pinpointed a trend there.
15 Q. And the trend would therefore be the same in both the
16 neonates and infants and the older paediatric cases,
17 a downward number of referrals?
18 A. Yes; or downward number of activity.
19 Q. I am grateful. We can see, I think what you may have
20 had in mind, was the sequence order of the total open
21 and closed cases, page 173. Bristol is third from the
22 bottom. We have already picked that up, the seventh,
23 the eighth and the ninth?
24 A. Yes.
25 Q. 174, table 6: Bristol third from the bottom, fourth,
0123
1 sixth and seventh. Again, that is something we have
2 picked up.
3 At 175 -- this may, I do not know, be the table
4 you had in mind -- let us go over again, perhaps, 176:
5 "Final league sequence for open and closed under
6 1 year ... 3 years cumulative ..."
7 A. It comes out at sixth equal.
8 Q. For the under 1s it is eighth equal, I think you will
9 see?
10 A. Yes.
11 Q. And for all ages open and closed, sixth equal?
12 A. Yes, thank you.
13 Q. That is how I interpret this table, and I think it is
14 probably right, is it not?
15 A. Yes, it is.
16 Q. So if one is looking to see which 5 to 7 centres are
17 going to retain designation, one would, on these grounds
18 alone, put a very big question mark over Bristol, simply
19 on the basis of activity, would one not?
20 A. If one had started out by saying that one was aiming to
21 reduce to 5, 6 or possibly 7 centres, yes. If one was
22 looking to retain an overall number of 9, which was
23 within the agreed regulations for supra-regional
24 designation, then one would not have been looking so
25 critically at that. I suspect that this is the way that
0124
1 the Working Party viewed it.
2 Q. Am I in the middle here of almost a political clash
3 between the Royal College of Surgeons and the clinicians
4 wanting to maintain the biggest number of designated
5 centres, on the one hand, and the Supra Regional
6 Services Advisory Group or the Department of Health who
7 wanted to reduce the number to the lowest possible on
8 the other?
9 A. No. I think that would be incorrect. I think there was
10 a difference of opinion, not a clash, and I think the
11 difference of opinion existed between continued
12 designation of the service, which the Royal College of
13 Surgeons and its professional advisers felt strongly
14 about, and the Supra Regional Services Advisory Group,
15 who saw the problems of trying to control the numbers,
16 the problems related to de-designating centres, the sort
17 of things that we have already discussed.
18 Q. In any event, this paper made the recommendation that we
19 have seen, if we go back to 2/167, that Bristol should
20 retain designation?
21 A. Yes.
22 Q. Given the information that we now have, looking at the
23 tables, where most of the information in this paper was
24 contained, what is your understanding of how it is that
25 this paper could come to that conclusion?
0125
1 A. I do not find it too surprising that they came to that
2 conclusion, that the authors of the paper did.
3 I certainly accepted it when I received the document.
4 I had thought that the Working Party might in fact
5 de-designate rather more than two centres, namely, Guy's
6 and Harefield, which is what they were recommending, to
7 get down closer to the 7 that had been suggested
8 earlier, but given the analysis that they had made,
9 I did not find it at the time too surprising. And
10 I forwarded on to the Department of Health in that
11 light.
12 Q. What argument would you derive from the data and from
13 what you have already told us as to your knowledge of
14 Bristol, which would justify its continued designation
15 as a centre for the neonates and infants?
16 A. That it was functioning at a lowish level, certainly not
17 the lowest; and that it was still regarded as being an
18 important centre.
19 Q. In terms of your own reasons for supporting it earlier:
20 geography was not essential, and potential appears to be
21 belied by the trend downwards?
22 A. Potential still has not been realised, I agree.
23 Q. Is it not the case that if you were to apply your own
24 approach to it, you would have said, "Well, this trend
25 really argues against there ever being a realisable
0126
1 potential here, now".
2 A. I certainly did not think that at the time that
3 I received this report.
4 Q. If you had the benefit of hindsight, do you think you
5 might have taken that view?
6 A. I think that I should have initially given a more
7 critical analysis, or given more critical analysis to
8 table 1 of the report, but I had asked a group of very
9 responsible clinicians to look at this. They had
10 accepted the terms of reference; they had collected
11 a lot of data, come up with a report that I could
12 understand their reasoning for wishing to continue to
13 advise that the service be designated and how this could
14 be achieved. And the recommendations to ask Guy's to
15 either amalgamate with another London unit or fail to
16 continue to get funding, and similarly, to ask Harefield
17 to amalgamate with the Brompton or face withdrawal of
18 funding, and to recognise that Leicester was doing good
19 work, these all struck me as being perfectly reasonable
20 at the time.
21 Q. On 17th July 1992, you got a letter, RCSE 2/188. This
22 is from Dr John Zorab, consultant anaesthetist, and
23 indeed, Medical Director of the Frenchay Hospital?
24 A. Yes.
25 Q. So a man who spoke from a position of some authority?
0127
1 A. Yes.
2 Q. And whose views were to be treated with respect and
3 could not be ignored, I take it?
4 A. Most certainly.
5 Q. He knew you personally?
6 A. He had served on the Council of the Royal College of
7 Surgeons when I was a Council member in the early years.
8 Q. So he knew you personally?
9 A. Yes.
10 Q. Hence the "Dear Terence" in handwriting at the start of
11 the letter.
12 Let us have a look at it:
13 "Some time last autumn, I made one or two efforts
14 to get to see you in order to discuss the delicate and
15 serious problem of mortality and morbidity following
16 paediatric cardiac surgery in Bristol."
17 Just pausing there, how would one get to see you
18 as President of the Royal College?
19 A. Simply phone the office and when he was in London,
20 I would have seen him.
21 Q. If someone phoned, would they leave a message as to what
22 it was about?
23 A. A matter such as this, I doubt it; he would have just
24 phoned my secretary and said he wanted to see me about
25 something confidential, and it would have been arranged.
0128
1 Q. So that would be for your secretary to arrange, would
2 it?
3 A. She would speak to me about it. If it was that
4 important and regarded as being confidential, she would
5 have said Dr Zorab had phoned and wanted to see me about
6 a confidential matter and I would have arranged an
7 appointment.
8 Q. So is the implication of those three lines that at some
9 stage, probably 1991, your Secretary would have had some
10 contact from Dr Zorab, saying, "I want to speak to
11 Sir Terence about something confidential"?
12 A. I have never interpreted it in that way at all.
13 I regarded this that he had made one or two efforts to
14 get to see me which had not been successful on his part,
15 I had assumed; that something else had cropped up and he
16 had not quite made it.
17 Q. He goes on to discuss great anxieties being expressed by
18 some of his colleagues at the Royal Infirmary:
19 "In the event, I never made contact with you and
20 the matter passed from the forefront of my mind", he
21 says.
22 His colleagues at the Royal Infirmary would be
23 anaesthetists?
24 A. Yes, I presume so.
25 Q. If, in a surgical firm, concerns were expressed about
0129
1 one or other member of the firm, in the event of that
2 being a surgical firm, would that be likely to come
3 through the routes we have heard described, the
4 grapevine, the whispers in the corridors and so on, to
5 the attention of someone such as yourself as the
6 President of the Royal College?
7 A. No, it would not come to the President unless it was
8 a very serious issue. It would normally be brought to
9 my attention by the managers of the hospital saying, "We
10 have a problem here. Could you help us resolve this by
11 perhaps sending down two people to look into it?"
12 something like that.
13 Q. So how common would it be for a letter to be written to
14 you saying, "We have a very serious situation here"?
15 A. Very uncommon.
16 Q. How many times a year, roughly?
17 A. I think during my three years as President, I had three
18 other instances similar to this which led to an
19 investigating team going from the College to the
20 hospital concerned, commissioned by the Trust rather
21 than sent by the College.
22 Q. So in those other cases, you got the letter, the letter
23 expressing concern, and one way or another, an
24 investigating team was set up?
25 A. Correct.
0130
1 Q. Who set the investigating team up in each of those
2 cases?
3 A. In a way, I was responsible, but I took the view fairly
4 early on in my Presidency that the role of the College
5 was to try and help and facilitate things in this way,
6 but that it should be either the Regional Health
7 Authority or the local Trust which would actually
8 commission the investigation, but I would help with
9 trying to name two appropriate surgeons or a surgeon and
10 a physician, as was the case.
11 Q. And because of the Royal College's role in seeking to
12 maintain standards, you would no doubt wish to press the
13 Regional Health Authority or the local Trust to carry
14 out just such an investigation?
15 A. They usually knew that there was a problem -- well, they
16 knew there was a problem and they were seeking our
17 professional help as to how to resolve that.
18 Q. Reading on:
19 "Matters have come to a head once again" and those
20 words, "matters have come to a head once again", suggest
21 some urgency about the issue?
22 A. Indeed.
23 Q. "The enclosed piece from Private Eye, whilst possibly
24 having some inaccuracies, quotes some statistics which
25 have been confirmed elsewhere."
0131
1 Can we look at SL D2/3? This, as you will see, is
2 dated by someone else in hand, "8th May 1992". I am not
3 sure whether it was this extract or another, which
4 I will show you in a moment, which you had, but
5 certainly on 8th May 1992, we can see:
6 "The great waiting list cash giveaway has
7 resurfaced at the Bristol Royal Infirmary...", and it
8 talks about orthopaedic surgeons. It talks then about
9 Dr John Roylance applying for a charter mark, and the
10 last two paragraphs:
11 "Before the DOH bestows its mark of excellence on
12 UBHT, it may wish to ponder the perilous state of its
13 paediatric cardiac surgery. In 1988, mortality was so
14 high that the unit was dubbed 'The killing fields'.
15 Despite a long crisis of morale among intensive care
16 staff, the surgeons persistently refuse to publish their
17 mortality rates in a manner comparable to other units,
18 and although Dr Roylance and the DOH are well aware of
19 the problems they won't recognise them officially.
20 Recently the unit failed to provide a paediatric cardiac
21 surgery nurse for post-operative care because it was
22 assumed the baby would not survive the operation, and
23 although Liverpool surgeons have successfully operated
24 on 160 babies with Fallot's tetralogy, the Bristol
25 mortality rate is between 20 and 30 per cent, hardly the
0132
1 stuff of commendations."
2 That is one I have read for the transcript. Can
3 we look at SL D2/5? Can we scroll down to the end of
4 the first column and the paragraph beginning there with
5 Mrs Bottomley:
6 "Mrs Bottomley claims that whistle-blowing through
7 the correct channels will get results. Staff at the
8 United Bristol Health Care Trust have been whistling
9 about the dismal mortality statistics in the paediatric
10 cardiac surgery unit since 1988 (I.793), and while
11 UBHT's Chief Executive, John Roylance, the Royal College
12 of Surgeons and Duncan Nicol, Chief Executive of the NHS
13 Management Executive, are all well aware of the problem
14 they seem more concerned with silencing the blowers.
15 "In America the mortality rate for arterial
16 switch, an operation to connect and congenitally
17 transfers arteries from the heart is now nought per
18 cent. Nearer to home in Birmingham, it is 3 per cent.
19 In Bristol, despite the fact that the operation has been
20 performed since 1988, it is 30 per cent. Sadly,
21 consultant cardiologists at the Bristol Children's
22 Hospital continue to refer patients to their surgeons to
23 support the local unit. As a recently retired and very
24 eminent cardiac surgeon in Southampton says, 'everyone
25 knows about Bristol'."
0133
1 Do you remember which of those two, or was it
2 both, that you got?
3 A. No, I had never seen the first one you showed me before
4 this afternoon. Dr Zorab enclosed a copy of the second
5 piece.
6 Q. What John Zorab says to you, in his letter, just going
7 back to RCSE 2/188:
8 "Whilst possibly having some inaccuracies, it
9 quotes some statistics which have been confirmed
10 elsewhere. One of the newer consultant cardiac
11 anaesthetists feels that the mortality rate is too
12 distressing to be tolerated and is job-hunting
13 elsewhere."
14 Just pausing there, you knew the identity, did you
15 not, of the eminent consultant surgeon who had just
16 retired from Southampton?
17 A. I presume it was Sir Keith Ross.
18 Q. It could not be anyone else, could it?
19 A. No.
20 Q. He was the one you had been corresponding with, of your
21 own results when you were at Papworth?
22 A. With his colleague, in fact, Jim Munro, but they would
23 have shared it.
24 Q. So you knew him well?
25 A. Yes.
0134
1 Q. Did you phone him up and say, "Keith", or "Sir Keith",
2 or however it was you talked to him, "This is said about
3 you in Private Eye; is this the case? What do you know
4 about it?"
5 A. I did not, in fact, no.
6 Q. So is that because you took what was said at face value?
7 A. I took it at face value and felt that I needed to act on
8 Dr Zorab's letter pretty quickly.
9 Q. It would follow that then John Zorab was saying to you,
10 and Private Eye was quoting a person you knew and
11 respected, Sir Keith Ross, as saying, "There is a very
12 big problem with mortality at Bristol."
13 A. Yes.
14 Q. And John Zorab goes on, the second from last paragraph:
15 "Whether the 'Eye' is correct in saying that the
16 matter has already been drawn to the attention of the
17 College and the NHS Management Executive, I do not
18 know."
19 Pausing there, the second of the Private Eye
20 articles I have shown to you suggested that the Royal
21 Colleges had known for some time?
22 A. They suggest it, but they certainly did not, and
23 I certainly did not.
24 Q. Suppose that the information is right and you took it at
25 face value, that everyone knew about Bristol, there was
0135
1 a widespread feeling that the situation is well
2 recognised, is what Dr Zorab goes on to say, the
3 likelihood must be that somebody in the Royal College of
4 Surgeons would have heard of it?
5 A. Well, I do not know that you can draw that conclusion,
6 in fact. I mean, the cardiac surgeons were a small --
7 are a small specialty within the whole discipline of
8 surgery, and I do not know that anybody would have
9 picked up the Private Eye piece at all, other than some
10 cardiac surgeons may have noticed and mentioned it to
11 others.
12 Q. It is not so much the Private Eye piece, it is what the
13 Private Eye piece reveals that may or may not be true?
14 A. Correct, yes.
15 Q. It might be entirely false, it might be correct, but
16 here Private Eye are plainly referring to someone you
17 knew had just retired?
18 A. Yes.
19 Q. And someone that you treated with some respect?
20 A. Yes.
21 Q. And here is John Zorab, a responsible and respectable
22 anaesthetist, Medical Director, after all, both to whom
23 is attributed the words, the other of whom is saying,
24 'people have had concerns about Bristol for a long
25 time', I think is the flavour of it?
0136
1 A. Yes.
2 Q. Now you have been in the know yourself, you told us on
3 Thursday, for some time, at any rate up until the
4 mid-1980s. From what you said on Thursday, I take it
5 that you did not have -- and I choose my words with care
6 because I do not wish to imply too much -- the highest
7 opinion of paediatric cardiac surgery at Bristol?
8 A. Yes.
9 Q. Did you, for your part, prior to the late 1980s when you
10 ceased to be so much 'in the know', have some inkling or
11 knowledge that there may be problems at Bristol?
12 A. I had no such inklings, until I received Dr Zorab's
13 letter. The Private Eye piece meant nothing to me. The
14 letter from Dr Zorab did. Private Eye had run
15 a campaign against perhaps the most distinguished
16 cardiac surgeon of my generation, Sir Donald Ross, some
17 years earlier and, quite honestly, I do not think
18 anybody paid a lot of attention to what they are
19 saying. But I did pay attention to Dr Zorab's letter.
20 Q. The second last paragraph:
21 "A widespread feeling that the situation is
22 well-recognised but being ignored - possibly because
23 no-one knows how to tackle it."
24 You cannot necessarily answer for the feelings of
25 others, but you can help me with this: if there is
0137
1 a feeling in a firm or in a unit that one or two
2 surgeons are not performing to standard; they may be
3 past it; they may have too much evidence of "the night
4 before in the morning after", or whatever it may be,
5 does that take time to come to attention of those who
6 can put it right? We are talking about the 1980s.
7 A. I think that it depends on the culture in the hospital,
8 because it is only going to come to light within the
9 hospital and the hospital management. I mean, there may
10 be whispers outside it, but it is the hospital
11 management which has to put these things right.
12 Q. So the Royal College itself does not have a role to play
13 in monitoring that?
14 A. We have absolutely no authority over performance within
15 hospitals in this respect.
16 Q. By 1991, when the purchaser/provider split was
17 institutionalised in the form of Trusts, would there be
18 any incentive for a Trust to reveal its problems to the
19 outside world rather than dealing with them internally?
20 A. No. I suspect that one of the effects of the new
21 arrangements which followed the 1990 reforms was that
22 because Trusts saw themselves in competition with the
23 other Trusts, they would try and solve these sort of
24 things internally.
25 Q. So again, one is thrown back on the question of the
0138
1 management of the Trust?
2 A. Yes.
3 Q. Does that run a risk that those who are in management of
4 the Trust may be close to or may themselves be the
5 clinicians about whose conduct there is some concern?
6 A. It could happen, but I think it would be unusual.
7 Q. If it did happen, how would it be resolved in the 1980s,
8 early 1990s?
9 A. It would still have to be resolved within the overall
10 management of the hospital: that the Chief Executive, if
11 he had a concern, would speak to the Trust Board or the
12 Trust Chairman and say, "We have a difficult problem in
13 a particular area of our operation; it needs to be
14 solved. The local surgeons or physicians do not seem to
15 be addressing it properly. I suggest that we have to
16 tackle this in a different way and perhaps commission
17 a professional analysis or an analysis by the profession
18 to come in and see what is going on. That would be one
19 way of doing it.
20 Q. The words that Dr Zorab uses:
21 "Possibly because no-one knows how to tackle it
22 [the situation]", might suggest this is a situation he
23 and others had not come upon before, at least to the
24 same extent. You are nodding. I have to say that for
25 the transcript.
0139
1 A. Yes, it might well be.
2 Q. How would one, in July 1992, have advised tackling this
3 sort of problem?
4 A. I think that is going over very much what I just said
5 a minute ago.
6 Q. It is all up to local management?
7 A. Yes.
8 Q. "I am sorry to bother you with this essentially local
9 problem but would be grateful for your advice as to how
10 the matter can be addressed."
11 You reply, jumping ahead for a moment, at
12 RCSE 2/195. You thank him for the letter. This is
13 27th July, and you say:
14 "I shall make a full response when I return from
15 holiday in mid-August ..."
16 You go on to deal with something else which we
17 will come back to.
18 Can I come back from that letter to 2/188? Did
19 you ever get back to him after that second letter, after
20 that first reply?
21 A. I believe I did. I am not absolutely sure. I would
22 have to look up the records.
23 Q. I tell you why I ask. We, for our part, have no copy
24 from any file of any letter that you wrote back to
25 Dr Zorab after that second one.
0140
1 What we do have is your own recollection, which we
2 see at PAR (1) 8/89, a letter by you to Nick Harvey MP
3 of 11th March 1996. You are recording the conversation
4 you had had with Dr Zorab. You are trying to put
5 together what had happened, and I think in the absence
6 of notes and documents at this stage, this is just your
7 memory?
8 A. Yes.
9 Q. You say as much. You have been trying to trace key
10 correspondence and appear to have been unsuccessful.
11 You have spoken, amongst others, to Dr John Zorab. He
12 tells you, you recall, that his letter arose from
13 a casual meeting he had had with Dr Bolsin when they
14 happened to meet at a private hospital where they were
15 both working, and at which time Dr Bolsin expressed to
16 Dr Zorab his general concern about a higher than to be
17 expected mortality rate for paediatric cardiac surgery
18 at the BRI. A general statement.
19 "Dr Bolsin told me that he would write to me in my
20 capacity as President of the Royal College, which he
21 did... I apparently responded by saying that I felt the
22 only way the Royal College of Surgeons would be able to
23 help would be through the Specialists' Advisory
24 Committee, who would look into the matter at their next
25 visit."
0141
1 A. Yes. That was completely erroneous.
2 Q. But it was obviously the impression that you had?
3 A. No, what happened, I think, was this: that when
4 I received the letter from Mr Harvey, some years had
5 intervened and I really was not sure about the details
6 of the whole case. So I phoned up Dr Zorab and asked
7 him whether he could remind me what had happened and
8 what I had done, and a lot of what I am reporting in the
9 letter was a consequence of the telephone conversation
10 that he and I had. It turned out that he was equally
11 uncertain, as I was, and in fact got the timing wrong
12 I think by two years, but two days after that first
13 letter to Mr Harvey, I then really set about trying to
14 find the correspondence, which at one time I thought had
15 all been destroyed. In fact, I found it, and I wrote
16 a second letter to Mr Harvey, and I said "Please
17 disregard what I have written, because I believe most of
18 it is erroneous".
19 The Specialist Advisory Committee should have been
20 there, the Supra Regional Services Advisory Group,
21 I think. This is basically what Dr Zorab was telling me
22 that he thought I had done.
23 Q. Yes, but what I am asking you about, you see, is your
24 recollection, bearing in mind there is no response on
25 file from you, it appears, to Dr Zorab beyond the letter
0142
1 I have just shown you, saying "I will come back to it
2 later. I am off on holiday and I will get back to you"
3 and your recollection here in the witness-box is that
4 there had been some further correspondence, you cannot
5 say quite what.
6 I am asking you now about this: your recollection
7 was, after speaking to Dr Zorab, and before you looked
8 at the contemporaneous documents, that you had indeed
9 gone back to him and said something to the effect that
10 the Royal College would be able to help through the
11 Specialist Advisory Committee?
12 A. Yes. I must have said something like that.
13 Q. Would that not be, forgive me, really a totally
14 inappropriate way of dealing with an urgent issue such
15 as this?
16 A. That is why I said earlier, Mr Langstaff, that I think
17 that what was meant here was the Supra Regional Services
18 Advisory Group and not the Specialist Advisory
19 Committee.
20 Q. So why do we have the words, "look into the matter at
21 their next visit"?
22 A. I do not know.
23 Q. Because that must relate to the Advisory Committee, must
24 it not?
25 A. I do not know, but I do think that at this time memory
0143
1 was really not very clear about what had taken place,
2 and this is what I thought the situation was, having
3 spoken to Dr Zorab. Clearly, it was wrong and I stated
4 that two days later, and I think it would perhaps be
5 better to concentrate on that and what I did actually
6 know to be true.
7 Q. Do I take it, because you have not answered the question
8 I asked a moment ago, that your answer is that it would
9 indeed be inappropriate to leave a matter like this to
10 be dealt with by the Specialist Advisory Committee?
11 A. Absolutely.
12 Q. Can we look at your impression, in the last sentence of
13 that same letter:
14 "Certainly my impression from Dr Zorab's letter
15 was that there was no great urgency."
16 Of course, you were not looking at the documents
17 at the time?
18 A. No.
19 Q. But you accepted a moment ago that indeed, re-reading
20 the letter, there plainly was urgency?
21 A. Yes.
22 Q. What the Royal College of Surgeons would do, therefore,
23 would not be to leave it for a body that would come
24 along, and as we know, the next visit was not going to
25 be until 1994, because we saw the report on Thursday?
0144
1 A. Absolutely not.
2 Q. It would have to be much more immediate and forceful
3 action, I suspect. You are agreeing?
4 A. Yes.
5 Q. So what would the Royal College of Surgeons do that was
6 immediate and forceful?
7 A. What I did do. I got the letter which was written to me
8 in my capacity as President of the Royal College of
9 Surgeons. It was forwarded on to me by the new
10 President, Norman Browse, asking whether I knew anything
11 about it, because he clearly did not. I am not sure
12 exactly when I received Dr Zorab's letter, but it
13 probably would have been somewhere around -- I would
14 have to look at my documents. It is there, but the
15 important --
16 Q. We may be able to help. If you have a look at
17 RCSE 2/191 --
18 A. I would like to come back to the timing involved during
19 this week, if I may, some time, Mr Langstaff, because
20 I think it is important.
21 Q. Certainly. The letter we have seen from Dr Zorab
22 arrived at the Royal College of Surgeons because it is
23 date stamped on 17th July?
24 A. Yes.
25 Q. On 21st July, Professor Norman Browse writes to you
0145
1 having been involved with this problem so far and
2 plainly this problem must relate to an enclosure?
3 A. Yes. That was Dr Zorab's letter.
4 Q. So he sent you a copy of the letter?
5 A. Yes, and the Private Eye.
6 Q. So he had seen it and read it and he is saying, "What do
7 you make of it?"
8 A. He passed it on to me as the immediate past President
9 and as a cardiac surgeon and the date he wrote it was
10 the 21st, so I would have received it, shall we say, on
11 22nd July.
12 Q. Or 23rd, it may be?
13 A. Or the 23rd.
14 Q. If we look at RCSE 2/192/193, you reply to Professor
15 Norman Browse. There is no date on it, or it may be
16 that in the photocopying someone has put a yellow
17 post-it or something, not us, over the date?
18 A. Can I say, Mr Langstaff, it is the same date as the
19 other letter which I dictated but was signed by my
20 Secretary, because I had left the country by the time it
21 was sent.
22 Q. Can we just have a quick look at that? That would be
23 RCSE 2/193. The date, "dictated 25th July", a letter of
24 the 27th?
25 A. Correct. It would be the same date.
0146
1 Q. So here you are, on 25th July, dictating a letter?
2 A. That was a Saturday morning, and I was leaving for
3 Pakistan that evening.
4 Q. You send it off to Professor Browse. The second
5 paragraph:
6 "Although I was aware that Bristol was not one of
7 the best paediatric cardiac surgical centres, I had not
8 appreciated that the situation was as serious as
9 described by John Zorab."
10 A. Yes.
11 Q. Pausing there, you are, I think, of South African
12 origin, or upbringing?
13 A. Yes, I am.
14 Q. Englishmen are often accused of understatement.
15 Somebody with English restraint, using the expression
16 "Bristol was not one of the best paediatric cardiac
17 centres", may mean something far worse than that. Did
18 you?
19 A. No. That was a fair reflection of my view at that
20 time.
21 Q. You "had not appreciated that the situation was as
22 serious as described by John Zorab". That might imply
23 that you had understood that the situation was serious
24 to some extent?
25 A. No, I had not got a view on that before I received this
0147
1 letter.
2 Q. So that is just a form of words?
3 A. Yes.
4 Q. You then described your discussion with Professor David
5 Hamilton from Edinburgh, who was Chairman of the recent
6 report. You note the report is to be considered on
7 28th July, which would be the Tuesday:
8 "Bristol is included as one of the centres for
9 designation. Clear from the review of table 1 in the
10 report that their mortality statistics both for the
11 infant age group and the older age group is worse than
12 any other centre. David Hamilton agrees that sufficient
13 attention was not paid to this by his Working Party."
14 With that in mind, can we look back and see what
15 those statistics were? It is at RCSE 2/165, where it
16 begins and we find the figures, table 1 is at 169.
17 If we go down to the third from the bottom, the
18 mortality, across the board, 38 per cent open operations
19 in 1988; 38 per cent, 1989; 13 per cent, 1990; 13 per
20 cent, 1991.
21 If one looked at the 1988 column, it is obviously
22 out of step with any other centre, bar perhaps Harefield
23 and perhaps Guy's. In 1989 it appears to be undoubtedly
24 the worst in the country, probably by a factor of
25 about 2, roughly.
0148
1 1990, 13 per cent, well within line; 1991, 30 per
2 cent, again, very much the worst in the country, on
3 those crude statistics?
4 A. Except that we do not have information from Newcastle or
5 Guy's or Oxford or Leicester, and incomplete returns
6 from the Brompton.
7 Q. So these are the figures that you subsequently described
8 as "disturbing". I asked you about that on Thursday.
9 A. Yes.
10 Q. And figures of this ilk, I take it, fit with what you
11 were telling us half an hour or so ago, that they demand
12 further investigation?
13 A. Correct.
14 Q. I take it you viewed those seriously?
15 A. Yes, I did, because I had forwarded the report on to the
16 Department, to Dr Halliday. I had looked at table 1.
17 I had not analysed it as carefully as I should have.
18 I saw that there were a lot of data missing from
19 a number of the units. I noticed the high mortality at
20 Harefield throughout. I knew that the explanation for
21 this was that Professor Yacoub did indeed receive a lot
22 of complex stuff. The Guy's figures, such as they were,
23 were disturbing but then there were gaps over two of the
24 four years. It was when I received Dr Zorab's letter
25 that I went back to the report and, taking the two
0149
1 together, I felt that there was sufficient concern here
2 that if we had allowed Bristol to go ahead and be
3 designated, as the report was suggesting, that this
4 would reflect badly on the whole service, or could, and
5 that it was therefore better to de-designate Bristol or
6 to recommend that it be de-designated. This is what
7 I discussed with Professor Hamilton.
8 Q. If I can get the pattern right, you have the report.
9 You did not focus particularly on table 1. You
10 recognise in retrospect perhaps you should have done,
11 but you did not?
12 A. That is right.
13 Q. When you were prompted by Dr Zorab's letter, you then
14 went back to table 1 and looked at it more carefully?
15 A. Yes.
16 Q. What you looked at was, to you, disturbing?
17 A. Not taken in conjunction with Dr Zorab's letter, yes.
18 Q. Taken in conjunction with the letter, not just the
19 figures on their own?
20 A. No, because the figures on their own, all they can do is
21 to suggest that there could be a problem there. They
22 are very crude. They are dealing with very small
23 numbers. They fluctuate. It is of concern; it needs
24 further investigation.
25 Q. So the figures on their own required further
0150
1 investigation?
2 A. Yes.
3 Q. And it was the combination of the figures on their own
4 which required further investigation and the concerns
5 relayed to you by Dr Zorab, that led you to suggest
6 these concerns were so great that Bristol should be
7 de-designated as a centre?
8 A. Yes.
9 Q. I have it right, have I?
10 A. Yes.
11 Q. So what follows in your letter -- let us go back to
12 RCSE 2/193, the bottom of the third paragraph:
13 "It is clear from a review of table 1 in the
14 report that their mortality statistics, both for the
15 infant age group and the older age group, is worse than
16 any other centre."
17 A. I think I was incorrect there. It was not correct to
18 say that mortality in the older age group was worse than
19 any other centre.
20 Q. "David Hamilton agrees that sufficient attention was not
21 paid to this by his Working Party."
22 So you spoke to David Hamilton?
23 A. Twice, on the telephone.
24 Q. And the upshot of that was that he agreed with you that
25 they should have paid more attention to the mortality
0151
1 statistics?
2 A. And that it would be right to de-designate Bristol -- to
3 recommend de-designating Bristol.
4 Q. So I understand the basis upon which you were suggesting
5 de-designation: was that because, as you emphasised
6 throughout your evidence to us, that one would want to
7 consider outcomes and mortality data and so on to see
8 whether small numbers meant that a unit was not really
9 viable, or was it because to allow Bristol to go forward
10 might prejudice the chances of the others?
11 A. It was both, I think.
12 Q. Because the one you select in your letter is actually
13 the latter of the two. There is nothing in your letter
14 about how awful it is for Bristol to do the work, as it
15 were, given the concerns and given the figures, even
16 though we may not know everything there is about those
17 figures?
18 A. Yes, but I am saying early on, the mortality, both for
19 the infant age group and the older age group, is worse
20 than any other centre.
21 Q. So you then record that you spoke to Norman Halliday,
22 who was to inform the Supra-regional Services Group that
23 the College did not support the inclusion of Bristol?
24 A. Yes. The time constraints were difficult here, in that
25 with Dr Zorab's letter arriving on the Tuesday or the
0152
1 Wednesday, I had to get the report, look through it,
2 speak to Professor Hamilton on the Thursday and Friday,
3 I believe it was. He agreed that I should phone
4 Dr Halliday and explain matters to him, because he had
5 the report; it was being discussed the following
6 Tuesday. I was not going to be there. And that he
7 would just simply say to the Advisory Group that the
8 Working Party did not recommend that Bristol be included
9 for continued designation.
10 Q. Can I ask you to have a look at WIT 71/47, please: your
11 handwritten notes.
12 A. Yes.
13 Q. Made at the time?
14 A. Yes.
15 Q. May I gently ask, when, later on, as we have seen, Nick
16 Harvey wrote to you, and you were trying to reconstruct
17 matters in your mind and you did not have the
18 correspondence to hand, where were your notes?
19 A. My notes at that time were in about 16 large box files
20 of correspondence which had been removed from my office
21 at Papworth when I retired on 30th September 1995, and
22 were sitting in the back of my office in St Catharine's
23 College, and it had been both my secretary's and my
24 intention to go through all this correspondence and
25 throw out what was not needed. It went back a long way
0153
1 and there were many different subjects. It was in one
2 of those box files.
3 Q. The phone calls that you had with Professor Hamilton:
4 you say you had two phone calls?
5 A. Yes.
6 Q. And that is 23rd and 24th July?
7 A. I think so.
8 Q. The notes:
9 "Heard figures were pretty bad down there."
10 Who is speaking?
11 A. I am making a note that David Hamilton, in response to
12 my talking to him, had said that he had heard that
13 figures were pretty bad down there. I think.
14 Q. "And they had to chase Bristol for them", that is
15 a reference to figures, presumably?
16 A. Yes.
17 Q. That, as it happens, appears to tie up with what Private
18 Eye had been suggesting: the figures had not all been
19 supplied or there had been some supplying figures?
20 A. I do not know.
21 Q. You cannot comment. The reference to Dhasmana -- what
22 has been blanked out on the screen is the phone numbers,
23 so there is no misunderstanding about it. What
24 reference is that?
25 A. I really cannot remember, but it may have been that
0154
1 Professor Hamilton suggested that I could get further
2 information from Dhasmana. I honestly do not know.
3 I do not remember.
4 Q. The bottom of the page:
5 "Need to phone Norman Halliday."
6 A. Yes.
7 Q. What then follows, that is a note of a conversation with
8 whom, when?
9 A. I think this is all still with Professor Hamilton. We
10 agreed that I would need to phone him. He went on to
11 say that it had been known for a long time that some
12 centres were not performing as well as others.
13 Newcastle and Leeds were mentioned, but that they had
14 improved.
15 The next comment which I think probably came from
16 him was that the impression was that Bristol had failed
17 to develop the paediatric services.
18 Q. Then he quoted some particular statistics?
19 A. Yes.
20 Q. "Simple operations", 0 per cent would rate mortality,
21 would it?
22 A. Yes. I think these were mortalities which he may have
23 had access to which I certainly did not.
24 Q. But they are quite surprising, are they not, as
25 figures?
0155
1 A. Yes. The Fallot's mortality is high. It is overall.
2 I presume that included infants and older children. The
3 total atrioventricular canal was high, 54 per cent.
4 Double outlet right ventricle, not too far out of line,
5 but high. Corrective transposition of the arteries, it
6 could have been one or two cases, I do not know, a very
7 difficult condition. The Fontan operation, again,
8 a complex procedure with a high operative mortality.
9 Q. So at this stage you had not only discussed, had you, or
10 at least, by the time you finished your two phone calls
11 to David Hamilton, you had not only discussed your view
12 of what the table itself showed, but you had had the
13 additional advantage of these further statistics?
14 A. Yes.
15 Q. Which would have confirmed, I take it, the view that you
16 had come to about the statistics needing a very clear
17 explanation?
18 A. Yes.
19 Q. I am asked to say by Mr Maclean, "JW", that is
20 a reference to James Wisheart?
21 A. Yes.
22 Q. So you and he, that is David Hamilton, agreed that on
23 the basis of this material, which he confessed he had
24 not looked at perhaps as closely as he might have done,
25 that really Bristol ought not to be a designated centre?
0156
1 A. Yes.
2 Q. And that was partly upon the basis, at any rate, of its
3 poor record in terms of outcome?
4 A. Yes. But the reason which had brought it to my
5 attention was Dr Zorab's letter.
6 Q. I appreciate that. You then phoned Halliday?
7 A. Yes, because there was not time, at that stage, for him
8 to discuss things with the other members of the Working
9 Party, and I think Sir Keith was away at the time, I am
10 not sure, but anyway, time was running out. The meeting
11 was on Tuesday. I was not going to be there, and it
12 seemed to me that it would be reasonable to take
13 Chairman's and President's action and bring this to the
14 attention of Dr Halliday.
15 Q. And you told Dr Halliday, did you, of the reasons as you
16 have explained them to us?
17 A. Yes, indeed. Absolutely.
18 Q. Did you tell Dr Halliday that Bristol's mortality record
19 appeared so bad that it required investigation?
20 A. I believe I told him the content of my discussions with
21 Professor Hamilton.
22 Q. Did you tell him about the Zorab letter?
23 A. Yes, I believe so.
24 Q. Did you tell him about the Private Eye article?
25 A. I do not know whether I did or not.
0157
1 Q. When you saw what had been minuted in the minutes,
2 which, as you have already indicated, was to the effect
3 that you no longer supported the inclusion of Bristol --
4 just that -- were you surprised?
5 A. Well, I was. I was very concerned about the fact that
6 the Department had -- well, that the Supra Regional
7 Services Advisory Group had gone against the
8 professional advice which they had sought and had
9 decided to de-designate Bristol.
10 The fact that my concerns were expressed as gently
11 as they were in the minutes was also of concern.
12 Q. I think there may be an error in what you meant to say
13 a moment ago. When you say "de-designate Bristol", you
14 meant de-designate the service?
15 A. De-designate the service, thank you.
16 Q. When you say you were surprised that your concerns were
17 raised as gently, you expected, did you, that what you
18 had said would have been raised before the whole group,
19 so that they knew what the position was at Bristol?
20 A. Well, not really, because I do not think that it was
21 possible for Dr Halliday to be as frank as that, because
22 by this time Professor Hamilton had, in consultation
23 with the other members of his Working Party, decided not
24 to follow what we had agreed to, but to let the report
25 remain as it was. And Dr Halliday had been informed of
0158
1 that on the Monday by Sir Keith Ross and he had been
2 relieved to hear it, so the report that went through for
3 consideration by the Supra Regional Services Advisory
4 Group had Bristol in it.
5 Q. When you said a moment ago that you were surprised that
6 your concerns were down-played -- that is my word,
7 I think reflecting the sense of what you were saying --
8 what did you expect to see minuted?
9 A. I do not know what I expected to see, I was just
10 interested to see what had been, during my absence.
11 Q. Following on from your conversation with Dr Halliday,
12 what would you expect to have been said, broadly?
13 A. It is difficult to answer that because as I have already
14 said, by this time my agreement with Professor Hamilton
15 no longer stood. If he had said that I was strongly
16 against the continued designation of Bristol, and the
17 report had been forwarded by me as President during my
18 term as President from the Working Party to the Advisory
19 Group, and it included Bristol, it would have looked
20 odd.
21 Q. So you do not think it was open to him to say, "Well,
22 this was forwarded to me by Sir Terence; he indicated to
23 me in a letter that the College supported it; he has had
24 a telephone conversation with me since in which he says
25 he has had cause to review the mortality statistics. He
0159
1 is very concerned about Bristol remaining a designated
2 centre. He no longer for his part supports it. You
3 ought to know his view because he is a member of the
4 committee"?
5 A. That would have been a fairer representation of what had
6 taken place.
7 Q. Dr Halliday, for his part, maintains stoutly that you
8 never said anything to him about mortality statistics at
9 all.
10 A. It was the only reason why I would have ever got into
11 this. The report had gone on, gone through. The
12 activity figures were all there. We were not
13 questioning those. The whole issue of having to do
14 something at such short notice arose through Dr Zorab's
15 letter and a review of mortality statistics and that was
16 made absolutely clear to -- and that was -- I mean,
17 again, the reason for Professor Hamilton reconsidering
18 his position, I mean, he must have -- he may have
19 forgotten it, but that was the reason for ...
20 Q. Do you normally take notes of the sort you have shown us
21 here of the telephone conversations which you have?
22 A. Yes, I do.
23 Q. We do not have one of the conversation with Dr Halliday,
24 do we?
25 A. No.
0160
1 Q. Do you know what has happened to it?
2 A. I do not know. I presume I never took one. I was
3 surprised to find these.
4 Q. May I just go over one question and answer, to make sure
5 we have what you want to say? Do you remember a moment
6 or two ago you answered me by saying "It was the only
7 reason I would ever have got into this. The report had
8 gone on, gone through, the activity figures were all
9 there, we were not questioning those. The whole issue
10 of having to do something at such short notice arose
11 through Dr Zorab's letter and a review of mortality
12 statistics and that was made absolutely clear to ..."
13 and then you do not say who it was made absolutely clear
14 to?
15 A. Well, it was to both Professor Hamilton in the first
16 instance, and then, following having talked to him, to
17 Dr Halliday.
18 MR LANGSTAFF: Sir, would that be an appropriate moment for
19 a short break?
20 THE CHAIRMAN: Yes. Shall we say 15 minutes, then, and
21 reconvene at 3.45? Thank you.
22 (3.30 pm)
23 (A short break)
24 (3.45 pm)
25 MR LANGSTAFF: Could we have on the screen RCSE 2/210. The
0161
1 next you knew, as I understand it, about what had
2 happened was when you came back from Pakistan?
3 A. Yes.
4 Q. Did you receive the letter which we see here dated
5 3rd August, if you just scroll up for the date, and it
6 is from David Hamilton in the Department of Surgery,
7 Lawrenston Place, Edinburgh?
8 A. Yes.
9 Q. It sets out in the middle paragraph, please, the fact
10 that you had the telephone conversations on the 23rd and
11 Friday the 24th, that Mr Hamilton was not happy about
12 the agreement to take Presidential and Chairman's
13 action. You realised there was a possible specific
14 source of breach of confidentiality which could arise,
15 and a further feeling that the de-designation of one of
16 the units would probably leak out in the course of time.
17 It adds that the Working Party had given
18 considerable thought, were unable to contact Keith
19 Ross. Then it says this:
20 "He [that is Keith Ross] was equally concerned
21 that we had changed the report and suggested on
22 reflection that we should both speak with Norman
23 Halliday to reverse the decision and the instructions
24 that you had given him."
25 "We should both speak". The "we" there? What did
0162
1 you read that as being?
2 A. That was he and Sir Keith.
3 Q. "The report is an advisory document to be considered
4 along with other letters and reports, both in...
5 [whatever it is] and hearsay evidence no doubt and as
6 such the Working Party could be requested by the
7 Advisory Committee to reconsider the mortality figures
8 of specific units (or unit) and possibly to amend its
9 findings."
10 That sentence reads possibly as report speech.
11 This was the attention of the David Hamilton and
12 Sir Keith Ross in speaking to Sir Norman Halliday. It
13 may on the other hand read as an expression of his,
14 David Hamilton's view. Which way did you take it,
15 knowing David Hamilton as you do?
16 A. I assumed that the two of them had spoken and had
17 suggested this as a possibility and that they were both
18 agreed on the way forward of asking the Supra-regional
19 Advisory Committee to perhaps look at Bristol again in
20 view of the fact that they were recommending that it was
21 to be continued to be designated, because in the event,
22 they did not know that the whole service was going to be
23 de-designated.
24 Q. It records that Keith, Sir Keith Ross, rang Halliday and
25 put the suggestion to him. The suggestion would appear
0163
1 to be that the Working Party could be requested to
2 reconsider the mortality figures of specific units?
3 A. Yes.
4 Q. It then describes Halliday's reaction to that, and if
5 you turn over the page to 211, his next dilemma was
6 whether to try to contact Norman Browse to appraise him
7 of the change of plan, and he suggests that you should
8 do that, presumably because Norman Browse was acting in
9 his capacity as President?
10 A. He was then the President.
11 Q. And he referred the letter on to you as such?
12 A. Yes.
13 Q. He identifies to whom he has spoken. The last sentence:
14 "This is a contentious issue and I hope you will
15 understand my actions in your absence."
16 Is that to describe the whole process as you
17 understood it of your deciding to take action and then
18 his second-guessing, having second thoughts about that?
19 A. Yes, that is the way I read it.
20 Q. Apart from that reference to mortality, we found it
21 difficult to find any record that you personally made of
22 having ever written anything at the time drawing
23 specific attention to the mortality figures at Bristol.
24 Did you ever write to any person in the Department
25 of Health to draw their attention to the mortality
0164
1 figures at Bristol?
2 A. No. The only things that I wrote relating to it are in
3 the correspondence that you have.
4 Q. Did you, or for that matter Professor Browse, so far as
5 you know, ever think that you might have phoned or
6 written to the Chairman, of, be it the region or the
7 UBHT, to tell them that this problem had been brought to
8 your attention?
9 A. No, that certainly did not cross my mind.
10 Q. Why not?
11 A. I felt that the Medical Secretary of the Supra Regional
12 Services Advisory Group understood our concerns, and
13 that it was up to him to take it up with the Trust and
14 if the Trust then wanted to look at matters further,
15 they could ask us either directly or through the Supra
16 Regional Services Advisory Group.
17 Q. In each of the other cases, where you had had
18 a complaint coming to you in this way, the three other
19 cases or thereabouts in your tenure of office, the Trust
20 or the health authority had been notified, you have told
21 us?
22 A. It was usually the Manager or the Chief Executive of the
23 Trust who approached me in the first instance. These
24 were not supra-regional services.
25 Q. If it had not been the Manager or the Chief Executive,
0165
1 it would have been part of the role and function, would
2 it not, of the Royal Colleges to tell local management
3 so that local management might deal with it?
4 A. Yes. I do not think that we had sufficient evidence at
5 that stage, or indeed that it was ever within the
6 authority of the College to tell management of Trust
7 hospitals something like this. This is a report that
8 had been commissioned by the Supra Regional Services
9 Advisory Group. This was the central NHS authority, and
10 I felt pretty sure myself that the communication should
11 go through them, not direct from the College.
12 Q. Was there anything which prevented you, or for that
13 matter, Norman Browse, from telling the Trust or the
14 region that concerns had been expressed which appeared
15 on the face of them to be supported by crude data,
16 therefore requiring investigation?
17 A. I do not think there was anything preventing that from
18 happening. It certainly did not cross my mind to do so.
19 Q. So what, in effect, prevented it happening, was that it
20 did not cross your mind, or probably Professor Norman
21 Browse's either?
22 A. Yes, and if it had, I am not sure I would have
23 considered it appropriate, for the reasons that I have
24 given.
25 Q. The meeting that followed, the Supra-regional Services
0166
1 meeting, on 28th July, you subsequently got the minutes
2 of?
3 A. Yes.
4 Q. If we can just look at that, it is DOH 2/99. I have
5 foreshadowed what appears at 4.1.2:
6 "Dr Halliday reported that he had been approached
7 by Sir Terence English who indicated he now had
8 reservations about the continued designation of the
9 Bristol unit."
10 4.1.3:
11 "The Advisory Group discusses the issue at length
12 but concluded that it was unrealistic to expect to
13 restrict the delivery of the service to those units for
14 which the Royal College of Surgeons' report recommended
15 continued designation. To ignore the delivery of the
16 service in non-designated units would be quite contrary
17 to the previously stated views and policy of the
18 Advisory Group."
19 I wonder if we could go split screen, please, with
20 WIT 71/53. Again, we have your handwritten notes here.
21 I think these are notes which you made in response to
22 having received these minutes, are they?
23 A. Yes. I think I made them in preparation for the next
24 Supra Regional Services Advisory Group meeting, which
25 was to be held on 29th September.
0167
1 Q. You refer at the bottom of the page, under item 6 on the
2 right-hand side, if we put yellow round that:
3 "See minutes 4.1.3, to ignore the delivery of the
4 service in non-designated centres", and you would be
5 making the point that you would not be, because it was
6 small, it was only 12 per cent?
7 A. This was a continuous issue, I am afraid, between the
8 views of most paediatric cardiac surgeons and the
9 Supra-regional Advisory Group, that many of them felt
10 that it was unrealistic to believe that all neonatal and
11 infant surgery could be concentrated into the designated
12 unit and as long as the great majority of it was there,
13 that was the best that could be achieved.
14 Q. You set out, at the bottom of the page, in your
15 handwriting, a quote from "dedesignation being a fairer
16 decision in terms of medical and surgical rights". You
17 say you must challenge that.
18 Does it follow that you, as I think with every
19 witness that I have asked about this so far, do not
20 understand the logic in that sentence?
21 A. Correct.
22 Q. Can you tell me, when you did challenge it, as you must
23 have done when you spoke to it at the next meeting, was
24 there any attempt to justify that as a statement?
25 A. I honestly cannot remember whether I did indeed
0168
1 challenge this specific part of the minutes.
2 Q. Despite your bold capitals saying "MUST CHALLENGE"?
3 A. I would like to think that I did, but I cannot say that
4 I know I did. I cannot say that.
5 Q. Does it follow that you cannot remember any purported
6 justification for that apparently illogical view?
7 A. Could you repeat that?
8 Q. Does it follow that you cannot recall any purported
9 justification for that apparently illogical view?
10 A. I think it does follow, yes.
11 Q. The outstanding issue, if we look at the left-hand side,
12 DOH 2/99, was when the service would be de-designated.
13 Am I right in thinking that you and others sought
14 to delay de-designation of the service?
15 A. Yes. I think when I went to the September meeting,
16 I still had hopes that indeed it might be possible to
17 reverse the July decision. I cannot remember exactly,
18 but some of my notes would suggest that. But certainly
19 the information that had come through from the August
20 meeting of the British Paediatric Cardiac Association,
21 was that the view was, "Well, if de-designation is
22 likely to happen, please do not let it be in too much of
23 a hurry". I think I was reflecting that.
24 Q. So the consequence of that would be that you, for your
25 part, had appreciated a problem with Bristol which
0169
1 required investigation, amongst other things?
2 A. Yes.
3 Q. It was sufficient of a problem, taken in the light of
4 Dr Zorab's letter, for you to consider, in your own
5 mind, that Bristol should be de-designated?
6 A. Yes.
7 Q. Whatever else happened to the other units?
8 A. Yes.
9 Q. By asking for the service to go on being designated for
10 a further year, beyond a potential cut-off date of April
11 1993, you were in effect asking, were you not, for
12 Bristol to go on being designated for yet a further year
13 until 1st April 1994?
14 A. Yes. And hopefully, during that time the mortality
15 could be reinvestigated.
16 Q. And knowing, therefore, that Bristol was not going to be
17 closed or shut or prevented from operating, whether by
18 financial or any other means, arising out of the Supra
19 Regional Services Advisory Group, until 1st April 1994,
20 if then, it was, was it, important to make sure that
21 others knew sufficient of the problem at Bristol for
22 those enquiries to be made?
23 A. Yes.
24 Q. The meeting in September -- it is DOH 2/154; we can go
25 single screen -- you attended as the last meeting,
0170
1 I think, of the group that you attended?
2 A. Yes.
3 Q. Just to pick up on what had happened before that, very
4 briefly, if I may, I will flick through some letters.
5 RCSE 2/200. The second paragraph ... you wish to speak
6 to the de-designation of the whole service, you say, in
7 looking through the minutes.
8 The next is 2/202: a reply back from Mr Owen as
9 Secretary, noting your wish to speak.
10 2/205: a letter to Sir Michael Carlisle, again
11 dealing with de-designation of the whole service and
12 wanting to speak to that.
13 So each of these three letters, two letters from
14 you, one letter to you, indicates that you wanted to
15 speak on the issue.
16 The issue to which you wish to address your
17 remarks was the de-designation of the service?
18 A. Correct.
19 Q. None of those letters says anything about the particular
20 position of Bristol, or the particular reasons why the
21 to and fro over Bristol had arisen in July, do they?
22 A. No.
23 Q. And your notes that we have already looked at, to which
24 you were going to speak at the meeting in September,
25 also do not say, or do not record, anything to show that
0171
1 you raised your personal concerns about the need to
2 investigate mortality at Bristol.
3 A. I think I had already been told by Dr Halliday, when
4 I phoned him after I got back from Pakistan, because
5 I obviously wanted to talk to him about the meeting,
6 I was so concerned with what had happened, and I think
7 that he had said that he had mentioned to the group at
8 the meeting when I was not there, that my view was that
9 Bristol should be looked at again.
10 Q. Just that?
11 A. Just that.
12 Q. So it followed that no-one in the group knew, because
13 from what you understood, Dr Halliday had not told them,
14 that you had serious concerns arising from respectable
15 sources as to the performance of Bristol?
16 A. I certainly would have assumed that Dr Halliday would
17 have discussed it with the Chairman and the other
18 Secretary. I would have assumed that they would have
19 known about it.
20 Q. Did you ever ask the other Secretary to see whether that
21 was so?
22 A. No.
23 Q. Or the Chairman?
24 A. No.
25 Q. So it might well have been that he did not?
0172
1 A. It might well have been.
2 Q. And if I can put a hypothetical to you, ultimately
3 mortality statistics are compiled from, about the deaths
4 of patients and if a unit is performing particularly
5 badly, then it may suggest, once one has looked at the
6 statistics, that there is a situation in which more
7 people are dying than need to, for whatever reason?
8 A. Yes.
9 Q. So however one treats it, it is a serious issue?
10 A. Yes.
11 Q. You have told us already you did not think to raise it
12 more formally with the Trust. Did you think to raise it
13 in conversation at the group, amongst the group
14 members?
15 A. I did not. I think that my attitude at the time must
16 have been that I had already stuck my neck out to the
17 extent of saying that I thought that Bristol should be
18 de-designated because of concerns about its mortality
19 statistics; that this had been brought to the attention
20 of the Department of Health and that, it being one of
21 the units within the designated service, it truly was up
22 to them to deal with this problem.
23 Q. It will be said of you, Sir Terence, that you gave no
24 follow-up at all after your phone call with Dr Halliday
25 to pursue the concerns that had been expressed through
0173
1 Professor Browse to you as past President of the
2 RCSE about the quality of surgery in Bristol. Would you
3 accept that?
4 A. I think that my last meeting of the group, I certainly
5 spoke to my concerns about the de-designation of the
6 service. I do not think I did mention Bristol
7 specifically at that time. That is where the matter
8 rested. I then left the group. I know that Professor
9 Browse knew of my concerns, but I think he did not feel
10 any need to take them any further forward, and indeed,
11 should not have, unless I had specifically asked him to,
12 and I did not.
13 Q. Because he left them with you?
14 A. Yes.
15 Q. So it was, as it were, your responsibility?
16 A. Correct.
17 Q. And you had expressed them orally to Dr Halliday, but
18 not otherwise?
19 A. Right.
20 Q. And never, it seems, from what you have said, thereafter
21 expressed those concerns?
22 A. That is right.
23 Q. Do you think, perhaps, that you ought to have done so?
24 A. I think it is a difficult question. I think that
25 I probably should have written at least to the Chairman
0174
1 of the group, Sir Michael, formally about it, if I had
2 not brought it up to the open meeting, the last one
3 I attended. I suspect that probably is what I should
4 have done.
5 Q. Although it may be difficult now in retrospect to say
6 why you did not, can you help as to why you might not
7 have done?
8 A. I think I was very cross that the group had failed to
9 accept the very considered advice of the professional
10 working party that they had commissioned. That may have
11 had something to do with it.
12 Q. So you felt outwith the group?
13 A. I did, rather.
14 Q. You simply did not think about raising the issue
15 anywhere else?
16 A. No. No. And would not. As I say, I think the right
17 thing probably would have been to have written formally
18 to Sir Michael.
19 Q. When you left the group, did you get the minutes that
20 came through?
21 A. No, not of the last meeting.
22 Q. So they would have gone to Professor Browse?
23 A. The College of Surgeons, yes.
24 Q. Did he ever come back to you and say, "Well, we did
25 speak about this; there is nothing in the minutes of the
0175
1 group about the letter you got from John Zorab which
2 I passed on to you, expressing those serious concerns;
3 what has happened?" No conversation like that?
4 A. I do not think so.
5 Q. One of the matters which is raised by Norman Halliday's
6 evidence is his suggestion that not only did you not
7 mention the matters to the group, or not only did you
8 not mention matters in writing, or at any stage after
9 the phone call you say you had with him, but he tells us
10 you never mentioned them to him during that phone call
11 either.
12 Do you think he may be right about that?
13 A. I think he is wrong, and I think the evidence of the
14 correspondence with the various parties confirms that.
15 Q. He also says that at a very early stage, when the
16 supra-regional service was being performed in the first
17 place, you had indicated to him that Bristol would have
18 the support of the Royal Colleges to develop, and it
19 follows, therefore, that that played some part in the
20 designation of Bristol in the first place, in 1983/84.
21 What do you say about that?
22 A. I do not recall this, I am afraid. I suspect if he said
23 it, that is true. I do not recall in what context I was
24 thinking. We did, as I mentioned, have one of their
25 Senior Registrars training with us subsequently.
0176
1 Q. You mentioned that the other day, but the passage --
2 I ought to put it to you clearly, so you can have
3 a chance to deal with it -- from Mr Halliday's evidence;
4 it is Day 13. I am sorry, I have to read it to you. It
5 is Day 13, page 33, the beginning of line 20. He had
6 just been asked:
7 "Would it follow from that that a unit such as
8 Bristol doing the small numbers that it was in 1983/84
9 was unlikely to grow very significantly over the next
10 few years?"
11 That was my question to him. His answer:
12 "If there were no other factors, but with the
13 assurance from the Royal College that they were going to
14 do what they could to strengthen the unit, then there
15 was every prospect that there would be a change in the
16 referral pattern.
17 "Question: So what you are saying is, really,
18 well, the Advisory Group were looking at this as
19 a matter of their own experience, and the criteria,
20 Bristol would not qualify except on geography, and
21 geography depends upon the quality being maintained and
22 improved. We are assured by the Royal College of
23 Surgeons that they are going to do their --
24 THE CHAIRMAN: Mr Langstaff, you may be going a little too
25 quickly, currently. We really need this, so perhaps
0177
1 a little more slowly for the stenographer.
2 MR LANGSTAFF: Thank you, Chairman. My question to him:
3 "So what you are saying is, really, well, the
4 Advisory Group were looking at this as a matter of their
5 own experience, and the criteria, Bristol would not
6 qualify except on geography, and geography depends upon
7 the quality being maintained and improved. We are
8 assured by the Royal College of Surgeons that they are
9 going to do their best to make sure that happens. Is
10 that essentially it?"
11 That was my question. His answer:
12 "That is essentially it."
13 A. Can you tell me the date --
14 Q. Then he says this:
15 "Do you remember who in the Royal Colleges you
16 spoke to at the time?"
17 Answer: Terence English, yes.
18 Question: Of course the discussion about the
19 units would be with the President at that time.
20 Answer: I cannot remember who it was that year."
21 That is in relation to 1983/84.
22 A. Yes. Well, I honestly cannot help you with that,
23 because I do not recall that conversation of 16 years
24 ago. I was on Council at the time. It is quite
25 possible that I suggested that I hoped the College would
0178
1 be able to help in some way, but quite in what way, I do
2 not know.
3 Q. Well, that was going to be the next question: if you did
4 say it, you have told us already, there was nothing
5 really the Royal Colleges could do?
6 A. Not a lot. Not in terms of performance within a unit.
7 Q. Can I, in the light of that -- it is going back on an
8 answer you made last Thursday: you were telling us then
9 that what the group could do was provide funding for
10 capital projects and in that way encourage the
11 throughput of patients, or encourage referrals?
12 A. Yes.
13 Q. Our information, and I just want you to have a look at
14 what we have and comment on it, is that the capital
15 funding did not begin until 1987. If we could have
16 UBHT 278/414 on the screen, it is paragraph 2:
17 "Health authorities were informed in January 1986
18 that capital allocations would be made under the
19 supra-regional arrangements for the first time in
20 1987/88 ..."
21 Have we understood that correctly: that this would
22 then be the first time that capital funding as opposed
23 to allocation on the basis of patient numbers would be
24 provided?
25 A. I am not sure that you have. It may be, but I had
0179
1 thought that we had got some capital allocations rather
2 before that time, at Papworth for the heart transplant
3 programme.
4 Q. There are one or two other matters which I need to
5 pursue with you, Sir Terence.
6 You have already dealt, I think to some extent,
7 with the events which took place after -- some time
8 after the events of 1992.
9 At some stage, I think in 1995, concerns were
10 being generally expressed about Bristol and the
11 performance and quality of outcome at Bristol.
12 Do you recall, in April 1995, 12th April 1995,
13 having a conversation with Mr Wisheart here in
14 Bristol -- I think you had given a lecture, and Roger
15 Baird is said to have been present as well.
16 A. I do not remember the nature of the conversation, but
17 please remind me.
18 Q. Mr Wisheart asked you, he being aware of the Zorab
19 letter, what you had said to Dr Zorab, and your response
20 is said to have been that you could not recall but you
21 probably asked him for more information.
22 What is your recollection?
23 A. I do not have any recollection of that conversation,
24 I am sorry.
25 Q. In 1996, in January, a letter was sent to you,
0180
1 PAR(1) 2/229. This was the first in a series of
2 letters. I think it was from Nick Harvey MP, raising
3 concern from his correspondence.
4 At the bottom of the page:
5 "I have received a letter from a Senior Medical
6 Officer at the Department of Health stating that 'The
7 Royal College of Surgeons was asked to advise the Supra
8 Regional Services Advisory Group only [underlined] on
9 whether the service for neonatal and infant cardiac
10 surgery should remain designated and funded as
11 a supra-regional service. Although the report listed
12 the then designated centres including Bristol Royal
13 Infirmary, there was no discussion of the results of
14 surgery for the different centres. In the event, the
15 [Group] decided to de-designate the service on the
16 grounds that service provision had expanded to the point
17 that it no longer met the very tight supra-regional
18 designation criteria."
19 Pausing there, is what the Senior Medical Officer
20 of the Department of Health is reported to have said
21 accurate or not?
22 A. Well, I think the first sentence is perhaps inaccurate,
23 but later on, where it says that there was no discussion
24 of the results of surgery for the different centres,
25 I think that was a true statement of what went on in the
0181
1 Advisory Group.
2 Q. So the "only" is too limiting, is it?
3 A. Yes. I mean, the terms of reference, as you have seen
4 from the documents, were not terribly precise about the
5 1992 report and tended to change a bit, but they were
6 certainly, I think, wider than is indicated in the
7 sentence.
8 Q. Then we see that you replied to that, PAR 1/8/78;
9 25th January. You point out many of your files have
10 been destroyed; you are trying to find out the
11 material.
12 PAR (1)8/89. We have looked at this already, but
13 we have not looked at the second page, page 90. You set
14 out what Dr Zorab had told you, at the top of the page?
15 A. Yes.
16 Q. I shall not trouble you with that. The second
17 paragraph:
18 "During the last year of your Presidency, you set
19 out the Working Party" -- that is the Working Party you
20 have been telling us about I think?
21 A. Yes.
22 Q. "At this time, this service was under threat of
23 de-designation from the Department of Health. The
24 Working Party looked at all the centres which included
25 Bristol and figures on mortality for operations were
0182
1 also obtained."
2 That is a reference, is it, to table 1?
3 A. Yes.
4 Q. "My recollection is that Bristol's results were towards
5 the bottom of the table, although I cannot be absolutely
6 sure of this."
7 No recollection, even four years on, that this
8 extraordinary series of events had taken place in July
9 1992 with the recommendation of the Working Party being
10 rewritten and then un-rewritten, and then concerns about
11 Bristol having been recognised by you?
12 A. No accurate recollections of that, certainly.
13 Q. Page 91: you set out I think that you have now found the
14 documents and read through them, and you have rewritten
15 your history really from the documents?
16 A. Yes.
17 Q. Does it follow that it is the documents that tell the
18 story rather than your recollection, or is it your
19 recollection as prompted?
20 A. No, absolutely the documents. Once I had access to all
21 the letters again and could remember what had happened
22 in the very brief time-scale in which it had happened
23 that I had demitted office as President, at the time it
24 all began to fit together again and that letter, as you
25 saw, was written two days after the first one, because
0183
1 I was very concerned that I may have given Mr Harvey the
2 wrong impression when I wrote the first time.
3 Q. I press you again on this. In the light of your obvious
4 uncertainties as to what had happened until you saw the
5 documents, are you still sure that you said to
6 Dr Halliday something about the mortality statistics at
7 Bristol and how disturbing they were?
8 A. Absolutely. There could be no other explanation of the
9 correspondence and what I had said there.
10 Q. You deal, page 8/92, with your view as to the
11 de-designation of Bristol. It is the fourth line down:
12 "I therefore informed the Department of
13 Health ..."
14 If I just read that out.
15 When you received Dr Zorab's letter, you reviewed
16 the statistics and it was clear they were disturbingly
17 high in comparison with the other units. You stand by
18 that, do you?
19 A. Yes.
20 Q. "In consultation with Professor Browse, I therefore
21 informed the Department of Health that it was the
22 College's view that Bristol should be de-designated,
23 along with two other units which we recommended be
24 de-designated on activity criteria."
25 It follows what you are saying there is that
0184
1 Bristol was to be de-designated on the basis of
2 performance criteria, rather than activity criteria?
3 A. Yes.
4 Q. Would you have on the screen, please, RCSE 2/209? The
5 second last paragraph. It is the third sentence:
6 "I considered that there was nothing further that
7 the Royal College of Surgeons should do as the
8 Department of Health had been made aware of our concerns
9 about the problems in Bristol."
10 You have spoken for yourself as to what you felt
11 you should have done but did not do. So far as the
12 Royal College of Surgeons is concerned, it would be
13 entirely in keeping with their role as arbiter of
14 standards and maintainer of standards to have written to
15 the Department of Health formally, would it not?
16 A. They might have done that. It would have been an
17 unusual move.
18 Q. But these were unusual circumstances, you have told us.
19 Do you know why it was not --
20 A. Yes, but it would have come -- I mean, Professor Browse
21 was the new President. He had left it to me to deal
22 with. I had dealt with the issue in the way that we
23 have described. My view was that there was nothing
24 further that the College should do about the matter and
25 that that was a view which he accepted.
0185
1 Q. What, you told Professor Browse there was nothing
2 further the College could do?
3 A. I do not know exactly what I told Professor Browse, but
4 I know I communicated with him about it. I do not
5 recall whether he -- I do not think he was at the
6 September Supra Regional Services Advisory Group
7 meeting, but I would have reported to him orally about
8 it after that, I am sure.
9 Q. You had finished your term at the Supra Regional
10 Services Advisory Group thinking to yourself, "Well, the
11 Department of Health know about the problem because
12 I have told Dr Halliday"?
13 A. Correct.
14 Q. That is the Department of Health that you refer to
15 there, is Dr Halliday, is it not?
16 A. Yes.
17 Q. So having left the Supra Regional Services Advisory
18 Group, you expected him to take matters further?
19 A. Yes.
20 Q. You never enquired whether he had?
21 A. No.
22 Q. Did it ever cross your mind afterwards that you had not
23 heard anything about Bristol, and it was perhaps a bit
24 surprising that you had not?
25 A. No, it did not, actually. I had many other things.
0186
1 Q. Is it perhaps the number of other things you had to deal
2 with that may have diverted or occupied your attention
3 elsewhere?
4 A. Yes. I think that when I finished with that last
5 meeting with the Advisory Group in the September, I felt
6 that the matter was closed and beyond my further
7 intervention.
8 Q. I hope you do not mind my suggesting this, but is there,
9 looking at it in retrospect, would you say perhaps
10 a problem with having prominent busy people with
11 a number of serious interests to concern them as members
12 of a group like the Supra Regional Services Advisory
13 Group, where time for considering minutes, memos and
14 action may be limited?
15 A. No, I do not accept that thesis, actually. I think you
16 need people who are experienced to serve on these
17 committees. They are inevitably extremely busy. There
18 is just an awful lot of work that needs to be done.
19 Q. You plainly understood from what had happened in 1992,
20 at any rate, that there was a problem with Bristol,
21 leave aside the exact details of it, perhaps, but there
22 came a time, I think in 1995, when you were involved in
23 the Medical Association, the BMA?
24 A. Yes.
25 Q. I wonder if we can have a look at a letter,
0187
1 UBHT 61/348. Let us have a look at the date, please:
2 25th September 1995.
3 It is addressed to Dr Roylance as the Chief
4 Executive of the United Bristol Healthcare Trust.
5 "As you know, Mr de Leval sent me a copy of his
6 letter to you of 13th September in my capacity as
7 President of the BMA.
8 "I have to say that I was astounded to hear that
9 Mr Dhasmana had been asked to give up his paediatric
10 cardiac surgery. I was aware that the review conducted
11 by Mr de Leval and Dr Hunter this year exonerated
12 Mr Dhasmana from any hint of professional incompetence
13 with regard to his paediatric cardiac surgery. It does
14 seem therefore completely unjust that he should be
15 treated in this way, which will inevitably be seen by
16 the local community as evidence that he was indeed
17 incompetent at his job.
18 "I hope therefore that you will include me in your
19 reply to Mr de Leval as, like him, I believe that this
20 is something which ought to be taken up at the highest
21 possible level."
22 What was "the highest possible level"?
23 A. The Department of Health; the Trust Board. The Chairman
24 of the Trust.
25 Q. This was a doctor in respect of whom it was said there
0188
1 were concerns as to the quality of his surgery, leave
2 aside for the moment whether they were justified or
3 not.
4 A. Yes.
5 Q. You, for your part, had seen statistics which you had
6 found disturbing some three or four years earlier when
7 he, to your knowledge, was one of the two cardiac
8 surgeons involved in paediatric cardiac surgery?
9 A. Yes.
10 Q. Can you explain why it should be that when it came to
11 his job being under threat, as it plainly was, you
12 should think it appropriate to write to the Trust, the
13 Chief Executive of the Trust, and to argue that the
14 matter should be taken up at the highest possible level,
15 when earlier, when you had had concern, disturbing
16 concern over the statistics in relation to the outcome
17 for the patients, you had not written to the Trust and
18 you had not considered, because you did not really think
19 about it, writing to those at the highest possible
20 level?
21 A. Yes. I think this is relatively easy to explain.
22 I had, and still have, the highest regard for
23 Mr de Leval, both in terms of his integrity and his
24 competence as a paediatric cardiac surgeon, perhaps one
25 of the leaders in the world at present.
0189
1 My understanding was that he and Dr Hunter, a very
2 respected paediatric cardiologist, had made a review of
3 the work and that there was no hint of professional
4 incompetence. This reassured me greatly, and I felt
5 that it was unjust that on the basis of what I heard,
6 Mr Dhasmana should be treated in this way. I think it
7 would be useful if we could, just look at Mr de Leval's
8 letters. I would like to be reminded by that.
9 Q. It is UBHT 61/346. The second paragraph:
10 " ... greatly surprised for two main reasons.
11 First Mr Dhasmana's results displayed during the recent
12 investigation in which I was involved compared
13 favourably with the best UK institutions and with the
14 best UK surgeons. Secondly, all professional bodies
15 that have advised on the constitution of paediatric
16 cardiac units in the US and in the UK over the last
17 20 years have emphasised the need for at least two
18 surgeons per unit. Single-man units are considered to
19 provide suboptimal service for obvious reasons. It is
20 along those lines that the report of which I was
21 a co-author was written, strongly advising a close
22 collaboration between Mr Dhasmana and the new surgeon.
23 "I am led to believe that the quality of
24 Mr Dhasmana's work is not disputed. The main reason for
25 his dismissal is the public perception that he is part
0190
1 of the bad image that has tarnished the Institution
2 during the recent months. If that is correct, it is in
3 my view an extremely serious precedent, and I believe
4 that the matter ought to be discussed at the highest
5 levels."
6 It goes on to talk about Mr Dhasmana's dedication
7 to the Paediatric Cardiac Unit. "He is working under
8 extreme pressure", I think that is a reference to recent
9 events?
10 A. Yes.
11 Q. The last sentence:
12 "Our human factor is now obsolete in the
13 decision-making of the managers of the National Health
14 Service."
15 That is the letter.
16 A. I think you can understand, Mr Langstaff, how on the
17 basis of that letter I should have felt that Mr Dhasmana
18 was being treated unfairly.
19 Q. You knowing, as there you did, that there were two
20 surgeons, knowing one surgeon personally -- I do not
21 know whether you knew Mr Dhasmana as well?
22 A. No.
23 Q. Having seen the results you had seen back in 1992, did
24 you stop to think at all "Why is it that the results
25 back in 1992 appeared to be as bad as they were when
0191
1 I looked at them; was Mr Dhasmana involved in that, or
2 was it the other surgeon?" Did you think anything along
3 those lines at this stage?
4 A. I do not think I did. I think my feeling was one of
5 relief, the pleasure that the work Mr Dhasmana had been
6 doing had been judged by someone of Mr de Leval's
7 stature, to be above the best compared with other good
8 UK institutions.
9 Q. Was it part of the function as you saw it of the
10 President of the BMA to write in support of a member
11 threatened with losing his practice in this way?
12 A. Not at all. I do not think I was writing so much as in
13 my capacity as the then President of the BMA as of
14 somebody who had an interest in cardiac surgery, had
15 been the President of the Royal College of Surgeons,
16 Mr de Leval knew me, knew my interests.
17 Q. The repercussions of de-designation back in 1992, had it
18 happened, would have been that you would have hoped that
19 paediatric cardiac surgery in Bristol would have
20 withered on the vine.
21 A. No, I do not think I thought that at all.
22 Q. Do you remember on Thursday when I began my questioning
23 of you, that I reminded you of something which you
24 recalled saying to "Dispatches" on 27th March 1996, when
25 you were asked the question by advising that the service
0192
1 be de-designated, because you said that you recommended
2 to the Department of Health that the service be
3 de-designated at Bristol:
4 "By advising that the service be de-designated you
5 were effectively advising that the service be stopped."
6 Your answer to that question was: "Yes,
7 essentially yes".
8 A. Yes, but I think the way you put it to me was that I was
9 hoping, did you not?
10 Q. Yes.
11 A. I was not hoping at all. I anticipated that the impact
12 of withdrawal of supra-regional funding would mean that
13 it would be likely to go into demise.
14 Q. Is there a contradiction in your mind in one capacity on
15 the Supra Regional Services Advisory Group advising
16 de-designation which might, as a matter of consequence,
17 lead to surgery stopping, on the one hand, and on the
18 other hand, complaining and writing in support of one of
19 the surgeons who continues to be doing just that work
20 three years later?
21 A. Well, if the evidence is that that surgeon -- and the
22 only evidence I had was that that surgeon was a good
23 surgeon -- then I do not see the point.
24 Q. The last matter I think I need to ask you about is
25 something rather different and it arises out of your
0193
1 statement to the General Medical Council. Can we have
2 RCSE 2/209?
3 It is the very last paragraph. You say that you
4 believe that a surgeon has a responsibility to analyse
5 his results on a regular basis so that when asked by
6 a patient about the risks of mortality and morbidity, he
7 can provide that information on the basis of his own
8 experience.
9 To whom does he have the responsibility?
10 A. To the patient.
11 Q. He must, presumably, know his own mortality and
12 morbidity statistics, as it were?
13 A. Yes.
14 Q. What would you say he has to know about comparative
15 data?
16 A. Comparative data is always helpful. This is what we
17 agreed when discussing the UK cardiac surgical register
18 and how this provided comparative data, which would act
19 as a stimulus to help surgeons improve their
20 performance.
21 Q. The point is a simple one. I think you are agreeing,
22 but confirm it for me if you are, that it is pretty
23 useless for a surgeon to say to a patient who may know
24 no different, "My chances are 50:50 or 60:40 in the
25 patient's favour", if in the national statistics in
0194
1 somebody else's hands it might be a 10 per cent risk of
2 mortality, or for that matter a 90 per cent risk. The
3 suggestion is incomplete, I am putting for your
4 consideration, without there being some, at any rate,
5 attempt at comparison?
6 A. Yes. I think the comparison is a sophistication which
7 is needed at times, but certainly in my own practice,
8 the three items which I felt were important for the
9 patient or his or her parents to understand when
10 advising an operation were really quite simple, but very
11 important. The first was, what would happen to that
12 patient if no operation were performed? In order to
13 answer that, you needed to know the natural history of
14 the disease and how that might be modified by medical
15 treatment. In some surgical conditions, that is a very
16 important issue. In many complex cardiac surgical
17 operations, there is no good medical treatment for it.
18 But quite a lot is known as to whether that infant would
19 live to one year or five years or ten years, perhaps,
20 before getting into trouble. So that is important. One
21 needs to go through that with the patient.
22 Secondly, you want to know what are the risks of
23 the operation that you are proposing to perform in terms
24 of both death and complications? In that regard, there
25 is no point in saying that at the Mayo clinic they are
0195
1 getting 10 per cent, but you really have to say what it
2 is in your hands. That is why it is important to
3 analyse that.
4 If your own results are way out of kilter with
5 either those of your surgical colleagues in your unit or
6 your country, then you ought to consider informing them.
7 The third issue is what are the benefits that you
8 are going to gain from taking these risks? You need to
9 go into that. The benefits may be in terms of added
10 life years; it may just be in terms of added quality of
11 life without extending life, but it is actually quite
12 a simple process. I have always believed that this was
13 the need, provided the need for surgeons to analyse
14 their mortality statistics, so that they could say, in
15 the last 200 coronary operations that have been done,
16 a whole spectrum, the risks have been whatever they
17 have, 0.8 per cent, or 2 per cent.
18 Q. Sir Terence, I have kept you there all afternoon.
19 I have finished with the questions that I have so
20 I shall not detain you further, save this: to ask if
21 there is anything that you yourself would wish to add so
22 that we have a fair and proper knowledge of what you
23 have to say to help the Inquiry.
24 A. I cannot think of anything right now, but I think what
25 I should do is to read the transcript carefully and if
0196
1 there are omissions or corrections that I feel are
2 necessary, then I could send them in to the Inquiry.
3 Q. If you do come upon any more documents, in particular,
4 if you come across any note of conversations which you
5 may have had with Dr Halliday, then would you please
6 send them through?
7 A. Yes.
8 THE CHAIRMAN: Sir Terence, there are some questions from
9 the Panel.
10 EXAMINED BY THE PANEL
11 MRS HOWARD: Just one question, Sir Terence, and it is the
12 development of at least two of your answers that we have
13 heard.
14 You have talked about de-designation and stated
15 quite early on in your evidence and then later that that
16 did not suggest in your mind stopping surgery if the
17 de-designation of the unit was suggested.
18 What my question really relates to is, if
19 de-designation did occur as a result of performance such
20 as the mortality issues we have discussed, what would
21 the College's view be if surgery of that nature
22 continued in that unit?
23 A. I am sure it would be one of concern, most particularly
24 if the recommendation for de-designation had come
25 through that particular college, and it would be
0197
1 something that it would wish to take up with the
2 Department of Health, I am sure, and with the local
3 Trust.
4 Q. When you say "it", do you mean yourself as the College
5 or do you mean the Department of Health?
6 A. I mean the College.
7 MRS HOWARD: Thank you.
8 THE CHAIRMAN: Sir Brian?
9 PROFESSOR JARMAN: Sir Terence, I would just like to develop
10 the point you were discussing at the very end with
11 Mr Langstaff, with regard to if the surgeon had
12 risk-adjusted data on himself, that it ought to be made
13 available to patients.
14 Do you have any views about whether it ought to be
15 made more widely available?
16 A. I have thought about this a lot. I think it should be,
17 but it is terribly difficult to do it in a way which is
18 an accurate reflection of the quality of surgery.
19 Q. I said "risk-adjusted".
20 A. Yes, but even with that, it is difficult. I believe
21 that what we are working towards within cardiac surgery
22 in general is, as I understand it, to try and develop
23 a risk-adjusted analysis in which the same instrument is
24 used by all units, because each instrument is imperfect,
25 but in that way, one would stand to have a better
0198
1 comparative system than we have up to now.
2 Q. If that could be developed, you think it should be made
3 more widely available?
4 A. I think it is almost inevitable that it will be
5 eventually, and it will need great education to make
6 sure that all the difficulties in such a process are
7 clearly presented to the public.
8 Q. Thank you. Another question. A little earlier this
9 afternoon you said that there is not a lot that the
10 College can do about poor performance in a unit?
11 A. Yes.
12 Q. It is page 178, line 16. Earlier on, on Thursday, you
13 had said that one of the things that can be done is when
14 the inspection of training visits takes place.
15 We know that the Royal College of Physicians
16 visited the BRI in 1992, and they said that there were
17 problems with excessive workload -- this is feedback
18 from the trainees -- such that "it was probable that at
19 times the quality of patient care may fall below
20 reasonable standards."
21 Would you like to comment?
22 A. I think that that can happen when a unit becomes so
23 pressurised that the overwork that is going on within it
24 actually compromises outcome for patients. I think this
25 was reflected in an article that was written about
0199
1 a neurosurgical unit in Oxford two years ago, where it
2 was an extremely good unit, but it became, as they
3 described it, "hyper-efficient", and then deteriorated
4 because the volume of work and the pressure that the
5 staff were being put under just became too great.
6 Q. Would you have any views as to whether it might have any
7 relevance to the current things we are dealing with in
8 the Inquiry?
9 A. It is a very difficult one to answer without
10 understanding what goes on in the unit. When I look
11 back on my own unit, there have certainly been times
12 when consultant and junior staff have worked
13 ridiculously long hours, and yet somehow, although
14 individuals have suffered, the quality of care I do not
15 believe did. But it is a dangerous path to tread.
16 Q. Thank you. Just a third question: whether you would
17 have any comments on the relationship between advisory
18 committees such as the SR, SRSAC, the Royal Colleges,
19 the Department of Health, Secretary of State, with
20 regard to who holds the ultimate responsibility?
21 A. Yes, I would like to comment on that, because I think it
22 is an important one. I do not believe that the Royal
23 College of Surgeons or physicians, or any other Medical
24 Royal College, can be held responsible for performance
25 in individual units. I think the value of the Colleges
0200
1 resides in their capacity to provide professional advice
2 when invited, and to do so in as objective and fair
3 a way as possible. I think if there are difficulties
4 that crop up in a unit, a College or two Colleges can
5 combine to provide a visitation that can be quite
6 extensive, and then very helpful to management. I think
7 the Supra Regional Services Advisory Group had
8 a responsibility -- a difficult responsibility, but
9 a responsibility nonetheless -- for performance in the
10 units that they designated, because they were funding
11 them. This was the difference, really.
12 Of course, the unit in the BRI was just a small
13 part of cardiac surgery, and indeed, a small part of
14 paediatric cardiac surgery, albeit a very important
15 part.
16 PROFESSOR JARMAN: Thank you very much.
17 THE CHAIRMAN: Sir Terence, may I ask you one question? It
18 arises from Mr Langstaff's questioning about what you
19 thought you or others could have done during the
20 sequence of events we were looking at.
21 It is, for the record, transcript 173, line 4.
22 I introduced the question by saying:
23 "We are in this Inquiry interested in a variety of
24 things and one of the things is the culture which
25 prevailed within the NHS that affected or may have
0201
1 affected decision-making".
2 You describe yourself as having:
3 "I had already stuck out my neck out."
4 I wondered: you were, and indeed are, Sir Terence
5 English, President of the Royal College of Surgeons
6 then. You are on the SRSAG. I put it to you for your
7 comment: one phone call or one conversation or letter
8 could be seen to be sticking one's neck out from one
9 perspective, but another person would have said that
10 some cages needed to be rattled here.
11 I would just value your observation.
12 A. I think it is a very difficult issue, because I do
13 accept the implied criticism, and indeed, the criticism
14 that I should have done more to bring my concerns to the
15 Supra Regional Services Advisory Group specifically
16 about the mortality and the concerns expressed by
17 Dr Zorab, than I did, and in retrospect I think I should
18 have.
19 I think one of the difficulties was that we had
20 already had this situation where I had asked the
21 Chairman of the Working Party, which I had appointed, to
22 change his recommendations. He had agreed. Then, on
23 further reflection and on discussion with the other
24 members of the committee, his committee, which was
25 absolutely right and responsible, the consensus was that
0202
1 they should not change them. That definitely muddied
2 the waters a bit as far as I was concerned.
3 Q. May I press you a little bit, forgive me if I do. The
4 reaction I get from you in your response to Mr Langstaff
5 was that there might have been an element of
6 professional pique at what had happened and the way in
7 which your recommendations, as it were, had been treated
8 and some private deal had been done while you were away
9 on holiday. I wonder at what point one has to transcend
10 whatever personal feelings one may have about this is
11 not the way to go about things, and remember the
12 consequences that flow from these decisions in groups
13 like this.
14 A. I would like to make it clear that there was absolutely
15 no professional pique involved in my response to what
16 Professor Hamilton had done. I regard that as being
17 completely understandable and within his authority.
18 There was professional pique as far as my reaction
19 to the decision to de-designate the service against the
20 professional advice, consistently, that had been given
21 over the years. That seemed to me to at one level
22 confirm my suspicion that had been growing that the
23 Department wanted to de-designate neonatal and infant
24 cardiac surgery and this may well have been related to
25 the changes that resulted from the 1990 reforms, where
0203
1 the supra-regional services fitted very uncomfortably
2 within the purchaser/provider relation. Here was money
3 that was being top-sliced and then distributed to
4 a selected group of services, and I acknowledge that.
5 But however it was to be achieved, the concept of
6 concentrating the services for this very difficult and
7 complex surgery, which depended not just on surgical
8 expertise, but if the paediatric cardiologists were not
9 doing their job properly, the patients would come too
10 late to surgery, this would be reflected. If the
11 anaesthetists were not doing it, it would be reflected
12 in mortality, so it had always seemed to me that you did
13 need to concentrate it in centres where you could bring
14 all the expertise together.
15 THE CHAIRMAN: I am grateful to you for that answer. I am
16 grateful more generally for your having come. I mean,
17 it has been two arduous days for you, as well as indeed
18 for others, and we are very grateful to you for coming,
19 for being so frank in circumstances where it may have
20 been difficult to be so. We are grateful.
21 I repeat what Mr Langstaff has said: if there are
22 matters which come to hand and you would wish to let us
23 have them further, we would be grateful if you would do
24 so, particularly, and I make specific reference to any
25 correspondence or any contact with Dr Halliday.
0204
1 For today --
2 THE WITNESS: Thank you for those comments.
3 THE CHAIRMAN: Thank you for coming. Caroline will show you
4 out.
5 MR LANGSTAFF: Sir, it will not be necessary to detain
6 Sir Terence, but Mr Lissack wishes to say some words.
7 THE CHAIRMAN: Sir Terence might wish to leave before we
8 hear any further observations.
9 THE WITNESS: Are you suggesting I should leave?
10 THE CHAIRMAN: Yes, please. I am suggesting you can leave,
11 but only so that -- you need not be sitting there and
12 feel that you are under --
13 THE WITNESS: I may sit over there?
14 THE CHAIRMAN: You may, and we shall be delighted if you
15 do. Mr Lissack, you wanted to say something, please?
16 ADDRESS TO THE PANEL BY MR LISSACK:
17 MR LISSACK: I think the smallness of the note in front of
18 me reflects the position in respect of this witness's
19 evidence.
20 May I take a moment to explain why, and then
21 revert to what you said this morning as we began
22 proceedings?
23 As you know, our concern on Thursday, coming from
24 a position which you were good enough to say you fully
25 understood and appreciated, was that issues as to who
0205
1 knew what and did what, when, would have to be explored
2 with this witness. That sat at the very heart of some
3 of the issues, important to you to resolve.
4 Again, as you know, sir, from what I told you on
5 Thursday, we on behalf of the Action Group which
6 I represent had exchanged details of matters we wished
7 to be explored with this witness: nine issues, a tenth
8 then became appended to them, with detailed references
9 as to documents as to each issue, and given those
10 details to Counsel to the Inquiry.
11 I hope Mr Langstaff will forgive me if I say,
12 I could not have done it better myself. I am sure he
13 will take that in the spirit in which it is meant. It
14 is meant as the highest compliment from one lawyer to
15 another. The groaning I understand, but it makes an
16 important point and the important point is this: that we
17 recognise fully, on behalf of those that I represent,
18 that this is an inquisitorial process, not an
19 adversarial one and we well understand and recognise
20 that just because there may have been a different way of
21 doing something or not, from one advocate to another, is
22 wholly irrelevant. That is why I say what otherwise may
23 have sounded really a rather ingratiating and clubbable
24 comment from one lawyer about another.
25 May I, with that introduction, thank you for what
0206
1 you said this morning, sir. May I thank you for the
2 gracious and helpful content of what you said. I am
3 conscious that those whom I represent across the
4 country, if not in the hall today, will be reading
5 tonight or tomorrow, or in the days to come, the words
6 that you uttered today.
7 May I, against that background, reassure you of
8 these four things: firstly, that we applaud the
9 inquisitorial process rather than the adversarial. We
10 respectfully agree, that is the way to the truth in this
11 situation, and no other. That is fully understood by my
12 sophisticated client base, as they are. They fully
13 appreciate the difference between court and inquiry, and
14 have done, really, from long before I ever insulted them
15 by explaining it myself.
16 Secondly, the guiding principle that has operated
17 guiding our approach to this Inquiry from the first and
18 will to the last, is merely this: that we do what we can
19 to ensure that you have before you all that we
20 respectfully submit you may find helpful, and that is
21 it.
22 The third point is this: the only disappointed,
23 picking up a word from that that you said this morning,
24 sir, that we will feel is if we fail in that task.
25 There is no room for forensic disappointment that one
0207
1 may not be able to ask questions of a witness had one
2 wished to in another forum or setting.
3 The fourth and the last point is the most
4 important: the real triumph of the system will be if
5 I never apply for leave to cross-examine. That will
6 show that it has all worked perfectly. But, sir, in any
7 system, things do not always turn out as one might
8 wish. May I reassure the Inquiry of this: if and when
9 we apply for leave to cross-examine a witness, it will
10 only be to elicit information which we think you may
11 find helpful: no more than that.
12 Thank you very much.
13 THE CHAIRMAN: Mr Lissack, forgive me if I detain you on
14 your feet. That was extremely helpful and very
15 gracious. I know we are all much affected by it, and
16 reassured.
17 I hope your clients will listen also to your
18 comments as well as to what I said this morning. We all
19 remember that we are all in this together. We only have
20 one ambition which is, as I said in the opening
21 statement, to get to the bottom of things. But we up
22 here -- or at the side, since we are not "up here" --
23 have also to recognise there are many different people
24 with many different views and it is balancing those
25 that, I agree with you, I think the procedure we have
0208
1 adopted will allow us to do.
2 May I, at the risk of transgressing what might be
3 a propriety, join you in thanking and praising the
4 counsel who are supporting the Panel. They have day in,
5 day out, worked very hard, and today is just a mere
6 example of what they do.
7 Finally, Mr Lissack, it would be a disappointment
8 for all of us if we were not to hear you on your feet.
9 MR LISSACK: What can I say!
10 THE CHAIRMAN: Mr Langstaff, for tomorrow, please?
11 MR LANGSTAFF: I was going to say for my part after that
12 I would ensure Mr Lissack never asked a question, but in
13 the nicest possible way.
14 Sir, tomorrow we have Mr Ross, the Chief Executive
15 of the UBHT. Can I make it clear, becoming more serious
16 for a moment, that the evidence which he gives will be
17 given in more than one part. That is important, because
18 it will not have escaped people's notice that although
19 we are formally on Block 2, because of the way in which
20 Dr Halliday allowed the evidence to be taken from him as
21 to the expression of concerns about Bristol, and because
22 of Sir Terence's willingness, having been informed that
23 that was an area we wished to pursue while the iron was
24 hot, as it were, to be asked questions about it, we have
25 rather strayed away from simply setting out the national
0209
1 scene.
2 We hope that it has been appropriate. Nobody has
3 suggested to me the contrary. But it needs to be
4 emphasised that when we come back to deal with Mr Hugh
5 Ross tomorrow, that his evidence is simply to set the
6 local administrative scene. He will be talking about
7 the fascinating topic of how Bristol is organised and
8 how it was organised. That is the Royal Infirmary and
9 the Children's Hospital. At a later stage in his
10 evidence, he will return to talk to us about his views
11 and what he did in respect of the retention of tissue.
12 I mention it now because that is a highly emotive
13 subject. It is liable to be misunderstood if Mr Ross
14 comes tomorrow and is asked no questions about it by
15 anyone, and it may be thought that in some way we have
16 failed to do that which you have declared today and
17 reminded us today is the object, which is to get to the
18 bottom of things. The reason is that he will be asked
19 about that at a later stage.
20 Amongst other things, the reason for that is that
21 of course, as you will know, but again, the wider
22 audience may not, the statements which witnesses give
23 are generally circulated a little bit in advance to
24 legal advisers and participants who may be able to give
25 us, Counsel to the Inquiry, comments and information
0210
1 which enable us to better question the witness, so that
2 in a sense it is a collaborative effort by all counsel
3 and solicitors here to make sure that the Panel over
4 there gets the full picture.
5 Sir, it will be a later stage still, but he says
6 what he has to say about the expression of concerns
7 about the surgery at Bristol, and so tomorrow is simply
8 the administration.
9 THE CHAIRMAN: Mr Langstaff, I am grateful to you for saying
10 that, and reinforcing the fact that there will be
11 occasions with some witnesses, there will be a number of
12 occasions on which we will hear them, so again, as
13 I said this morning, we may have to have patience as
14 regards some of the matters so we take them in the
15 proper order.
16 May I also say, I cannot now remember because it
17 has been a long day, whether you made it clear this
18 morning that we will be most anxious to hear from
19 parents as witnesses during, for example, the vexed
20 question of retention of tissue, and we will be calling,
21 I imagine, a number of parents to help us on that
22 matter, as on others. You said that this morning,
23 I think.
24 MR LANGSTAFF: If I did not, I should have said on both
25 the issues relating to the split of site between the
0211
1 Children's Hospital and the Royal Infirmary, and in
2 respect of retention of tissue, both issues we expect to
3 explore in the room within the next two months.
4 THE CHAIRMAN: It has been a long day, but I feel a valuable
5 day. I am grateful to everyone in the room. We will
6 adjourn now and reconvene tomorrow morning at 9.30.
7 Thank you.
8 (5.15 pm)
9 (Adjourned until 9.30 on Tuesday, 18th May 1999)
10
11
12 I N D E X
13
14 ADDRESS TO THE PANEL by MR LANGSTAFF ............... 1
15 CHAIRMAN'S STATEMENT ............................... 7
16
17 PROFESSOR DAVID BAUM (Sworn)
18 Examined by MISS GREY ........................ 17
19 Examined by the PANEL ........................ 88
20
21 SIR TERENCE ENGLISH (Recalled) ..................... 93
22 Examined by MR LANGSTAFF (continued) ......... 93
23 Examined by THE PANEL ........................ 197
24
25 ADDRESS TO THE PANEL BY MR LISSACK ................. 205
0212
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Published by the Bristol Royal Infirmary Inquiry, July 2001
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