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Daily transcripts
Hearing summary
22nd MARCH 1999
The second week of the Inquiry will hear from eight more parents on
Monday, Tuesday and Wednesday. Families will be called throughout the Inquiry to
contribute to subsequent blocks of evidence.
The second block of evidence starts on Thursday and will look at the
national scene - including evidence from the Department of Health, witnesses from the
Supra-Regional services and possibly the Royal Colleges and professional organisations.
On Monday March 22 the proceedings began with evidence from Paula Jordan from Somerset,
followed by Penelope Plackett from Devon and lastly Ellen Sheridan from the West Midlands.
Paula Jordan told the Inquiry about her son Joe (now 8 years old), who was born at
Musgrove Park Hospital, Taunton, in January 1991. Shortly after his birth Joe was
diagnosed with a heart problem and referred to the Bristol Maternity Hospital for tests.
These identified that Joe had a blocked aorta and only one ventricle. Mr Dhasmana carried
out a successful operation on Joe at the Bristol Children’s Hospital during the first
week of his life to repair the blocked aorta and apply pulmonary banding. Joe underwent a
second successful bypass operation in January 1993 at the BRI. Mrs Jordan felt that Mr
Dhasmana had given realistic, cautious and honest advice to her at all times.
Penelope Plackett told the Inquiry about her daughter Sophie (now 10 years old) who was
born in June 1988 with a congenital heart defect. An initial diagnosis of a heart murmur,
led to outpatients appointments and a subsequent cardiac catheterisation procedure at
Bristol Children’s Hospital to confirm the diagnosis of Truncus Arteriousus.
Sophie was admitted to the BRI in November 1988 for Mr Dhasmana to operate to correct the
heart defect. A week after Sophie’s operation it emerged that Sophie had suffered
brain damage, which has left her severely, disabled physically and mentally. Before
returning home, Sophie was transferred to the Bristol Children’s Hospital and
subsequently to the Royal Devon and Exeter Hospital. Mrs Jordan told the Inquiry of her
dissatisfaction with the amount of information Dr Dhasmana had given her about the risks
involved with Sophie’s operation. She also expressed dissatisfaction with the care
that Sophie received at the Bristol Children’s Hospital.
Ellen Sheridan’s son John was born in Barnstaple, Devon, in March 1979 with a
heart murmur. A few days after his birth John was transferred to Bristol for a cardiac
catheterisation, which identified a hole in John’s heart. Medication was prescribed
and the Sheridan’s were given appointments at six weekly intervals in Bristol. In
November Mr Wisheart performed a successful ‘Shunt’ bypass operation, explaining
that a further operation would be necessary when John was seven years old. In May 1986,
the Sheridan’s returned to Bristol with John for an open-heart surgical procedure.
They queried this, asking whether another ‘shunt’ operation could be performed
and were told that a Fontan operation was the only operation left. Before John went to the
operating theatre Mrs Sheridan’s husband questioned Mr Wisheart and the anaesthetist
separately about the most recent Fontan operation that had been carried out in Bristol. He
received conflicting information about the outcome of that operation. Mrs Sheridan told
the Inquiry that John died in Intensive Care following his operation. Mrs Sheridan told
the Inquiry she was very distressed when she learned recently that John’s heart and
lungs had been retained by the BRI.
|
FULL TRANSCRIPT
1 Day 4, 22nd March, 1999
2 (10.30 am)
3 HOUSEKEEPING
4 MR LANGSTAFF: Sir, inevitably, on a Monday morning, there
5 are bound to be matters of housekeeping. There are two
6 particular matters which I ought to deal with before the
7 outset of today's proceedings. The first is that the
8 Inquiry has received a letter from the representatives
9 of Dr Joffe which has noticed that on the transcript of
10 the evidence of Mr Curnow at page 82, line 8, I am
11 recorded as having said to Mr Curnow words as follows --
12 this is in relation to a conversation in April, between
13 Dr Joffe on the telephone and Mr Curnow, and you will
14 recall that the recollection of Mr Curnow of that
15 conversation was to the effect that Dr Joffe volunteered
16 that Mr Dhasmana was not part of any investigation, out
17 of the blue, as it were. I am recorded as having put to
18 Mr Curnow:
19 "I think you appreciate that Dr Joffe for his part
20 accepts that the conversation took place as you describe
21 it."
22 Of course to anyone who was listening, that does
23 not represent what in fact I said, and what I in fact
24 said and put to Mr Curnow was that Dr Joffe for his part
25 does not accept ...
0001
1 Unfortunately in the process of LiveNote
2 transcripts, the negative has given way to the positive,
3 and completely the wrong effect was given to what I put
4 effectively on Dr Joffe's behalf, to test Mr Curnow's
5 evidence to him.
6 The matter I know has been raised with the
7 shorthand writer and it needs, I think, to be said, sir,
8 that it is appreciated that it is impossible in any
9 transcript done as it is immediately, in realtime, for
10 there not to be some errors. So what is necessary is
11 that there should be a system for dealing with errors
12 when they arise. It is not really a case of when and
13 if, it is a case of when they arise.
14 It is unlikely, I suspect, that the mistake will
15 be either so obvious or dramatic as the missing "not",
16 but it may be. What I would simply publicly say is
17 this: if anyone notices an error on the LiveNote during
18 the day, would they please raise it with the shorthand
19 writers at the end of the day. The shorthand writers
20 themselves will ensure nobody else needs to be troubled
21 with it. They have, after all, got a tape-recording of
22 what has been said and they will ensure that the record
23 is corrected. If there is a dispute about it, then they
24 will raise it further, so that what needs to be
25 clarified is clarified and the record put right.
0002
1 Secondly --
2 THE CHAIRMAN: Before you go on to that second point, may
3 I first of all agree that we should bear in mind that
4 mistakes are inevitable, although one should also
5 recognise the consequences can be unfortunate.
6 I endorse what you said about a process. I have also
7 looked into this myself and advised that the Internet
8 itself can be altered when such an error exists, and
9 that is, I think, important also. I am advised by the
10 stenographer that an appropriate amendment can be made
11 in the Internet record, so it does not appear on the
12 Internet in its previous form.
13 MR LANGSTAFF: In this particular error, there will not only
14 be the remarks I am making now, but also the corrected
15 version will be transmitted henceforth.
16 THE CHAIRMAN: That is what I am advised.
17 POINT BY MR LANGSTAFF REGARDING COMPUTER RECORDS
18 MR LANGSTAFF: If I can turn to the second matter, it is
19 a matter of record, that the Trust has been in
20 correspondence with the Inquiry in relation to the issue
21 of the stolen computer which I made reference to in the
22 course of my opening. What I said having been drawn
23 from a letter from the Trust, which I hope was
24 self-explanatory, and which was itself released onto the
25 Internet, as I understand it, and made public.
0003
1 The letter again speaks for itself. It is
2 a letter dated 19th March 1999, and if I can simply say
3 it is part of the record now of these proceedings, the
4 main point it makes is that none of the information on
5 the computer was uniquely held on the computer. It was
6 entered there for the use of perfusionists, and was
7 information that was also held on perfusionists' charts,
8 anaesthetic charts and patients' records.
9 Because all that information was available to the
10 Inquiry, no information has been lost to the Inquiry
11 because of the theft.
12 Those are the immediate matters of housekeeping.
13 Miss Grey will call Mrs Jordan to give her evidence
14 first. We will then proceed with Mrs Plackett and
15 Mrs Sheridan.
16 THE CHAIRMAN: Thank you, Mr Langstaff. Miss Grey?
17 MISS GREY: May I ask Mrs Jordan, please, to come and take
18 a seat?
19 Mrs Jordan, I think the first thing that will
20 happen is that you will be invited to take the oath,
21 since we do take the evidence on oath here, if you could
22 just stand for that, please?
23 MRS PAULA JORDAN (Sworn):
24 Examined by MISS GREY:
25 Q. Is your full name Miss Paula Jordan?
0004
1 A. Yes.
2 Q. Do you live with your partner, Michael McCleary?
3 A. Yes.
4 Q. You have two children, I think, Joe and Molly?
5 A. That is right, yes.
6 Q. Can everyone hear at the moment? If you can speak up
7 a bit, the microphone is sensitive but it does need to
8 be addressed.
9 Can you tell us a little bit about the birth of
10 Joe, please? Where was he born?
11 A. He was born at Musgrove Park Hospital, Taunton.
12 Q. When was he born?
13 A. 17th January 1991.
14 Q. I think you may need to speak up again, just a little
15 bit louder. Were there any particular problems during
16 his birth?
17 A. I am a diabetic, so it is par for the course that Joe
18 would be taken up to special care as soon as he was
19 born, which he was done, and yes, as he was born on
20 a Thursday, and as the days progressed, Thursday,
21 Friday, Saturday, Sunday, it was becoming apparent he
22 was not very well.
23 Q. What sort of things were becoming apparent that were
24 wrong?
25 A. He had not really woken up at that stage. I now think,
0005
1 why did I not ask "Why has he not woken up at four days
2 old?". A consultant came back from his holidays on the
3 Monday and saw Joe was starting to pant.
4 Q. So a consultant came back on the Monday after the birth
5 on the Thursday and this is still at the Taunton
6 hospital?
7 A. Yes.
8 Q. Had they been able to diagnose what was wrong with Joe
9 before the consultant returned from holiday'?
10 A. No. They had done several tests but they did not know
11 what they were looking for. As soon as Dr French came
12 back from his holidays on the Monday, he did an ECG
13 which he found was not quite normal, so he straightaway
14 sent him up to Bristol.
15 Q. What sort of a consultant was Dr French?
16 A. He is a paediatrician.
17 Q. He arranged for Joe to be taken up to Bristol for
18 further tests?
19 A. That is right.
20 Q. Did he say why he was referring Joe to Bristol in
21 particular?
22 A. No. He was being sent to Bristol for heart tests that
23 they did not have the facilities to perform in Taunton.
24 Q. Were you given any reason why Bristol would be
25 a suitable place for those tests to be carried out?
0006
1 A. Not really, no.
2 Q. Did you ask any questions about that?
3 A. No.
4 Q. Can you tell us why you did not ask any questions at
5 that stage?
6 A. I assumed they knew what they were doing. They knew
7 best, and Bristol was the best place for him to be sent,
8 for him to have these detailed tests.
9 Q. At that stage, were you expecting him to be a long time
10 in Bristol?
11 A. No, I was expecting him to be a few hours.
12 Q. And then to return?
13 A. And then to return to me in Musgrove.
14 Q. Did that prove to be the case?
15 A. No.
16 Q. What happened?
17 A. I was waiting at home in Musgrove for Joe to come back
18 and as the hours progressed, they then came to tell me
19 no, he was not coming back, so I then made my way up to
20 Bristol.
21 Q. I think you had travelled with your partner, did you
22 not?
23 A. Yes.
24 Q. To the Special Care Baby Unit at the Bristol Maternity
25 Hospital; is that right?
0007
1 A. Yes.
2 Q. So when you first arrived at the Bristol Maternity
3 Hospital, did you meet with anyone?
4 A. Yes, I walked into the Special Care Baby Unit and
5 a nurse approached me. She said she was very sorry.
6 Q. What did that make you think?
7 A. At this stage I was quite concerned because I was
8 expecting Joe to be coming back a few hours after he was
9 taken away, so I made my way up to Bristol and I do not
10 know what was going on in my mind, all sorts of
11 scenarios. I was quite concerned. When a nurse came up
12 and said "I am terribly sorry", I did not know what she
13 meant. I was quite frightened.
14 Q. Did you manage to see a doctor at the Maternity
15 Hospital?
16 A. Yes, I did. Unfortunately, I cannot remember his name.
17 He was very kind and he tried to explain to me some of
18 the problems which Joe had. I was traumatised at this
19 stage and I did not take it on board. He got halfway
20 through trying to explain to me and I got very upset and
21 he gave up for a few minutes, until I was able to get
22 control.
23 Q. Did he try and use any particular aids or help in any
24 way with the process of explaining what was wrong with
25 Joe to you?
0008
1 A. They drew me diagrams, but the initial people I saw,
2 I could not quite take it on board. I could not
3 concentrate on what they were trying to tell me. I knew
4 it was bad news and I got very, very upset. So the
5 first two or three occasions when people tried to
6 explain to me what was wrong, they never finished
7 telling me because I got too upset.
8 Q. You have obviously had a lot of experience over the last
9 few years in people explaining to you what was wrong
10 with Joe and also trying to convey information to you
11 about what the best course of action would be for Joe.
12 On this initial occasion, the person who tried to
13 explain things to you did not really succeed because you
14 were too upset. It was new news to you, and you were
15 traumatised by what he said, but I think particularity,
16 right at a later stage, other doctors were more
17 successful?
18 A. Yes.
19 Q. Can you explain to the Inquiry what sort of things made
20 a difference between occasions when you could take in
21 what was being told to you and the occasions when you
22 had difficulty?
23 A. It was the next day I met with Dr Martin, and he sat me
24 down and explained exactly -- I mean, I was told in the
25 evening when obviously the cardiologists were not
0009
1 there. The gentleman tried to explain what was wrong.
2 When I met with Dr Martin the following day, he sat down
3 and basically told me exactly the same as I had been
4 told the previous evening, but I did not cry. I can
5 remember actually saying to him, "You must be
6 a psychologist, because you have told me exactly the
7 same as I was told before and you have not made me
8 cry". He sat down and drew me diagrams and explained
9 exactly what the problems were with Joe's heart.
10 Q. What was it that you meant when you said "You must be
11 a psychologist"?
12 A. Because he told me, he had explained it to me in a very
13 matter-of-fact way, and I do not know why it was
14 different than the previous time they tried to explain,
15 but I understood everything he told me and I did not
16 cry. I did not cry -- he managed to get all through the
17 story before I cried.
18 Q. So he was matter-of-fact?
19 A. Very matter-of-fact.
20 Q. And other than that, was it just that you had had
21 a little more time to take in the sorts of problems that
22 Joe might be experiencing? Or do you think there was
23 anything more than that?
24 A. I do not know. He was just very clear to the point and
25 just explained things to me so that I understood.
0010
1 Q. So you have described a discussion with Dr Martin, whom
2 I think is a cardiologist from the Bristol Children's
3 Hospital, the following day?
4 A. Yes.
5 Q. What did he explain about Joe's condition?
6 A. He explained that Joe basically had half a heart. He
7 had a blocked aorta, which obviously was the primary
8 cause why he was panting, but he was very truthful in as
9 much as he did not really know if there was anything
10 that could be done for him.
11 Q. Were the terms "coarctation of the aorta" used?
12 A. Yes.
13 Q. And also possibly "double inlet left ventricle"?
14 A. Yes.
15 Q. Can we look at medical record 2517/81 on my screen,
16 please? If you could just put that up on the screen,
17 can you see that now, Miss Jordan?
18 A. Yes.
19 Q. That is actually a record from Dr Martin's notes and on
20 22nd January, it says, towards the bottom of that page:
21 "Diagnosis explained to mother with to (sic)
22 uncertain outcome."
23 If we just drop down a little bit so we can see
24 the second half of the page:
25 "Discussed at meeting with cardiac surgeons. Will
0011
1 take for coarctation repair and pulmonary artery banding
2 query tomorrow."
3 Then Dr Martin writes:
4 "I have had a long discussion with parents of
5 risks of forthcoming surgery and the need for a modified
6 Fontan's operation later (with all of its risks)."
7 Can you remember that discussion with Dr Martin?
8 A. Yes.
9 Q. What was being said to you about the operation Joe
10 needed at this stage and what might happen in the
11 future?
12 A. I knew Joe needed the surgery. They could not guarantee
13 any quality of life after the surgery. I can remember
14 Dr Martin saying that he did not think Joe would ever
15 run a marathon or play football for England, but then
16 I said "I do not think he will either". He said, "Fair
17 enough". I said, "He will just have to become a heart
18 surgeon, then won't he?"
19 Q. So what was being said about the chances that Joe would
20 survive the surgery; can you remember?
21 A. I do not know whether it is naivety on my behalf.
22 I knew Joe needed surgery and I wanted someone to help
23 us, so the fact that they were going to help us, that is
24 all I can remember, feeling so elated that someone was
25 going to help us.
0012
1 Q. What would happen if no-one had helped you and Joe at
2 that stage, did you understand?
3 A. He would have died.
4 Q. You have spoken about a discussion with Dr Martin about
5 Joe's chances of survival and what was likely to
6 happen. Did you also meet with any of the surgeons to
7 discuss the surgery?
8 A. I can remember, I do not know who it was, I can remember
9 speaking with a surgeon, possibly -- I do not know
10 whether it was later that same day or the next day, and
11 he did not think there was anything that could be done
12 for Joe; that possibly he -- he did not think there was
13 anything that could be done for him.
14 Q. Can you name that surgeon?
15 A. Not 100 per cent, no.
16 Q. Was it Dr Dhasmana?
17 A. No.
18 Q. When did you first meet Dr Dhasmana?
19 A. I met him two or three days after we had been in
20 Bristol, I met Mr Dhasmana. I met him with the
21 knowledge that I think no-one could help us; that
22 nothing could be done for him. When he said to me that
23 he thought he could try and do something, I thought
24 I had won the pools.
25 Q. I think we can all understand that, Miss Jordan. Can
0013
1 you tell us what he described to you that he would do in
2 order to assist Joe?
3 A. Yes. He drew me really simplified diagrams of what
4 Joe's heart looked like, what a normal heart should look
5 like and he drew me diagrams of how he thought he could
6 overcome the problems. He said he would try and replumb
7 Joe, and he explained it to me like -- I needed it
8 explaining to me like I was a child and he said the
9 heart is like a roundabout and all the roads go into
10 your heart and they shoot off where they need to go, but
11 Joe's heart does not work like that, so we have to
12 divert the traffic around the heart. He drew me all the
13 diagrams of what he thought he would be able to do.
14 Q. Can we look at medical record 2517/482, please? Can you
15 enlarge that. That is a diagram from Joe's medical
16 records. Is that the sort of diagram Dr Dhasmana drew
17 for you?
18 A. Yes.
19 Q. Can you recognise that particular one?
20 A. We had several.
21 Q. I just wondered, looking at it, Miss Jordan, whether or
22 not, if you look at the shaded area at the top, that
23 might have been a description on a diagram of the
24 coarctation of the artery, with the aorta, is that
25 possible?
0014
1 A. Yes.
2 Q. If one drops towards the bottom of the diagram, at
3 a sort of ring that is shown about a third of the way up
4 the heart, is it possible --
5 A. That would be the pulmonary banding, yes.
6 Q. So that is an example, is it, of the sort of diagram
7 that you were being given?
8 A. Some were even more simple than that.
9 Q. What did Mr Dhasmana explain to you about what would
10 happen if the surgery was not carried out?
11 A. It was not a question of whether the surgery was not to
12 be carried out. He needed the surgery. He would die if
13 he did not have any surgery, so there was no question
14 that the surgery would go ahead.
15 Q. Did you discuss the risks that would be created by the
16 surgery itself?
17 A. To some extent, but not very much. As I say, I do not
18 know whether it is naivety. I knew he needed surgery;
19 if he did not have it, he would die, so if the risks
20 were a million to 1, I would still have to go with
21 that 1.
22 Q. Was this surgery that was being proposed at that time
23 final surgery or merely temporary surgery at this stage?
24 A. It was temporary surgery.
25 Q. What was it intended to do?
0015
1 A. To buy him some time until he was older, a bit bigger.
2 Q. I think the surgery being proposed was firstly repair of
3 the coarctation of the artery and banding of the
4 pulmonary artery; is that right?
5 A. Yes.
6 Q. So the surgery was proposed and I think it is right, is
7 it not, that you and your partner gave consent to it?
8 A. Yes.
9 Q. What were the procedures involved for preparing Joe for
10 the operation? What did you do?
11 A. He was in the Special Care Baby Unit at the Maternity
12 Hospital at this stage. He was scheduled to be taken
13 for surgery at 2 o'clock. Unfortunately, it was delayed
14 a few hours. I think he eventually went at 6 o'clock.
15 I stayed with him whilst he was in the incubator and
16 a porter came to collect him. I can remember saying to
17 the porter, "Can I just have another half an hour?"
18 because I was fully aware that he might be taking him
19 away and that was it, but I stayed with him for as long
20 as possible and the porter came and took him to surgery.
21 Q. What did you do whilst Joe was having surgery?
22 A. I just waited.
23 Q. So when did you next have news of Joe, then,
24 Miss Jordan?
25 A. A few hours later, because at that stage, because I had
0016
1 had a Caesarean, I was a patient in the Maternity
2 Hospital, although I did not stay there, I was usually
3 with Joe, so we waited.
4 Q. Who brought you some news then?
5 A. On the initial --
6 Q. Can you tell us how you heard the news of what had
7 happened in the operation?
8 A. When he was born, we were waiting for him in the
9 intensive care, because by then it would be the
10 Children's Hospital, he had been taken back to the
11 Children's Hospital, and I waited in a family room in
12 intensive care for him to come back.
13 Q. This is from the operation we have just been describing,
14 the coarctation?
15 A. Yes.
16 Q. What was the outcome of the operation?
17 A. Everything went according to plan.
18 Q. So how did you feel about that?
19 A. It was really quite strange -- I could not believe that
20 he would come back -- and obviously delighted, elated,
21 because I was willing to take him home with a drip in
22 his head or anything to keep him alive. When he came
23 back, I was thrilled.
24 Q. And he came back to the Intensive Care Unit of the
25 Children's Hospital; is that right?
0017
1 A. Yes.
2 Q. Can you just describe how long it took Joe to recover
3 from that operation and go home again?
4 A. He stayed in intensive care for possibly three weeks,
5 and then we went to the Special Care Baby Unit which is
6 a bit further along the corridor in the Children's
7 Hospital, so we stayed for approximately 6 weeks before
8 we went home.
9 Q. What was your impression of the nursing care that was
10 given to Joe at that time?
11 A. Absolutely brilliant. They were equally as concerned
12 for me as they were for Joe, not medically for me,
13 obviously, but mentally for me. They did everything
14 they could. I could hold Joe -- as soon as I could hold
15 Joe they let me hold him, and I could wash him. Yes,
16 they were marvellous.
17 Q. Did they help you in trying to find out how you could
18 care for Joe at this stage, then?
19 A. Yes.
20 Q. And what about explanations of how Joe was at any
21 stage? Who offered those to you?
22 A. Anybody and everybody I asked. There was never any --
23 if I asked a question, they told me. It was not "I will
24 find somebody else who can explain". They explained
25 it -- anyone whom I asked, they helped me.
0018
1 Q. Did you see Mr Dhasmana at any stage during that period?
2 A. All the time, yes. He was always there.
3 Q. What do you mean by that? He cannot have been there
4 every moment of the day?
5 A. He was there, no matter what time of day, I would often
6 say, I joked with him, because he seemed to be there two
7 or three times a day, seven days a week, and I would
8 often say, "Does your wife remember what you look like?
9 Does she have a photo of you on her mantelpiece?"
10 because he always seemed to be at the hospital caring
11 for the children.
12 Q. How did he react or interact with Joe, then?
13 A. Some doctors are very officious, but Mr Dhasmana, if
14 ever he came to see Joe, it always struck me that when
15 he undid his nappy to check him over, instead, when he
16 finished, of walking away, he always made sure his nappy
17 was done up, and I remember thinking that not all of the
18 doctors do that.
19 Q. So after about six weeks, you were able to take Joe
20 home; is that right?
21 A. Yes.
22 Q. Did he have any medication that he had to take at that
23 stage?
24 A. Yes.
25 Q. Any instructions for his care?
0019
1 A. Yes. I had it all written down, an idiot guide,
2 idiot-proof guide to giving him his medicines.
3 Q. Where was he receiving follow-up care at that stage?
4 A. Fortunately we lived just a stone's throw from Musgrove
5 in Taunton, so I could take him over to Musgrove to see
6 any doctors over there, if need be, and we went to the
7 outpatients in Bristol.
8 Q. How did Joe develop after the first operation?
9 A. As a normal child should develop. In the early days he
10 would grow like any other children. A difference only
11 became apparent when -- I do not know at what stage
12 babies are supposed to roll themselves over, but Joe
13 never actually moved. He would never try and roll
14 himself over. When I went back to the outpatients,
15 I would say "He can't go blue because he does not do
16 anything". I do not think they really believed he did
17 nothing. He did not roll over, try and crawl, or ...
18 Q. Did that cause you concern?
19 A. I justified it. I justified all his shortcomings.
20 I can justify them in my mind. There were reasons, he
21 was okay, it was fine.
22 Q. So you were perhaps noticing that Joe's general
23 development was perhaps a little slow?
24 A. Yes.
25 Q. Was there any time when he gave you particular concern?
0020
1 A. In what ...
2 Q. I think there is an incident you talk about in your
3 statement in October or November 1992 --
4 A. I could not put a coat on him. He would never wear
5 a coat because he used to sweat. It was a really cold
6 day, a hat and scarf day, and Joe was in a sweatshirt in
7 his pushchair, because he used to sweat quite a lot.
8 I could justify that because he had a cold. To anyone
9 else it would look quite cruel on a cold day to be
10 taking a small child out in a sweatshirt, but he did use
11 to sweat.
12 Q. In your statement, if we could look at paragraph 13 of
13 witness statement 26, page 5, please, paragraph 13, you
14 talked about a particular incident in October or
15 November when you took him into Musgrove Park Hospital.
16 I think it is right there you found out that some of the
17 medication given to you was incorrect. It is right, is
18 it, that that was prescribed at Taunton rather than
19 anywhere in Bristol; is that correct?
20 A. That is correct, yes.
21 Q. You then go on to speak about the fact that you were
22 having regular check-ups with Dr Jordan, or also
23 possibly seeing Mr Dhasmana; is that right?
24 A. I never -- yes. Mr Dhasmana in the outpatients or
25 Mr Jordan, yes.
0021
1 Q. What was the concern being raised by these doctors about
2 Joe's development at that stage? Were they worried
3 about his health condition?
4 A. We went for out-patient check-ups as a formality,
5 obviously, because he needed further heart surgery, and
6 it was only when we went in November, on this particular
7 occasion, one day all of a sudden I could not put his
8 shoes on any more, his feet totally puffed up.
9 Fortunately the following week we had a regular
10 outpatients appointment, and it was then that they said,
11 "Oh, yes, we think the surgery should be sooner rather
12 than later".
13 Q. So they were bringing forward the timetable of Joe's
14 next surgical procedure?
15 A. Yes.
16 Q. Was it explained to you what needed to be done to Joe at
17 this next stage?
18 A. Yes.
19 Q. Can you tell us what that was?
20 A. This was when I was drawn the diagram possibly with the
21 roundabout, and the replumbing that Joe's heart needed.
22 Q. So you understood that there was some further surgery
23 needed that would involve replumbing. Was there any
24 detailed description given of that surgery?
25 A. Yes. Again, I had all the diagrams and, yes, I knew
0022
1 exactly what the aim was.
2 Q. Can you tell us, was it regarded as being risky
3 surgery --
4 A. Yes.
5 Q. Or was it straightforward?
6 A. It was risky surgery.
7 Q. What did you understand that to mean?
8 A. That he might not survive.
9 Q. Did you have any discussion of how likely it was that he
10 might or might not survive?
11 A. I think I always tried to look upon it -- always in
12 a positive way: yes, everything was going to be all
13 right. I kept telling myself since the day he was born
14 he was going to be all right. I knew that there were
15 risks, but I just had to believe he was going to be all
16 right.
17 Q. What was the alternative to not having the surgery?
18 A. He would die.
19 Q. So did you ever seek to put percentage chances on the
20 risk --
21 A. I did not really -- they were almost irrelevant to me.
22 As I say, he needed the surgery. Without surgery, he
23 was going to die. He needed the surgery.
24 Q. Could we just have a look at medical record 1679/325 on
25 my screen, please? This is a letter of July 1992. If
0023
1 we could scroll it up, it is a letter of July 1992. You
2 will see it is from Mr Dhasmana. It is talking about
3 "a meeting with Joe's parents", that is yourself, and
4 partner, with Mr Dhasmana. He is discussing the advice
5 that he gave to you. He says there:
6 "As discussed in the meeting, Joe needs total
7 cavo-pulmonary connection and at the same time, the main
8 pulmonary artery to aortic anastomosis need to be
9 carried out because of moderate subaortic obstruction."
10 Is that the procedure which was being described to
11 you at the time?
12 A. Yes.
13 Q. Then Mr Dhasmana continues:
14 "This is a major procedure and does carry a rather
15 high risk."
16 He puts a figure on it there, 20 to 25 per cent.
17 Is that a figure that you have any recollection of
18 him mentioning to you?
19 A. I cannot really -- I cannot say, no, that I can remember
20 this.
21 Q. So it might have been something that he might have
22 mentioned but you can't remember one way or the other?
23 Is that a fair summary?
24 A. Yes.
25 Q. So Joe needed surgery. He needed it sooner rather than
0024
1 later?
2 A. Yes.
3 Q. And you were obviously concerned to have it because as
4 you understood it, if he did not have it, Joe would die?
5 A. Yes.
6 Q. Was there any discussion of other risks that might be
7 attached to the surgery, such as, for instance, brain
8 damage?
9 A. Yes, yes.
10 Q. What was explained to you about that, Miss Jordan?
11 A. That it was a possibility that they may have explained
12 it further, but I did not -- I am not an ostrich, but
13 I did not want to worry about things that might --
14 I cope with things when things happen. I do not want to
15 anticipate having to cope with things, so I possibly
16 turned myself off.
17 Q. Was there any discussion of the drugs that Joe might
18 need after the surgery?
19 A. Yes, yes.
20 Q. What were you told about that, Miss Jordan?
21 A. That he would need -- I was explained everything, that
22 when he had had surgery he would be given drugs to help
23 him. That some of his heart basically would not have to
24 work the rest of his body, he would have drugs to work
25 the rest of his body until his heart was strong enough
0025
1 to take over again.
2 Q. Having had all these matters described to you, what were
3 your feelings about the prospects of the operation and
4 your feelings about Mr Dhasmana carrying it out?
5 A. I can remember before we went in, we had the letter to
6 say that Joe was scheduled to have heart surgery, and
7 I can remember, I said to people, I was adamant
8 Mr Dhasmana was to do it. I said "I hope they do not
9 give me anyone else", because I had had such faith in
10 his abilities in the past, I was quite adamant only
11 Mr Dhasmana was going to do it. Obviously I was
12 petrified for Joe going into surgery again.
13 Q. You say you had great faith in Mr Dhasmana. Can you
14 just tell me and this Inquiry on what you base that
15 faith?
16 A. Purely and simply because I was told there was no hope
17 for him myself and he got to two years old. He would
18 help me. I had such admiration, and felt such
19 admiration and gratitude to him, for the two years he
20 had so far, and I had a feeling he would see we were
21 okay again.
22 Q. Did you ever consider sending him anywhere other than
23 Bristol?
24 A. No.
25 Q. Why not?
0026
1 A. I did not want anyone else. Mr Dhasmana was the only
2 person I wanted to continue our treatment.
3 Q. So arrangements were made for surgery, and at some point
4 Joe was taken into hospital for that surgery to be
5 carried out?
6 A. The day after his second birthday.
7 Q. So where was he taken?
8 A. To the BRI.
9 Q. That was the first time he had been admitted to the BRI
10 then; is that right?
11 A. Yes.
12 Q. What impression did you form of the ward there, compared
13 to the Bristol Children's Hospital?
14 A. When I first heard I was going to the BRI, I was
15 slightly daunted in that we had always been to the
16 Children's Hospital and I knew where I was, I knew where
17 the sandwich machine was and I knew where I slept and
18 I knew where the wards were, so I felt quite comfortable
19 being there. They told me this was at the BRI and
20 I felt slightly daunted, I do not know where I have to
21 go and all that. But I had a letter before with
22 a contact name and number of someone I could ring, so
23 I rang up a few days before and introduced myself and
24 said I was coming up. She expected me, and she
25 reassured me about the hospital and when we got there,
0027
1 I felt a lot happier, having had the contact before.
2 Q. Contact with whom? Who was showing you around or
3 assisting you there?
4 A. A cardiac liaison, I do not know if they call her
5 a sister, officer or nurse, Helen Stratton.
6 Q. What was her role?
7 A. She was basically a go-between, between medical staff
8 and parents, so if there is anything you did not know or
9 did not understand, you could ask her and if she did not
10 know or could understand, she would find out for you.
11 Q. Was that helpful?
12 A. Absolutely wonderful.
13 Q. How good were the medical staff in general in dealing
14 with your feelings, your concerns about Joe's operation?
15 A. They were marvellous. They were really marvellous.
16 They were so thoughtful, and as I say, they thought of
17 me equally as much as they did Joe and they looked after
18 me.
19 Q. If we could have a look, please, at medical record
20 1679/466, if we could just scroll up three or four
21 lines, this is a note made on 20th January, I think, by
22 one of the nursing staff, very shortly after Joe had
23 been admitted and it is a note of a record with you and
24 your partner. It is rather difficult to read, but if
25 you look at the faint writing just about six lines down,
0028
1 you will see that Joe is noted as having slept for long
2 periods, and then:
3 "Both parents feeling anxious, very anxious. Dad
4 very quiet. Mum frightened. She does not want to be
5 woken during the night with bad news. She wants to stay
6 by the bed in ITU."
7 Then they mention that is due to a previous
8 experience when he was in ITU. Then there is a note:
9 "Does not want anyone to say, 'I know how you
10 feel'."
11 Can you remember that discussion?
12 A. Yes.
13 Q. Is that a summary of how you were feeling at the time?
14 A. "I know how you feel." It is the most patronising
15 statement ever written. No-one knows me, no-one knows
16 how I feel. Yes, I can remember.
17 Q. It mentions there that you would like to stay by the bed
18 in the ITU?
19 A. Yes.
20 Q. Were you able to do that?
21 A. Yes.
22 Q. So what did you do as Joe was -- firstly, immediately
23 after the operation, thereafter, what arrangements were
24 made?
25 A. I felt happier, sat next to him I felt happier, because
0029
1 I could see if anything was happening, anything was
2 going wrong, I was there and I could see it. I did not
3 want to be called, "Can you come now, please". I was
4 sat there right next to him the whole time.
5 Q. You have described the role of Helen Stratton in
6 assisting you and the nursing staff also taking a record
7 of your concerns, your feelings. What did you do as Joe
8 went into the operation?
9 A. They came and got him from the ward quite early on in
10 the morning, about 7 o'clock, the porter came to collect
11 him with Helen, and the nurse. I carried him -- he did
12 not want to go on the porter's trolley -- down a lift
13 into the operating theatre and took him into the
14 operating theatre and I held him until they put him to
15 sleep.
16 Q. What did you do then?
17 A. They told me to go away from the hospital for the day,
18 but that is easier said than done. I wandered away from
19 the hospital for a few hours, but I went back just
20 before lunchtime to see if there was any news.
21 Q. When you went back, was there anywhere that you could
22 wait?
23 A. Yes. I could go in the parents' waiting room, or I had
24 a room at the hospital if I wanted that I could sleep
25 in. I could have gone back there.
0030
1 Q. So what news did you receive of the operation and how it
2 had gone?
3 A. I went back at lunchtime and I was told that when they
4 had opened up Joe, it was not exactly as they had
5 thought, so they were having to go and look at the
6 records and the scan, the videotapes, again, to reassess
7 what they were going to do.
8 Q. Did you get the impression they had to stop the
9 operation for that?
10 A. Yes.
11 Q. So what had happened in the meantime? Were you told?
12 A. I am sorry, I do not understand.
13 Q. If they had had to stop the operation for that --
14 A. I had visions of Joe being on an operating table all
15 open whilst they went in the other room and had a cup of
16 tea, yes.
17 Q. What did they explain they were doing whilst they were
18 checking the tapes, the records, to see what was going
19 on?
20 A. I am sorry, I do not --
21 Q. What happened to Joe in the meantime? You said you had
22 visions of him waiting while they had a cup of tea. Do
23 you know what happened to him in the meantime?
24 A. No. He was in the operating -- no.
25 Q. So do you know how long that gap lasted?
0031
1 A. No, I do not.
2 Q. So what was the next news that you had?
3 A. I then regularly went back to Helen to ask her if she
4 had any news.
5 Q. What news did you next get of the operation?
6 A. The nurses let me use their swimming-pool at the
7 hospital, so in the afternoon I actually went swimming
8 and I went -- I finished swimming, I went back to my
9 room to get changed and Helen was waiting at the door
10 and I walked, I saw her at the end of the corridor, and
11 I thought "There is something terrible has happened".
12 She said "No, it is all right, he has come off --" in my
13 mind, I knew or I thought I had this fixation in my mind
14 he had to come off the bypass machine, and I just wanted
15 to know when he had come off the bypass machine, and she
16 was there to tell me he had come off the bypass machine.
17 Q. When did you next see Joe?
18 A. It was about early evening in the intensive care.
19 Q. How did he look?
20 A. As I expected.
21 Q. Which was how?
22 A. He was connected, wire --
23 Q. Were they able to tell you anything about how the
24 operation had gone at that stage?
25 A. Yes. They explained, Mr Dhasmana explained exactly what
0032
1 he had done. Yes, I think he was stable.
2 Q. What did he say about what he had done?
3 A. He had done -- he achieved what he set out to achieve.
4 Q. So the operation had been successful in that Mr Dhasmana
5 had succeeded in what he set out to do?
6 A. Yes.
7 Q. What were Joe's prospects at that time, as you
8 understood them?
9 A. I was totally aware he was no way out of the woods and
10 it would be days, weeks, however, before he was on the
11 road to recovery.
12 Q. So what were the sort of problems that Joe was still
13 encountering at that time?
14 A. I think the rest of his body packed up eventually, one
15 by one, because I would say, "He came in for heart
16 surgery; why has the rest of his body broken down?"
17 He had a clot on his liver and then pneumonia on his
18 lungs; then he had no bowel signs, he stopped going to
19 the toilet, but it did not happen together; these things
20 happened one at a time. One got better and then the
21 next hurdle to overcome. The worst was he had
22 a terrible temperature and they could not find out where
23 the bug, the germ, was.
24 Q. What was Mr Dhasmana saying to you at that time about
25 Joe's prospects?
0033
1 A. He told me the truth, every single time I asked him, he
2 told me the truth. He never ever said to me "He will be
3 all right". In fact, we had been there several weeks
4 and I just wanted someone to say something nice about
5 Joe, I just wanted to hear something positive, because
6 it was always very honest, very truthful, and never
7 overly positive, and I actually said, "I want you to lie
8 to me, I want you to tell me, just for an hour, that he
9 is going to be okay" and he said he would never do
10 that. I just wanted someone to cheer me up for a short
11 time, even though I did not know it was true. I did not
12 care, I just wanted him to say those words to me. He
13 said "I will not say that until you are on your way
14 home".
15 Q. How often did you see Mr Dhasmana?
16 A. Three times a day, every day, even on Saturdays and
17 Sundays.
18 Q. Was he the only person explaining to you how Joe was?
19 A. No, I would see an anaesthetist, they were good at
20 explaining and the nurses every day would explain to me,
21 because I did say, I did not sleep all night next to
22 Joe's bed, I would try and sleep in the room and get
23 back half 5, 6 o'clock in the morning, and I would see
24 the night nurse before the day nurse came on. They
25 explained everything and went through the charts with
0034
1 me, so I understood how it was going.
2 Q. Were you able to assist in Joe's care in any way at this
3 stage?
4 A. Yes. I would wash his mouth out, pack him in ice,
5 because we had to try and take his temperature down, go
6 down to the porter, get the ice bucket, pack him in
7 ice. I washed him. So I cared for him as much as
8 I could.
9 Q. So what impression did you form of the Intensive Care
10 Unit at the BRI as opposed to the BCH?
11 A. Both hospitals were faultless. The nursing care was
12 faultless in both hospitals.
13 Q. Were there any differences in the atmosphere at the two
14 units?
15 A. The BRI possibly is darker, quieter, because it is
16 primarily for adults. There are just two beds set aside
17 for children, so it is quite quiet and dimly lit.
18 Q. Were there any adults there as patients in the ICU
19 whilst Joe was there?
20 A. Yes.
21 Q. Did that make any difference to how you felt about the
22 treatment that Joe was receiving?
23 A. At the time, no. No.
24 Q. And now?
25 A. Because Joe was not -- he was getting better. His body
0035
1 parts were getting better, but he was not very -- he did
2 not respond, he was not very responsive and Mr Dhasmana
3 suggested that he go into the Children's Hospital where
4 it is brighter and sunnier, the atmosphere. We left on
5 Sunday morning and in an hour we were in the Children's
6 Hospital. After being at the Children's Hospital for an
7 hour, it was unbelievable, the difference, in Joe. He
8 perked up, he was alert, he was responsive. It was
9 miraculous.
10 Q. Why do you think he changed in that way so quickly?
11 A. Possibly because there were children shouting, laughing,
12 screaming, crying and it is much more colourful and
13 bright. We were out of the dark lighting.
14 Q. Had you come directly from the ITU at the BRI?
15 A. Yes.
16 Q. So Joe was there all long?
17 A. Yes.
18 Q. He was not moved at any stage to a children's side ward?
19 A. No.
20 Q. You have described how Joe was eventually moved to the
21 Children's Hospital. How long was that after the
22 operation, roughly?
23 A. Approximately six weeks.
24 Q. How much longer did he spend in hospital after that?
25 A. Another four weeks.
0036
1 Q. So after that, what happened?
2 A. In the Children's Hospital?
3 Q. Yes.
4 A. We were actually, after three days, put in an isolation
5 ward, because there were bugs on the ward, so more for
6 Joe's protection than anything else, he was put in an
7 isolation booth, but Joe could still see the other
8 children, so he was picking up all the time.
9 Q. Did you see anything of Mr Dhasmana in the Children's
10 Hospital?
11 A. Yes. He came to visit us over there, possibly not three
12 times a day, twice a day.
13 Q. So how did Joe progress once the move had been made to
14 the Children's Hospital?
15 A. Fast and furious. He got better.
16 Q. And you were able to take him home?
17 A. Yes.
18 Q. How is he now, Miss Jordan?
19 A. He is a normal, happy, well-adjusted little boy. He is
20 eight years old, he goes to a normal school, he plays in
21 the village football team. He just looks very
22 different. He just knows he was born with a broken
23 heart but he is all right now.
24 Q. He is still under the care of the Bristol Royal
25 Infirmary, the Bristol Children's Hospital; that is
0037
1 right, is it not?
2 A. Yes.
3 Q. Who does he now see?
4 A. He sees Alison Hayes.
5 Q. Is there any need for further surgery, do you think?
6 A. Possibly, but, again, I will cope with that when the
7 time comes. I do not want to anticipate -- I do not
8 want to anticipate worry; I will cope.
9 MISS GREY: Thank you, Miss Jordan. I think the panel may
10 or may have not some questions.
11 Examined by THE PANEL
12 THE CHAIRMAN: Before I ask my colleagues on the panel
13 whether they have any questions, is there anything you
14 would like to add yourself that maybe Miss Grey did not
15 ask you that you would like to tell us, or to clarify?
16 There may not be, but feel free, if you wish to now.
17 A. I do not think so. To this day, I cannot believe that
18 this has happened to someone like Mr Dhasmana.
19 Obviously, I held him in such admiration and gratitude,
20 and he was such a genuinely caring person, I cannot
21 believe that this can have happened to him. I owe him
22 my son's life. I think this must be devastating for
23 someone that was as caring as he was.
24 THE CHAIRMAN: There are no questions from us, but is there
25 any re-examination?
0038
1 MR SHARP: No, thank you, sir.
2 THE CHAIRMAN: I am grateful. Thank you very much for
3 coming and telling your story and Joe's story. If you
4 wish to get in touch with us again, if there is anything
5 else you want to tell us, please realise we will be here
6 for a while and we will always be happy to hear from you
7 if you have anything else to tell us. Thank you for
8 coming to talk to us today.
9 (The witness withdrew)
10 MISS GREY: I think that might be an appropriate time to
11 take a quarter of an hour's break before the next
12 witness, Mrs Plackett.
13 THE CHAIRMAN: I am grateful, yes. A quarter of an hour, so
14 we reconvene just after 20 to, thank you.
15 (11.25 am)
16 (A short break)
17 (11.40 am)
18 MR LANGSTAFF: Sir, Mrs Penelope Plackett, please.
19 Mrs Plackett, I think, as you know, we have
20 adopted the practice of someone standing to take the
21 oath or affirm, if you would like to do that now,
22 please.
23 MRS PENELOPE PLACKETT (Sworn):
24 Examined by MR LANGSTAFF:
25 Q. Mrs Plackett, your full name is Penelope Plackett, and
0039
1 you prefer to be known as Pen?
2 A. Yes.
3 Q. You are the mother of Sophie Louise Plackett?
4 A. That is right.
5 Q. She was born on 23rd June 1988?
6 A. That is right.
7 Q. So she is now 10 years of age?
8 A. Yes.
9 Q. What you are going to tell us about is an operation for
10 truncus arteriosus which was performed by Mr Dhasmana
11 and after that operation, it emerged that Sophie was
12 brain-damaged?
13 A. That is right.
14 Q. You have been caring for her since?
15 A. That is right.
16 Q. The operation you are going to tell us about took place
17 on 22nd November 1988. That would be when Sophie was
18 almost exactly to the day 5 months old?
19 A. That is correct.
20 Q. You already had, I think, another daughter, Charlotte?
21 A. That is right.
22 Q. Who was what, 6 years old when Sophie was born?
23 A. Yes.
24 Q. And Sophie was your second child?
25 A. Yes.
0040
1 Q. A normal birth?
2 A. Yes -- no, sorry, Caesarean.
3 Q. But the weight was a normal weight?
4 A. Yes.
5 Q. And that was in Exeter, was it?
6 A. Yes, it was.
7 Q. At the Wonford Hospital?
8 A. At Heavitree Hospital.
9 Q. What was your first knowledge that anything might be
10 untoward about Sophie?
11 A. About two days after she was born she was seen by
12 a paediatrician, in fact, I think there were two
13 paediatricians. One was Dr Orme and the other was
14 a more junior doctor and they came and examined Sophie,
15 as they did all new-born babies, and Dr Orme told me
16 that Sophie had a heart murmur. He did not give me any
17 indication as to how serious it might be, and he told me
18 not to worry, just go home and she would have an
19 appointment to see a cardiologist when he had his clinic
20 in Exeter. That happened when Sophie was about three
21 months old.
22 Q. So there was a heart murmur picked up?
23 A. Yes.
24 Q. But no investigations were conducted then by the
25 hospital?
0041
1 A. No.
2 Q. Nor was there any referral by that hospital?
3 A. The only referral I was given was that she would see the
4 cardiologist when he came down to Exeter.
5 Q. So what you were actually told was that there would be
6 a referral, but it would take -- how long were you given
7 to understand?
8 A. They told me he came down every month but the list was
9 full for the following month, so she would see him in
10 two months time, which is what happened. There did not
11 seem to be any urgency about it.
12 Q. So no immediate referral. Two months later, I think in
13 August 1988, you saw a locum cardiologist, Dr Benatar,
14 I think his name was, although you may not recall it?
15 A. Yes, I did recall it, actually.
16 Q. Let us look, please, on my screen first, at 2459/139.
17 Can we go back up to the top for a moment? This is in
18 relation to a clinic on 26th August 1988. Can we scroll
19 down below the address, please?
20 This is a note by Dr Benatar about the clinic and
21 he says, in the third line:
22 "A cardiac murmur was heard on the third day of
23 life, but Sophie remained completely asymptomatic from
24 the cardiac point of view. Under more direct
25 questioning, the mother admits that Sophie has been
0042
1 panting since birth. She has not noted any change in
2 colour."
3 Was "panting" how you described it?
4 A. That is probably how I described it. What I meant was
5 that her chest moved very quickly. She was not gasping
6 for air or anything like that, but she was breathing
7 very quickly.
8 Q. Had you noticed anything untoward about Sophie's
9 development up to that stage?
10 A. No.
11 Q. How did she compare with your first born?
12 A. I would say absolutely on a par in every way. She was
13 meeting all her milestones at the correct time, and she
14 just had a completely normal development.
15 Q. The very last full paragraph of that:
16 "The clinical findings as well as the ECG and
17 chest x-ray would suggest a diagnosis of truncus
18 arteriosus. I will attempt doing an echocardiogram here
19 today in order to elucidate the diagnosis. If the
20 images are of poor quality, we will ask Mrs Plackett to
21 bring Sophie to Bristol for better imaging."
22 In fact, was the consequence, the upshot of this
23 investigation by Dr Benatar that Sophie was indeed
24 referred to Bristol for a catheterisation?
25 A. Yes, she was. He tried to do an echogram at Exeter but
0043
1 they only had a portable ultrasound machine and he said
2 he could not get a clear picture of her heart on it. He
3 said he wanted Sophie to go to Bristol to have a cardiac
4 catheter which would give a very clear picture as to
5 what was wrong with her heart.
6 Q. Can we look at 2459/130 on my screen? The date of this
7 is 6th September 1988, and again if we can scroll up,
8 just below the address, please, it is addressed to
9 Dr Joffe, who was the cardiologist that you understood
10 Sophie was to come under?
11 A. Yes.
12 Q. Although I think you did not see him until very much
13 later?
14 A. No, I did not.
15 Q. If we look at the letter, please:
16 "This is a girl seen by Avram Benatar while you
17 were on leave and I thought you would like an update on
18 her progress. Her mother was not quite sure as to
19 exactly when it was proposed to get her up to Bristol."
20 A. No, that is right. I had not got a date at that time.
21 Q. Sophie had been seen initially, the murmur was picked
22 up. There was a need for a referral but it was delayed
23 because the clinics are full. She is seen towards the
24 end of August, and then here we are, in September, and
25 nothing had yet been arranged?
0044
1 A. No, that is right.
2 Q. When in fact was the catheterisation eventually
3 arranged?
4 A. Sophie must have been about four months old when she
5 finally had the cardiac catheter, probably slightly
6 younger than that, three and a half months.
7 Q. That, I think, was what, 22nd September 1988?
8 A. I cannot remember the exact date.
9 Q. I think that is the date we pick up from her medical
10 records. Awaiting that, did there seem to be anything
11 untoward with Sophie's condition?
12 A. Apart from her breathing quickly and tiring quickly,
13 Sophie was just like any other child. She liked going
14 in her baby bouncer, she enjoyed playing with toys, she
15 liked music, she liked being cuddled as all babies do.
16 She was feeding well but not gaining much weight, but
17 apart from the fast breathing and slightly underweight
18 for her age, she was just as I would have expected her
19 to be at that age.
20 Q. Did you ask questions of anyone as to what truncus
21 arteriosus was?
22 A. At that time I was seeing Sophie's paediatrician,
23 Dr Orme, about every other week at Exeter Hospital, and
24 he was at great pains to explain to me what truncus
25 arteriosus was. He drew diagrams for me on two
0045
1 occasions, I believe, to show me what Sophie's heart was
2 like and what a normal heart was like and to show me
3 what the operation would entail if Sophie underwent the
4 operation in the end.
5 Dr Orme was my immediate contact and the person
6 I asked all the questions of at that time.
7 Q. Did you ask him why, for instance, the operation had to
8 be done in Bristol and not in Exeter?
9 A. No, I did not.
10 Q. Was anything said about Bristol as centre of surgery?
11 A. Dr Orme told me that the results at Bristol were
12 excellent and on one occasion he also told me that he
13 knew of a child in the Exeter area who had had Sophie's
14 particular operation and who was running around fit and
15 well like a normal child.
16 Q. Was anything said to you by him -- I appreciate he is at
17 Exeter and not at Bristol, but was anything further said
18 by him to you about the risks of the operation?
19 A. He made it quite clear to me and I understood quite
20 clearly that there were risks, particularly as Sophie
21 was such a young child and particularly as it was open
22 heart surgery that she would need.
23 Q. You then took Sophie -- or was she taken -- to Bristol?
24 A. I took her.
25 Q. For the catheterisation?
0046
1 A. Yes.
2 Q. If we could just look and trace it through, please,
3 2459/129, I do not know if you have seen any of your
4 daughter's records since?
5 A. I have seen some of them, yes.
6 Q. What you are looking at here is a note of a meeting of
7 3rd October 1988. It is a review meeting at which were
8 present Drs Joffe, Cormack, Benatar, Hayes and
9 Mr Dhasmana. It is obviously about Sophie. It deals
10 with the catheterisation.
11 We can see what Mr Dhasmana, who writes this memo,
12 says about it: "catheterisation on 22nd September",
13 which is why I gave you that date a moment or two
14 ago, "a further diagnosis of truncus type 1 with some
15 doming of the truncal valve ... gradient of 30 mm across
16 the truncal valve."
17 He deals with truncal saturation, and then
18 pulmonary vascular resistance, and someone has
19 underlined this. "Angiogram does suggest marked
20 pulmonary vascular changes on both lung fields.
21 "According to catheter and angiographic data,
22 this patient is inoperable but her age, that is three
23 months, may make us reconsider. It was agreed we should
24 submit this patient fairly soon for a lung biopsy
25 followed by total repair next week if the lung biopsy
0047
1 was not positive for advanced pulmonary vascular
2 disease.
3 "Can I see the parents fairly soon in
4 outpatients, hopefully next week."
5 We see what he hopes to be within a week of
6 3rd October 1988 appears to have been arranged for
7 19th October at 2.30?
8 A. Yes.
9 Q. Did you develop an understanding from what you may have
10 been told as to why it was that the lung changes might
11 be affecting Sophie's chances in an operation?
12 A. After she had had the cardiac catheter, you were told
13 that the pressures in her lungs were extremely high for
14 a child of her age and that because the pressures were
15 so high, her lungs may have undergone some vascular
16 changes and if they had gone so far that the arteries
17 had actually hardened, then, if she had the operation to
18 repair the truncus, it would make her worse, not
19 better. So they had to ascertain at what stage the lung
20 damage was by that time and whether, if she had the
21 operation, the lung damage could be reversed or whether
22 she was totally inoperable by this stage.
23 Q. So the question was a function, as you understood it; of
24 time?
25 A. I am sorry, what are you asking me?
0048
1 Q. As you understood it, the longer the condition had gone
2 on uncorrected, the greater the damage was likely to be
3 on the lungs?
4 A. Most definitely. I was told it was urgent she had the
5 operation, if her lung damage had not gone too far. It
6 was imperative that she was operated on immediately.
7 Q. Who told you that it was urgent?
8 A. Mr Dhasmana.
9 Q. Do you recall when it was that he told you that?
10 A. I believe we saw him in outpatients at Bristol, after
11 she had had her cardiac catheter. I also spoke to
12 Dr Benatar after the catheter, immediately after the
13 catheter, and he told me that the catheter had shown
14 that his diagnosis of truncus was correct and it had
15 also shown that the pressures in her lungs were very
16 high, but it had shown it was a truncus type 1, the
17 easiest type to repair and he said she would have to
18 have an operation as soon as possible.
19 Q. If we have a look, please, dealing with that
20 conversation in outpatients, at the previous record,
21 2459/128, again, if I just mention the date and then
22 scroll down on my screen before it goes to the public
23 screen, the date is 19th October 1988. It is a letter
24 from Mr Dhasmana to Dr Joffe. It is about Sophie. Can
25 you enlarge it?
0049
1 The body of the letter:
2 "Thank you very much for asking me to see this
3 baby who has persistent truncus arteriosus type 1.
4 Unfortunately with pulmonary vascularity. I am
5 disappointed to note that her pulmonary vascular
6 resistance was calculated at 9.94 per square metre. The
7 angiogram also suggested marked pulmonary vascular
8 changes on both lung fields, but this baby is only 3 and
9 a half months old and I feel we should proceed with lung
10 biopsy before making a final decision. I have therefore
11 put her name on the list for a lung biopsy next week.
12 "I have explained Sophie's cardiovascular data,
13 clinical findings and our plan of action to Sophie's
14 parents, to which they have agreed. I hope I may be
15 able to help Sophie in the future."
16 How does that reflect what Mr Dhasmana told you in
17 the last paragraph? Did he explain the cardiovascular
18 data, clinical findings and plan of action to you?
19 A. Yes, he did.
20 Q. Apart from stressing the urgency, do you recollect what
21 in general terms he told you?
22 A. Well, he did stress the urgency that this must be done
23 as soon as possible. He did stress that he could not go
24 ahead with the operation until this lung biopsy had been
25 done, and until he had the results. And he did say that
0050
1 it might still come to it, but he could not actually
2 operate on Sophie, that we would have to wait for the
3 lung biopsy results before we knew.
4 Q. So everything now depended on the biopsy?
5 A. Yes.
6 Q. There is one record I would like to ask you about which
7 arises in relation to this time. It is 2459/193.
8 It is three days after the biopsy, which was
9 24th October 1988, so you tell us in your statement, and
10 of course that is right.
11 THE CHAIRMAN: Do you wish me to bring it up?
12 MR LANGSTAFF: Yes. Can I please ask the screen to focus
13 on the entry for 27th October 1988?
14 Obviously it is looking at a time just after
15 Sophie was transferred from the ITU on the occasion
16 following her biopsy, but it is what follows I want to
17 ask you about:
18 "Two conflicting stories told to parents: one that
19 she probably won't live to be a year; the other that she
20 may get to her teens and be a heart/lung transplant
21 candidate! Information taken from sister on ITU."
22 Is that what happened?
23 A. I do not remember it being on 27th October. I remember
24 us being given conflicting information. Mr Dhasmana on
25 the one hand was telling us if she did not have this
0051
1 operation, she would die within a year; she would be
2 dead before she was one year old. We spoke to
3 Dr Benatar also, and he said that was not necessarily
4 the case. He said that if we left Sophie, she may
5 live. She would have a very poor life, very poor
6 quality of life, she would not have a normal development
7 like other children because she would be so short of
8 breath, so tired all the time, she would not be able to
9 attend normal school, but he said she may live to her
10 teens and then be a candidate for a heart/lung
11 transplant. We found this information extremely
12 confusing. We were being told by one doctor she must
13 have this before she was 1, and by another doctor that
14 was not necessarily the case.
15 My memory is probably not clear on this, but
16 I remember this as being the night before her operation,
17 in fact.
18 Q. By "her operation", you mean the repair operation?
19 A. Yes.
20 THE CHAIRMAN: Mr Langstaff, may I interrupt for a moment?
21 We think that the matter that you read from the note,
22 the reading is not complete without your reference also
23 to the exclamation mark.
24 MR LANGSTAFF: Yes. I am very grateful. After the word
25 "candidate" there is an exclamation mark. That must be
0052
1 read into the text, I am very grateful.
2 So you had these two conflicting points of view at
3 some stage. You must have had them, if this note is
4 made on 27th October, before 27th October?
5 A. Yes, I must have done, but as I say, I just remembered
6 it being the night before the operation, but I must have
7 got that wrong. It must have been then.
8 Q. Then or before?
9 A. Yes.
10 Q. It was plain that you must have had a number of
11 conversations about this time with Mr Dhasmana on the
12 one hand and Dr Benatar on the other?
13 A. We tended not to see Dr Benatar after this time; it was
14 mainly Mr Dhasmana that we spoke to.
15 Q. In any event, let me go to the biopsy. Sophie was in
16 Bristol for the biopsy and stayed three days at the
17 Children's Hospital. You were obviously concerned to
18 know, particularly in the light of the expressions of
19 urgency that you had, what the results of the biopsy
20 were?
21 A. That is right.
22 Q. How did you find out?
23 A. It seemed to take for ever, I know it did not, but it
24 just seemed to take for ever to get these results
25 through. After a couple of weeks after the lung
0053
1 biopsy -- I had understood from Mr Dhasmana that we
2 might get the results the very same week of the biopsy,
3 if not the next day. But two weeks went by and I still
4 had not heard from him, so I phoned the hospital and
5 asked if they had the results.
6 I was told that the Bristol pathologist had looked
7 at Sophie's lung biopsy --
8 Q. Just pause there. You phoned and you were told, told by
9 whom?
10 A. I think what must have happened, from what I remember,
11 I phoned the hospital. I did not speak to Mr Dhasmana,
12 but I spoke to somebody on the ward, who then spoke to
13 him and phoned me back with this information. I cannot
14 remember who it was I spoke to.
15 Q. So you did not speak to Mr Dhasmana directly about this?
16 A. Not that I remember.
17 Q. But you understood that the information from whoever was
18 talking to you came from Mr Dhasmana because that is
19 what that person conveyed to you?
20 A. That is what I understood. I think that is right, yes.
21 Q. What did this person -- male or female, can you
22 remember?
23 A. I cannot remember.
24 Q. What did this person convey to you that Mr Dhasmana had
25 said about it?
0054
1 A. He had said that the pathologist at Bristol had looked
2 at Sophie's lung biopsy but was unable to come to
3 a conclusion. He could not decide whether the vascular
4 damage had gone too far to operate on Sophie. He had
5 asked that her biopsy should be sent to Great Ormond
6 Street to get a second opinion.
7 Q. Did he say anything further about what had happened at
8 Great Ormond Street?
9 A. I had to wait a long time, then. I think it was about
10 three weeks, and I was getting more and more anxious, in
11 that I had been told that this was an urgent operation
12 and the sooner she had it the better if the operation
13 was to go ahead at all.
14 So after waiting again, I had an appointment with
15 my paediatrician in Exeter, and during that appointment,
16 he said, "I have just heard from the pathologist at
17 Bristol, will you phone the hospital, because they have
18 the results from Great Ormond Street." He did not tell
19 me what those results were.
20 I then went home and phoned the hospital
21 straightaway. Again, I cannot remember exactly who
22 I spoke to, but I was told that the results had come
23 back from Great Ormond Street and that Mr Dhasmana
24 wanted to see me.
25 Q. Just picking that up in the medical records if we may,
0055
1 can we have on my screen, please, 2459/122?
2 This is a letter dated 18th November 1988, so it
3 is the best part of four weeks after the last
4 operation. If we just scroll down on my screen below
5 the date, again, it is -- below the address -- it is
6 written to Dr Joffe; it is signed by Mr Orme, who was
7 your consultant, or the consultant paediatrician to
8 Sophie at the Royal Devon and Exeter Hospital.
9 If we just read it:
10 "Dr Berry kindly telephoned through the result of
11 Sophie's biopsy and as it happened, I was able to pass
12 on the good news to Mrs Plackett when I saw them an hour
13 later in my clinic. In herself, Sophie remains much the
14 same and there is no change in her clinical signs. Her
15 weight gain is ... rather poor ... as expected.
16 "I think from everybody's point of view, the
17 sooner the operation can go ahead the better.
18 Mrs Plackett I think fully understands the seriousness
19 of the operation, but as she says, 'At least now I have
20 some hope'."
21 A number of prompts that letter may give us.
22 Date, 18th November 1988: how far does that correspond
23 with your memory of when it was that the results of the
24 biopsy came through. Was it just four days before the
25 operation? Or longer?
0056
1 A. I cannot believe it was only that short time before.
2 Q. So it is probably a letter Mr Orme has written later on?
3 A. I think possibly, yes. I cannot be absolutely clear on
4 that.
5 Q. Did he pass the good news on to you, or did you get it
6 from Dr Berry?
7 A. I do not think he did. I do not think I spoke to
8 Dr Berry either. I think it was Mr Dhasmana who told me
9 he was going to operate on Sophie.
10 Q. By phone?
11 A. By phone.
12 Q. We will come back to it, I think, at a later stage in
13 your evidence, but Mr Orme says that you fully
14 understand the seriousness of the operation, but "at
15 least now I have some hope."
16 Is that a fair reflection?
17 A. I did understand how serious the operation was. He had
18 been at great pains to explain to me how serious it was,
19 but I still do not remember him actually giving me the
20 results of the lung biopsy. I really do not think he
21 did. I am sure I got that from Bristol.
22 He knew that I was keen for Sophie to have the
23 operation, in that I understood if she did not, she
24 would be dead before she was 1, so he knew that if
25 I thought Sophie was going to have the operation, then
0057
1 I would have some hope for her. I had no hope at all,
2 if she did not have the operation.
3 Q. You had the two conflicting views put to you, it
4 appears, before the end of October as to what Sophie's
5 future might be with or without the operation. Had you
6 discussed that with Mr Orme?
7 A. I did discuss it with him, and he said to me, "Do you
8 want Sophie to go through life not being able to do
9 anything and not having a normal life-style at all?" and
10 of course, I had to say, "No, I want her to have the
11 operation and be like a normal child". All the way
12 through her care, before her operation, I was told that
13 if she survived the operation, she would have a normal
14 life; she would be like any child of her age.
15 Q. So he did not, for his part, take either doctor's side,
16 he just asked about your feelings, what you wanted for
17 Sophie?
18 A. I believe he recommended that she have the operation.
19 I believe he thought it was Sophie's only hope.
20 Q. Did you subsequently see Mr Dhasmana to talk to him
21 about the results of the biopsy?
22 A. We had to go to Bristol. We were told we had to be at
23 Bristol for the Friday night, which would be the
24 18th November? Is that right? Monday was the 22nd, was
25 it not? The 19th November. We had to go to Bristol.
0058
1 Sophie was to be admitted then and her operation was to
2 be done on Monday, 22nd November.
3 Q. Was that arranged by telephone with you?
4 A. Yes.
5 Q. And when you spoke to Mr Dhasmana, did he say anything
6 about the results of the biopsy and what Great Ormond
7 Street had found?
8 A. From what I remember, he said to me that the pathologist
9 at Great Ormond Street had also not been able to come to
10 any conclusion about Sophie's lung biopsy. He, too, was
11 unable to say whether her lungs had undergone so much
12 damage that she was inoperable, but he said, "As they
13 are inconclusive, I have decided to give Sophie a chance
14 and to give her the operation", and I was pleased about
15 that.
16 Q. You say that is as far as you recollect?
17 A. Yes.
18 Q. That sounds as though you may be a shade hesitant about
19 it. Are you, do you think?
20 A. The only reason I am a shade hesitant about it is
21 because I have discussed all my statement with my
22 ex-husband and the only thing we do not agree entirely
23 on is this one point. My husband cannot remember what
24 Mr Dhasmana said about the lung biopsy, even though he
25 spoke to him at the same time as I did.
0059
1 Q. By phone?
2 A. No. This was, I am sorry, we had a meeting with
3 Mr Dhasmana when we got to Bristol, and discussed all
4 this again. Now, I firmly believe I have a firm
5 recollection of what Mr Dhasmana said to me, and he said
6 that the lung biopsy was not clear and that Great Ormond
7 Street could not say whether Sophie was operable or not,
8 but he was going to give her a chance and give her the
9 operation.
10 Q. But in fairness, you point out that your husband's
11 recollection of the same conversation --
12 A. I have to be truthful and honest and say that my husband
13 cannot remember that. It is the only thing we do not
14 agree on.
15 Q. If we could just look, because you make a point in your
16 statement about this, just look and see what
17 Great Ormond Street had in fact reported, it is
18 2459/121.
19 It is a letter which is addressed to Dr Berry, the
20 pathologist at Bristol:
21 "Dear Dr Berry, re: Sophie Plackett. Thank you
22 very much indeed for asking me to look at the biopsy on
23 Sophie Plackett. As you will see from the report,
24 I quite agree with your findings and think that she is
25 operable, despite the high resistance found at cardiac
0060
1 catheterisation. I have asked my secretary to see if we
2 have a reprint of my Truncus Paper and if so, she will
3 certainly send you one."
4 Then there is a handwritten note saying:
5 "Sorry, we have run out.
6 "With kind regards, yours sincerely, Sheila
7 Haworth, Reader in Paediatric Cardiology".
8 "Received 14th November 1988", which may give us
9 some indication as to the time you had the conversation,
10 which must have been between the 14th and the
11 18th. "Copies to Mr Dhasmana and Dr Joffe."
12 So the point which you make in your statement is
13 that that is a positive recommendation as opposed to an
14 inconclusive one?
15 A. Yes.
16 Q. What did you understand was going to happen at the
17 operation?
18 A. It was explained to me by Dr Orme on two or three
19 occasions what was going to happen and Mr Dhasmana on
20 one of our meetings. It was explained to me instead of
21 two chambers at the bottom of her heart Sophie had only
22 one, and this would have to be divided by putting a wall
23 across it, and she would have to have another valve and
24 artery put on the side of the chamber that did not have
25 these; they were missing.
0061
1 Q. What did you understand the outcome was likely to be?
2 A. All the way through, I was told that there were serious
3 risks with the operation, but it was, you know, a major
4 operation for a small child to undergo; I was told it
5 was her only chance of life, and if she did not have it,
6 she would be dead by the time she was 1.
7 If she survived, she would have a normal life; she
8 would be like any child of her age. She would be able
9 to do anything that a normal child could do.
10 Q. So, so far as the risks of the operation succeeding at
11 all were concerned, or not succeeding, the principal
12 risk was one of not surviving to the age of 1?
13 A. Yes.
14 Q. Did you understand anything about the nature of the
15 risks of the operation so far as that was concerned?
16 A. Again, all the way through, I understood that her
17 chances were being put at roughly 50:50.
18 Q. So the toss of a coin?
19 A. Yes. She would either live or she would die.
20 Q. And when you say you understood they were being put as
21 what I have called a "toss of a coin", by whom?
22 A. By Mr Dhasmana and by Dr Orme.
23 Q. And that comes from --
24 A. Actually, that is not true. I am not sure Dr Orme put
25 a figure on it, but he did say that there were serious
0062
1 risks. But he did also say it was her only chance of
2 survival.
3 Q. So he was putting it to you on the basis of there being
4 no alternative?
5 A. Yes.
6 Q. Mr Dhasmana was saying it was 50:50?
7 A. Yes.
8 Q. So far as the operation was concerned?
9 A. Yes.
10 Q. But he also, you have indicated, was saying there was in
11 effect no real alternative?
12 A. I very much felt there was no alternative.
13 Q. Did anyone mention any other risks to which the
14 operation might give rise?
15 A. No.
16 Q. You went into the Royal Infirmary on the 19th, you
17 have told us?
18 A. Yes.
19 Q. You have, I think, some photographs with you of
20 Sophie as she was at that age?
21 A. Yes, I have.
22 Q. There are, I think, only one copy of three photographs,
23 two of which show her actually at the hospital?
24 A. Yes.
25 Q. And one of which was taken a little while before?
0063
1 A. Yes.
2 Q. If you would like to take a little time and show the
3 panel, if you would, then we will wait for a moment
4 while they are circulated to those behind me, as they
5 may want to see them.
6 MR SKELTON: We have seen them, thank you very much.
7 MR LANGSTAFF: Would you take each them in turn? Let us
8 have them back for a moment. They will make more sense
9 if we have a little description about each of them in
10 turn. I wonder if they would be passed back to Pen.
11 She will say what each of them is.
12 THE CHAIRMAN: May we see them first?
13 MR LANGSTAFF: Of course. (Pause). If you would like to
14 indicate and show the panel, because they are the ones
15 who have to see, in respect of each of those
16 photographs, what they show?
17 A. That shows Sophie in her baby bouncer. This was after
18 her lung biopsy but before her truncus operation. As
19 you can see, she is just like any normal baby, bobbing
20 around in her baby bouncer, having a good time and very
21 happy as well.
22 The other two photographs were taken actually on
23 the cardiac ward the night before her operation. They
24 show she can grasp toys, looking at things. She enjoys
25 being held, standing on her feet, feeling her weight and
0064
1 again, just like you would expect a five month old baby
2 to be. In fact on that night, the night before her
3 operation, she learned to roll over for the first time.
4 Q. Can we have on my screen 2459/38? Can we scroll down,
5 please, to "On examination ..."
6 This is the clinical note on the occasion of the
7 biopsy, so 24th October 1988. Can we have it on the
8 main screen? At the bottom of the page:
9 "O/E", two underlinings, "on examination". Can we
10 go down to the bottom of the page and highlight the bit
11 which comes after "O/E". Can we have that enlarged?
12 "Alert and active. Pink. Slight 'panting'."
13 So "alert and active" is the way she is described
14 on that occasion. Is that the way she normally was?
15 A. Absolutely.
16 Q. If we go in the same record, the next page, page 39,
17 down below the word "spine", "CNS", and highlight the
18 five or six entries that follow, please. And enlarge
19 it, please:
20 "CNS [central nervous system is what it stands
21 for], follows and fixes", that is obviously in relation
22 to her gaze?
23 A. Yes.
24 Q. Just taking you ahead for a moment, after the operation,
25 when she recovered from it, was she able to follow and
0065
1 fix?
2 A. No.
3 Q. "Smiles": how does that compare?
4 A. She could not smile, not for many years after.
5 Q. Then deals with "Fontanel normal, moving all limbs,
6 grossly normal."
7 If we can please have page 192, rotate it on my
8 screen. Can we please go across to the right-hand side
9 under the heading "Breathing and circulation".
10 Before we put it up on the screen, enlarge that
11 chunk.
12 This again comes from the same time. It is
13 a nursing record, I think.
14 "Breathing/circulation", and underneath that,
15 after "skin", "Development: reaches out to grab toys.
16 Puts everything in mouth. When prone pushes up on arms
17 with good head control, sits with support. Normally
18 a happy and contented baby, enjoys her bouncer, no
19 dummy, just sucks finger, likes to sleep on tummy, has
20 her favourite toys with her."
21 Just anticipating again for a moment, how does
22 that record the way she appeared at the end of October,
23 compared with the way she was when she recovered from
24 the operation which you are going to tell us about?
25 A. When she came off all her sedation, we noticed --
0066
1 I mean, she opened her eyes and immediately we noticed
2 she was not focusing on anything and there was just
3 a blank stare there. Shortly afterwards, she started to
4 thrash with her arms and legs. They were going like
5 steam engines, and she did not seem able to stop this at
6 all. It was as if she was frantic, just going like
7 pistons, and everything that you did to try and console
8 her, only made her worse. If you touched her she got
9 worse, if you played music to her she got worse. It
10 just seemed like she was totally inconsolable. She was
11 making very strange strangled yelling noises, and for no
12 apparent reason. She was just an inconsolable and very
13 distressed baby.
14 Q. I have taken you a little out of your way. Following on
15 from showing the photographs, the photographs came about
16 when you had taken Sophie into the Bristol Royal
17 Infirmary?
18 A. Yes.
19 Q. That was Friday the 19th?
20 A. Yes.
21 Q. The operation was due on the Monday, the 22nd?
22 A. Yes.
23 Q. Over that weekend, did you stay with her?
24 A. Yes, we did.
25 Q. Do you recollect any particular conversation that you
0067
1 may have had with anyone over the course of that
2 weekend?
3 A. The only conversation I recollect in any great detail is
4 the one we had with Mr Dhasmana, which I believe was the
5 night before her operation, and he was going around the
6 ward seeing his patients, and he called into our ward
7 and saw us on that occasion.
8 Q. Was there anyone else there, apart from yourself and
9 your husband?
10 A. No.
11 Q. And of course --
12 A. We were in a side room off the main cardiac ward. There
13 were four or five beds in this room and that is where we
14 were, by ourselves.
15 Q. What do you recollect being said to you about the
16 operation?
17 A. He talked us through the operation again. He told us
18 that the operation would take about 12 hours, he
19 thought. I found it very difficult to hold
20 a conversation with Mr Dhasmana. It was always question
21 and answer. He never was forthcoming with any
22 information. You had to ask him questions all the time,
23 to get anything out of him. I actually found him quite
24 difficult to understand on occasions as well and had to
25 re-ask questions, but, you know, again, we said, "How
0068
1 would you put her chances of survival now?" because we
2 were a month on from when she had had her lung biopsy,
3 and he stressed to me the sooner she had the operation,
4 the better, so in a way I was thinking her chances were
5 less good now than they had been at the time she had her
6 lung biopsy. At that time, he had given her a 50:50
7 chance of survival from the operation.
8 On this particular occasion when we met him, when
9 he came on to the ward and saw us, we actually showed
10 him how she had learned to roll over on the bed, and in
11 conversation, he said to us that she looked very strong
12 and very healthy, which she always had been. She never
13 had a day's illness in her life. She had always been an
14 extremely healthy baby, not even a cold or cough,
15 nothing. He said that as she looked so fit and healthy,
16 he was going to say that she had a better chance than he
17 thought originally, and he was going to put her chances
18 of survival at 80 per cent.
19 Q. Are you sure of that?
20 A. Yes.
21 Q. In the course of telling us what happened in various
22 conversations, you may have got the occasions of some
23 conversations mixed up?
24 A. It is very difficult after ten years to get the exact
25 chronology of the thing and what was said on each
0069
1 occasion, but I do remember quite clearly what he said
2 to me, and he said to me the night before her operation
3 he would put her chances higher than he had done because
4 she was so strong and so healthy.
5 Q. You made a statement for the purposes of the GMC
6 hearings?
7 A. Yes, I did.
8 Q. And in that statement you spoke about the 18th November
9 or soon thereafter, when you saw Mr Dhasmana?
10 A. Yes.
11 Q. And you recall asking him about possible risks to
12 Sophie, and you say that he said there are risks, but
13 she has a 50:50 chance of surviving.
14 You do not mention, I do not think, any other
15 conversation in that statement to the GMC?
16 A. I can only say that for the statement for the GMC, it
17 was a question and answer session. It lasted about an
18 hour and I was acutely aware that I had to pick Sophie
19 up from school at the time, so my mind was probably not
20 as well trained on it as it should have been. But I am
21 absolutely clear that on that night he told us Sophie
22 had an 80 per cent chance. He was going to raise her
23 chances because she looked so strong. Up until then he
24 had always said 50:50 and so had the cardiologists we
25 had seen on occasions. Everybody had given her a 50:50
0070
1 chance, but on that occasion I am certain he said an
2 80 per cent chance.
3 Q. You think probably the reason you did not mention it to
4 the GMC was a function of worry in relation to time?
5 A. It could be that, or it could be that he did not ask me
6 a specific question that would have brought that
7 response out. He probably said to me what had her
8 chances been, you know, "How have they assessed her
9 chances?" and they had always said to me a 50 per cent
10 chance of survival.
11 Q. And your conversation, of course, you are now telling us
12 about, was on 21st November, whereas to the GMC it was
13 some time round about or after 18th November. Were
14 there a number of conversations with Mr Dhasmana over
15 the weekend, or not?
16 A. The GMC? I am sorry, I am not with you there.
17 Q. It is my fault, I am not being very clear.
18 The passage which I reminded you of in your
19 statement to the GMC was in relation to a conversation
20 held on 18th November, or shortly thereafter?
21 A. Or during that weekend, anyway.
22 Q. And what I was asking you, here, was to the best of your
23 recollection, did you just have the one conversation
24 with Mr Dhasmana, or were there a number of such
25 conversations over that weekend?
0071
1 A. As far as I can recollect, just the one.
2 Q. That was the night before?
3 A. That was the night before, as far as I can recollect.
4 Q. Was it at that conversation -- again, harking back to
5 your earlier evidence today -- on the night before that
6 Mr Dhasmana said, "Well, nobody could make their mind up
7 about the biopsy, so I have decided to give her a chance
8 and operate anyway" -- not his words, but --
9 A. No, that happened before. I am certain that happened
10 before we went up to Bristol.
11 Q. That was actually at a physical meeting with
12 Mr Dhasmana, that he said that?
13 A. I believe so.
14 Q. Anyway, back to the night before: you see Mr Dhasmana on
15 his ward round. Roughly what time?
16 A. It was quite late. It was dark, so it must have been
17 about 6 o'clock.
18 Q. Was anything else said by him in the course of that
19 meeting?
20 A. Not that I can remember.
21 Q. How long did it last, roughly?
22 A. Roughly half an hour.
23 Q. At some stage on the night before the operation, did you
24 see the anaesthetist who was to take part in the
25 operation the next day?
0072
1 A. I think it was at that time, but we had certainly met
2 her some time before the operation.
3 Q. Was that Dr Masey?
4 A. It was, yes.
5 Q. Was anything said by her or about her that you
6 particular recollect?
7 A. I remember that Mr Dhasmana said to me that they had
8 a new anaesthetist who had started at the BRI. She had
9 not been there very long, but since she had been at the
10 BRI, results had improved and more people were surviving
11 their operations and he believed it was because of
12 Dr Masey. He held her in very high regard.
13 Q. The operation --
14 A. Can I say something which goes with this? Before
15 Sophie's operation, with hindsight, I am acutely aware
16 that I did not ask enough questions. I think that is
17 partly because I had great difficulty having any rapport
18 with Mr Dhasmana. I found it difficult to hold
19 a conversation with him, but also, I felt I did not need
20 to ask questions. I trusted the system and I trusted
21 him. I thought that any doctor who became a surgeon
22 must be extremely skilful. I thought that a cardiac
23 surgeon would be even more so, and I believed that
24 a paediatric cardiac surgeon would be at the very top of
25 the tree; he would be supremely skilful and competent in
0073
1 his work, and I never thought for a second to doubt that
2 Mr Dhasmana was so, and I never thought to question what
3 his record was. I never thought to ask him how many of
4 these operations had been done, how many have lived, how
5 many have died. It just did not occur to me. I had
6 complete faith in the system. I just could not --
7 I mean, for many years I could not imagine that somebody
8 would be a paediatric cardiac surgeon and not be
9 supremely competent, skilful, honest. I still have
10 difficulty with that now.
11 Q. What is it since all this has happened that has given
12 you the difficulty?
13 A. Since all the publicity surrounding the GMC Inquiry and
14 all the facts which have come out since and the
15 investigations which my solicitor has undertaken on
16 Sophie's behalf, I have discovered that Mr Dhasmana had
17 done four truncus operations before Sophie's, three of
18 which were type 1, the same as Sophie, and all four had
19 died. I was not told that. I do not see how he could
20 give me a 50 per cent chance of her surviving if all
21 four of his cases had died.
22 Q. Can I just pause you there for a moment and tell you,
23 because it will be of interest to the panel, that of
24 course we as an Inquiry have not yet conducted the
25 detailed analysis of the cases that should give the
0074
1 definitive answer, but we have been able to check and
2 have checked the surgeon's logs for Mr Dhasmana. The
3 surgeon's logs, certainly, record exactly what you have
4 said: that prior to the operation on Sophie, he had
5 conducted four operations for truncus arteriosus, three
6 type 1, and all four were fatalities. I mention that
7 now because it may have to be dealt with by further
8 evidence at a later stage.
9 I am sorry, I interrupted your flow.
10 A. Well, there is nothing else to say, except that we were
11 not acquainted with these facts at the time.
12 Q. You first became aware, did you, or felt that something
13 had gone wrong so far as Mr Dhasmana was concerned at
14 the time of the GMC hearings, or shortly before it, or
15 when?
16 A. I think shortly before it.
17 Q. Because of the publicity?
18 A. Because of a programme which I watched.
19 Q. You are mentioning the number of operations he had done
20 before, because that is something that you never asked
21 him about?
22 A. I never asked him about that. It did not occur to me to
23 ask him about that.
24 Q. It was not something he said to you, it was something
25 you did not ask him about. Did you blame yourself for
0075
1 not asking?
2 A. I blame myself every single day of Sophie's life.
3 Q. The blame -- I am sorry to explore this, but it may be
4 useful -- did the blame come really as a result of what
5 you learned shortly before the GMC hearings?
6 A. Yes.
7 Q. But not before that?
8 A. Not before that.
9 Q. Can we deal with the operation. That began, I think,
10 about 8 o'clock on the morning of the operation?
11 A. Yes.
12 Q. Did you take Sophie down?
13 A. Yes, I did.
14 Q. And you were happy to do that?
15 A. Yes.
16 Q. She had had her pre-med?
17 A. Yes.
18 Q. Was she asleep when she went into the operation room or
19 not?
20 A. To be honest, I cannot remember. I just remember
21 handing her to the nurse.
22 Q. Then you had to wait?
23 A. Yes.
24 Q. It was, I think, a little bit more than the 12 hours,
25 was it, that you had to wait, or not?
0076
1 A. No, it was not.
2 Q. You returned in the evening?
3 A. We returned at about 5 o'clock. We were told to go out
4 for the day.
5 Q. And you did?
6 A. And we did. We did not know what else to do.
7 Q. You came back roughly what time?
8 A. At about 5 o'clock.
9 Q. What time did you see Sophie?
10 A. We saw her straightaway, because she was already in the
11 recovery room.
12 Q. Did anyone say anything to you about the operation?
13 A. Yes. The nurse on the recovery room said that she was
14 doing fine. We were told later by Mr Dhasmana that the
15 operation had gone extremely smoothly. There were no
16 hitches at all. Everything had gone according to plan,
17 and that she was doing well in her recovery period;
18 there were no immediate problems.
19 Q. Were you with Sophie then while she was on ITU?
20 A. Yes.
21 Q. What do you recall about the early days in ITU?
22 A. Sophie was on a ventilator; that was doing her breathing
23 for her. She had lots of tubes and drains coming out.
24 I remember two nurses in particular, because they spent
25 more time with Sophie than other nurses, and I felt that
0077
1 we had a real rapport with these two particular nurses.
2 One was called Louise, Lou, and it was them we spoke
3 to. She would explain everything she was doing to
4 Sophie. She seemed to be working all the time, she
5 never stopped. She explained things like why she had
6 little boots made of space blanket on and she explained
7 what all the tubes were for, the catheters. She tried
8 very hard to explain to us about Sophie's care.
9 Q. Was she a paediatric nurse, do you know?
10 A. I do not know.
11 Q. Did she seem to have a rapport with the children, at any
12 rate?
13 A. Because Sophie was so sedated, you do not know
14 whether -- in a way Sophie was just a living organism,
15 lying there not doing anything. She was not aware of
16 anything, because she was heavily sedated and on the
17 ventilator.
18 Q. If we can have a look at some of the clinical notes for
19 the early days at the ITU, let us look at 2206/46. This
20 is 23rd November 1988. It is 0035, so it is less than
21 12 hours after the operation. If we read down to where
22 the little arrow is, it is the very last line on the
23 present screen. Let us highlight that, please, because
24 it is easy to read the handwriting with the highlighting
25 up. It mentions a particular drug. "Episodes of
0078
1 hypertension and tachycardia."
2 Is that something you knew about at the time?
3 A. It was explained to us. There were loads of monitors
4 around the bed and we knew which was the heart monitor.
5 On the heart monitor, it not only shows the pattern of
6 the heartbeat but how many beats per minute, and we
7 could see that Sophie's heart was racing for quite long
8 periods, until she was given more sedation and her heart
9 rate would go from sort of 150, 176, it even got as high
10 as 240, 250 at times, just for short periods, but they
11 told us that this was a very fast heart rate, and
12 Dr Masey would come along and give her something called
13 Diazemul, I believe, which then sedated her and calmed
14 her heart down. These episodes were going on for a good
15 two or three days after the operation.
16 Q. You say that the very high heart rates of 240 were going
17 on for short periods?
18 A. Yes.
19 Q. And the other episodes of fast heart rate were going on
20 for longer periods?
21 A. Yes.
22 Q. Can you give us some idea of the length of time?
23 A. I suppose from the time when it was first noticed by the
24 nurse and by us, it would be gradually going up for
25 about 10 minutes; then it would peak at the really high
0079
1 rate, by which time a doctor had usually been called, or
2 Dr Masey, and then, as soon as she was given sedation,
3 it would take about five minutes, I suppose, for it to
4 come down to a reasonable level, which was about 120.
5 Q. So the episode would be about 15 minutes?
6 A. About 15 minutes.
7 Q. That is what you called the "longer period".
8 A. Yes and the peak would be about -- depending on how
9 quickly the Diazemul was given to her, could be anything
10 from three to five minutes, I suppose.
11 Q. The way you are talking, this happened repeatedly?
12 A. Yes, several times.
13 Q. Can you give us some idea of what "several" means?
14 A. I remember the first night we did not actually go home
15 until about half three in the morning, because she was
16 having these episodes, so she must have had four or five
17 on that night, and then the next day, she must have had
18 at least a half a dozen more.
19 Q. Can we have a look, please, at the intensive care notes
20 2206/11, and 24th November, am. I do not think we need
21 to highlight this one to read it. It is "2 days, 2 over
22 7, after truncus arteriosus. Remains fully ventilated,
23 paralysed and sedated."
24 Then it deals with drugs.
25 In the next line:
0080
1 "Problems with hypertension and tachycardia, BABG
2 have been good. Diazemuls [and that is what you
3 remember] given, and bagged and sucked when [I am not
4 sure what the next word is] which has happened two
5 times".
6 THE CHAIRMAN: The word is "mottled".
7 MR LANGSTAFF: I am grateful. It is obviously a reference
8 to colour.
9 A. Yes.
10 Q. So the colour changed twice?
11 A. If that is what it says.
12 Q. Do you recollect there being some spotting of --
13 A. No, I do not.
14 Q. A mottled effect on the skin?
15 A. No.
16 Q. Were you there pretty well throughout?
17 A. Pretty well. We would get there at about 7 in the
18 morning and stay until gone midnight, and we would only
19 leave very briefly for meals. So we were there most of
20 the time. I remember her being bagged and I remember
21 a lot of suction going on, but I do not remember her
22 actually looking mottled.
23 Q. If you read down another couple of lines, just above
24 where it says "CVS."
25 "Over ventilating, bear cub adjusted."
0081
1 That I think is a reference to the ventilator
2 equipment itself?
3 A. Yes.
4 Q. Can you help us any further with that entry?
5 A. I am sorry, I cannot, no. I have no idea.
6 Q. The days went on and Sophie was still sedated, still on
7 the ventilator?
8 A. Yes.
9 Q. But slowly being weaned off the ventilator?
10 A. Yes.
11 Q. And at some point she began to breathe pretty much for
12 herself?
13 A. Yes.
14 Q. How long did that take, roughly?
15 A. I think roughly 24 hours. I cannot remember there ever
16 being any problems with her breathing.
17 Q. How long was it before she was fully off the ventilator?
18 A. As I said, I think about 24 hours from starting to turn
19 it down to her actually being off the ventilator
20 completely.
21 Q. Can we just have a look for a moment and clear up
22 something that may be a misunderstanding in your witness
23 statement? It is witness 12, page 9; the first
24 paragraph, if you read it to yourself for a moment.
25 "After a week, Sophie was weaned off her sedation
0082
1 and began to breathe for herself as the ventilator was
2 turned down. I do not know why she remained on the
3 ventilator for so long."
4 Your immediate recollection was 24 hours or so,
5 you told us a moment or two ago?
6 A. Yes.
7 Q. Which was right: 24 hours or after a week?
8 A. I am sorry, there is a misunderstanding here. She was
9 on the ventilator for a week, from the time they started
10 to bring her down to actually getting her off the
11 ventilator was 24 hours. She is on 24 breaths a minute
12 or whatever.
13 Q. It is my fault for not making it sufficiently clear.
14 When was she completely off the ventilator?
15 A. After about a week.
16 Q. It is my fault; you have cleared it up and I am
17 grateful. You deal in this paragraph with what you
18 found when in fact she was off the ventilator and she
19 opened her eyes?
20 A. Yes. At the same period she was coming off the
21 ventilator, they were also weaning her off the sedative
22 drugs.
23 Q. That is when you noticed some movements in her arms and
24 legs?
25 A. Yes. Until then she had been totally immobile, but as
0083
1 the drugs wore off, the first thing we noticed was that
2 she suddenly opened her eyes, and a little later, she
3 started to move all her limbs.
4 Q. I think, if we look, please, take the screen and go to
5 the medical record 2206/47, if we look at 30th November
6 1988, again in the clinical notes:
7 "A bit of twitching and [difficult to read the
8 next word]."
9 If we go further on down, 1st December:
10 "Weaned off infusions now, twitching remains.
11 Stopped the Diazemuls, evidence of cerebral oedema from
12 fundi, small haemorrhage on the left. 4 EEG. Dr Schutt
13 to see, please, for neuro opinion."
14 So the note there, is that the medical staff seems
15 to have picked up what you picked up, in terms of the
16 way that the eyes looked at you from some twitching of
17 the limbs?
18 A. Yes.
19 Q. You describe how Dr Schutt came to see and provide the
20 opinion which had been asked for?
21 A. Yes.
22 Q. And dropped you the bombshell?
23 A. Yes.
24 Q. I am not going to ask you about that. It was plain to
25 you, or became progressively plain after that, that
0084
1 Sophie was not the girl that she had been?
2 A. Yes.
3 Q. She was moved from the Royal Infirmary to the Children's
4 Hospital I believe on 5th December 1988. You are
5 nodding.
6 A. I do not know the exact date. I know we were moved to
7 the Children's Hospital.
8 Q. It was in fact the 5th. We can see that, I think, if
9 we -- just give me one moment. If we go to
10 page 2459/43.
11 You have various criticisms of the care that was
12 given at the Children's Hospital by comparison with the
13 Royal Infirmary?
14 A. Yes, I have.
15 Q. What we have in this note -- by all means let us see it:
16 "5th December 1988, transferred from the BRI,
17 Ward 5. It deals with the operation. Then, if we look
18 at the drugs for a moment, the first of those, Nystatin,
19 1 ml tablet, I think it is daily.
20 THE CHAIRMAN: Three times a day.
21 MR LANGSTAFF: Thank you, I am obliged. I am going to pick
22 that reference up in a moment or two, because it is
23 something you have a particular complaint about, but in
24 general terms, how did you find the Children's Hospital
25 by comparison?
0085
1 A. I can only say I hated every second I spent there. It
2 was like a group of goldfish bowls. You walked into to
3 the ward and on the left-hand side were glass walled
4 rooms each of which had a baby in. On the right was the
5 storeroom and there was a kitchen where the nurses would
6 prepare feeds for the babies and the nurses spent most
7 of their time in there, in fact. I very rarely came
8 into contact with the nurses there. They spent their
9 whole time in the kitchen having cups of tea and having
10 a chat. They used to come out in -- there was like
11 a mass exodus every four hours where they would come out
12 and feed all the babies, change them all, and then they
13 would all go back again. You just did not see them
14 walking around the ward looking after the babies who
15 were there. There would be babies screaming, not just
16 crying, really screaming and nobody seemed to take any
17 notice. I know that nurses on a baby ward probably get
18 very used to crying and can ignore it, but I certainly
19 could not ignore it, and I do not think, maybe, other
20 parents could ignore it either. I found it extremely
21 distressful. There were things like, there was a child
22 in an incubator next to Sophie, next to our little room
23 and it was in isolation because of the trouble that it
24 had. They put it in this incubator on the bed and it
25 kept getting the wrong way round so its head was lower
0086
1 than its feet, because its bed was on an incline so its
2 head should have been higher than its feet, so it spent
3 its time the wrong way round. If you told the nurses,
4 "He has got himself into trouble again, he has got
5 himself the wrong way round", "I will do it in
6 a minute", and it would sometimes not get done until the
7 next feed or whatever. I just felt they did not care at
8 all about the children in their care. That was my
9 personal feeling.
10 Q. So that was dealing with other children. I think with
11 you yourself, you had problems feeding. You found some
12 difficulty getting simple advice?
13 A. Sophie could not, we were told by Dr Schutt she would
14 never suck or swallow, but I could not accept that.
15 I could not accept that my daughter would have a nose
16 tube for the rest of her life, and I was determined
17 I was going to try to get her to feed. I was given
18 bottles of milk to give to her, but she could not manage
19 it and I did not know why, so I asked several of the
20 nurses, "Please will you come and just try and feed her
21 and tell me what I am doing wrong". I had never
22 bottle-fed a baby for a start, my children were both
23 breastfed and I was not sure if it was my technique that
24 was at fault. They would say "We will come in
25 a minute", "We will see you later", "Next feed we will
0087
1 do it", and they never came.
2 I struggled for about 48 hours just to try and get
3 some milk down her and they would not give me the help
4 I asked for. In the end, it was actually a nurse who
5 was on night duty, and she saw me very early the next
6 morning, and she said "I think I know what is wrong with
7 her. She has got her tongue pressed against the roof of
8 her mouth. If you get the teat over her tongue, she can
9 suck and do it". I did not understand to this day why
10 somebody could not have come in the first time I asked
11 and just shown me that, but they did not. I did not get
12 any help at all with Sophie's care.
13 Q. Again, so we can place this, which ward was she on?
14 A. She was on the baby unit. It was called the baby unit.
15 Q. How many times did you ask for help with the feeding,
16 roughly?
17 A. Every feed time. I mean, every three or four hours,
18 I would ask somebody, "Please can you come and show me
19 what I am doing wrong?" and I used to ask them about
20 other things as well. I remember on several occasions,
21 I mean, when you are in a situation like that, you have
22 not got anything else to actually think about, and
23 I noticed that they used to come with the drug trolley
24 and they used to give me Sophie's drugs to give to her
25 in little syringes, but nobody signed her drugs chart.
0088
1 I knew from my experience in the BRI that every time
2 a child was given something, their drugs chart should be
3 signed and their time put down and it just did not
4 happen. When I questioned the sister about this, I was
5 told "She is an agency nurse, she is not allowed to sign
6 the drugs chart". I said "How do you know then, if
7 somebody else comes along on a later shift, how do you
8 know they are not going to look at Sophie's drugs chart
9 and say 'She has not had her 1 o'clock dose, I will give
10 it to her now'?" She said "That would not happen, we
11 have little meetings and discuss what we have done", but
12 I felt if an agency nurse could not sign the drugs
13 chart, she should not be giving out the drugs.
14 Q. Let us look at the drugs chart, 2459/211. Can we rotate
15 it? It is the top left-hand corner, please. You
16 remember that I showed you a moment or two ago the
17 letter which recorded the transfer on 5th December. If
18 you take the first drug, Nystatin, each day it appears
19 to be signed for in the Bristol Royal Infirmary, which
20 this chart takes you up to the 5th. For 6th December
21 there are I think three entries over the next seven
22 days, for which there is a signature.
23 Do you have any particular complaint in relation
24 to that particular drug?
25 A. I did ask what was Nystatin for, and she said, "Oh, it
0089
1 is not very important". I said, "Well, what is it for?
2 Why is it on her drugs chart?" She said "It is a little
3 thing that we are supposed to give so they do not get
4 thrush in their mouths when they are on antibiotics".
5 I felt it was quite important that Sophie did not get
6 thrush in her mouth, since she was already having
7 problems with feeding, and I was just furious that they
8 were so complacent about the fact she had not been given
9 this drug and they seemed to consider it was not
10 important at all.
11 Q. If we look at the rest of the chart, the Digoxin, moving
12 down the page, please, that appears to have been signed
13 for on each and every day, so no complaint was made
14 about non-signature for that?
15 A. It was not necessarily signed at the time it was given.
16 Q. So somebody entered it up at some stage?
17 A. Yes.
18 Q. And again, if we go to the top right-hand, Frusemide,
19 please, again there is a time and an initial on each
20 occasion for that drug, between the 6th and the 12th,
21 but the same comment applies, does it: it was not
22 necessarily signed on that occasion?
23 A. Frusemide is a heart drug, and I assume that they
24 thought that these had a greater importance than the
25 Nystatin would have had, but to my mind, anything on the
0090
1 drug chart that should have been given, they should have
2 made sure it had that dose, and they did not.
3 Q. While Sophie was at the Children's Hospital, did you see
4 anyone who had been concerned with her clinical care
5 earlier?
6 A. In fact, we had been on the baby unit earlier, in that,
7 when she had had her lung biopsy, she was admitted to
8 the baby unit in the Children's Hospital, so I had
9 already spent time there. So I did actually, I mean,
10 I had a passing acquaintance with some of the nurses who
11 were now in charge of her after the operation.
12 Q. Did you see any of the surgeons involved, the
13 cardiologists?
14 A. I remember Mr Dhasmana visiting us quite briefly.
15 I cannot remember on how many occasions, but not very
16 often. I remember one conversation with him where he
17 was trying to surmise what had gone wrong with Sophie's
18 operation, and I remember one conversation with him
19 where he insisted that I went home for the weekend, even
20 though I did not want to.
21 Q. Tell me about the first of those, what had gone wrong
22 with the operation?
23 A. When he came to see me, he found it very difficult to
24 look at me. I was across the bed from him, but it was
25 as if he was trying to avoid me, avoid my gaze,
0091
1 certainly, and he said "I would rather Sophie had died
2 than that she had been left like this". He seemed not
3 able to cope with how she was. I am not saying he
4 seemed upset, because that is too strong a word, but he
5 certainly did not seem able to cope with the way she
6 was, the way she had been left.
7 Q. If I can just pause and see if we can get that clear, if
8 it was not upset, it was approaching being upset, was
9 it?
10 A. Yes.
11 Q. So it was that sort of emotion that he was conveying?
12 A. Yes. After saying this to me, he then said, "I have
13 been going over it in my mind, what could have gone
14 wrong with Sophie's operation. The only thing I can
15 think of is in that when I looked at her truncal valve",
16 which was the one that was already there as opposed to
17 the one he had to put in, "it had little florets around
18 it". He described them as being like cauliflower
19 florets. He said the valves are usually smooth but this
20 one had these florets around. "The only thing I can
21 think of is that during the operation I might have
22 dislodged one of those florets and they travelled up
23 through her circulatory system and into her brain and
24 caused massive brain damage". But I did not actually
25 believe him. It did not seem possible to me that this
0092
1 was the probable explanation. It just seemed like he
2 was trying to give me something, tell me something, to
3 give me some explanation. I do not think he believed it
4 himself. He was just surmising what might have
5 happened. He was not saying this definitely happened.
6 Q. Was there any clue from the way in which he said this to
7 you as to what his motive in saying it might have been?
8 A. No. Other than I was standing there and he felt
9 uncomfortable and felt that he had to say something and
10 tried to give me some explanation for Sophie's state at
11 that time.
12 Q. Is there anything else about that particular
13 conversation that you recollect?
14 A. No. I mean, the main thing I think about is this --
15 almost like there was a wall between us. He could not
16 communicate to me. He could not even look at me when he
17 was giving me this information.
18 Q. When he suggested you went home and had a break, first
19 of all was it in fact sensible advice, do you think, in
20 retrospect?
21 A. I am sure it was. I was at the end of my tether, there
22 is no doubt about that.
23 Q. Secondly, do you think it was kindly meant?
24 A. Probably, yes.
25 Q. He did manage to communicate that to you, at any rate?
0093
1 A. Yes.
2 Q. Because you took his advice?
3 A. He just went on and on and on that I had to have
4 a break.
5 Q. So you did?
6 A. That is right, I did. I did not want to. I really did
7 not want to leave Sophie there by herself for the
8 weekend.
9 Q. When you came back and saw Sophie again, was there
10 anything about her condition that made you unhappy to
11 have taken the break?
12 A. Oh, most definitely. I was absolutely dismayed.
13 Q. Why?
14 A. When I got back, the nurses said "We have got something
15 to show you" and they took me through and Sophie was
16 lying on top of the bed, and she had no nappy on. The
17 whole of her bottom was covered in lesions, and she had
18 the most awful nappy rash. I have never seen anything
19 like it. They were like blisters all over her bottom.
20 When I asked them "What on earth has happened?" they
21 said "It must be because she is on antibiotics", but she
22 had been on antibiotics all the time since her
23 operation, and it had not happened. I know it is
24 because they had left her in a soiled nappy and left her
25 there, and not changed her when she should have been
0094
1 changed. It did not happen when I was looking after
2 her, it happened when they were looking after her.
3 Q. When you took over her care again, did the rash resolve?
4 A. I went down to the chemists and got some medication
5 myself for her.
6 Q. And the rash resolved?
7 A. Eventually, yes.
8 Q. And did it resolve despite the fact she was still on
9 antibiotics?
10 A. Yes.
11 Q. There came a time, I think, after about three weeks,
12 that you were told by Mr Dhasmana you were going to be
13 transferred to Exeter?
14 A. Yes.
15 Q. You were transferred to Exeter and Sophie was kept in
16 for a day and then discharged?
17 A. Yes.
18 Q. She has been in your care ever since?
19 A. Yes.
20 Q. She was followed up by Bristol?
21 A. I had to bring her up to Bristol about a fortnight later
22 for an outpatients appointment with Mr Dhasmana.
23 Q. And did he examine her?
24 A. He did.
25 Q. And was there the same problem of communication or not?
0095
1 A. Again, I do not recollect that he was able to look at
2 me, or actually talk to me. He examined Sophie, he
3 listened to her heart. He said that her heart was doing
4 fine. He then put her on the bed and she was kicking
5 her legs about a bit, aimlessly, you know, as she always
6 did, and he said, "Oh, well at least she has the use of
7 her legs back", and I said, "But she is not kicking them
8 properly; she is just sort of --", it was like a spasm,
9 if you like, she was just spasmodically kicking her
10 legs, it was not with any purpose or any reason, and
11 I could not understand why he seemed so pleased. I mean
12 she was in an awful state. He said he was pleased with
13 her progress. Maybe I misunderstood him, maybe he was
14 talking just about her heart, but it seemed to me he was
15 talking about the whole child and saying she was better
16 than last time he had seen her.
17 Q. How did you relate to that?
18 A. I just felt I wanted to get home again. I wanted
19 nothing to do with him and nothing to do with Bristol.
20 I just wanted to be home with her.
21 Q. That is what you felt at the time. That is not
22 something you have since remembered feeling in
23 retrospect?
24 A. No, I felt it very strongly.
25 Q. I think 10 years have passed since Sophie was born,
0096
1 10 and a bit. I think you have recently seen the new
2 cardiologist at Bristol?
3 A. Yes, I have.
4 Q. So you have gone back to Bristol for those services?
5 A. I have had to. I get no choice.
6 Q. So far as you are concerned, apart from the episode of
7 care that you have been telling us about, have you had
8 any further problems as you call them with Bristol?
9 A. I felt very strongly that I did not want to see any of
10 the cardiologists who had seen Sophie before her
11 operation. I am not talking straightaway here, I am
12 talking within the last three years.
13 Q. Since the GMC?
14 A. Yes, just slightly before the GMC. I felt I did not
15 want to see Dr Joffe and I did not want to see
16 Dr Martin, and I felt that point quite strongly. In
17 fact, when I was sent an appointment for Dr Martin,
18 I phoned up the hospital and said I was not going to see
19 him. I could see no physical change in Sophie, and
20 I said "They are not going to do the next operation.
21 What is the point in her seeing the cardiologist?"
22 I was just determined I was not going to be seeing Joffe
23 or Martin. I was then referred to Bristol yet again, to
24 see a neurologist, because of Sophie's epilepsy. This
25 was about 18 months ago. When I was up seeing the
0097
1 neurologist, she suggested that I see another
2 cardiologist, Dr Hayes, whom I did, and she put Sophie
3 on to a drug called Captopril which is to help the heart
4 action. The next time I went to see Dr Hayes she said
5 "Would you like to meet the new cardiologist?" so
6 I said "Yes, that would be great", so I met Dr Stewart,
7 who had just started at Bristol. We only had a very
8 brief meeting, and he seemed very helpful, very
9 supportive and said he would be pleased to see me in
10 Exeter in the future, so I did not have to see Dr Joffe
11 or Dr Martin. That is what I have done. I have seen
12 him twice now, with Sophie.
13 Q. That brings matters so far as we are concerned up to
14 date. One or two general matters I want to ask you
15 about. Did, at any stage, anyone suggest anywhere other
16 than Bristol for the operation?
17 A. No.
18 Q. Did you yourself make any enquiries as to any centre
19 other than Bristol?
20 A. No.
21 Q. Secondly, I think perhaps in retrospect, you have
22 thought back over the care that was provided, the
23 intensive care, with which at the time you were
24 thoroughly satisfied?
25 A. I felt that the nurses worked extremely hard and they
0098
1 were always very supportive of me. They involved me in
2 Sophie's care. I did not feel shut out at all.
3 Q. Do you in retrospect, have a concern at any rate about
4 the nature of the nursing in intensive care?
5 A. I have a concern about the whole after-care. I think
6 that -- I mean, I understand now that the nurses were
7 not necessarily trained to work with children, and
8 I think this might have had a disastrous effect on some
9 of the children in their care, in that things like serum
10 levels and glucose levels and sats and things like that
11 might be tolerated by an adult, but be absolutely
12 disastrous for a baby. If they were not specifically
13 trained to deal with children and babies, they might
14 have been working extremely hard, but not doing the
15 right things. You can't blame them for that, you know,
16 they did not have the training that they needed to look
17 after these babies.
18 Q. So what you are saying is that although you have nothing
19 to prove it, as it were, you have a query in your mind
20 about the care?
21 A. Yes, I do.
22 Q. And the query really arises from what you have learned
23 since?
24 A. Yes.
25 Q. And not from anything that you actually observed at the
0099
1 time?
2 A. No, that is right. Could I say something, here?
3 Q. Certainly.
4 A. Since meeting Dr Stewart, he has been very helpful and
5 very supportive of me, and very kind to me, and we have
6 had several discussions about the Bristol set-up, and
7 I understand that Bristol is having a new Children's
8 Hospital built, but they are not having a separate
9 cardiac ward for babies and children, and can I say,
10 I think that is a travesty. I think after all that has
11 happened in the past, they should have learned some
12 lessons from that and in this brand new building, they
13 should have a separate cardiac ward with specially
14 trained nurses and doctors. They should not be on
15 a general surgical ward.
16 Q. The third thing I was going to ask you about was really
17 in relation to the early days, where we began the
18 account of Sophie's problems.
19 A. Yes.
20 Q. When you saw Mr Orme in Exeter?
21 A. Yes.
22 Q. Am I right in thinking that although you were very
23 concerned and have been very concerned about the delays
24 in Sophie's referral and getting the treatment that she
25 needed, you have never actually written to complain or
0100
1 made a formal complaint in respect of the Exeter care?
2 A. No. In fact, stupidly, I actually wrote to Mr Dhasmana
3 and thanked him for trying to do the operation on
4 Sophie, when I got home.
5 Q. I have asked you lots of questions. You still have
6 time, I think, to make the train back with some ease, so
7 long as there are not too many further questions. If
8 there is anything I have missed, I know Mr Lissack will
9 pick it up, but is there anything you wanted to add
10 which you do not think I have covered?
11 A. I understand that the Trust will not divulge information
12 on the incidents of brain damage at the BRI. I know my
13 solicitors have asked for this information and the Trust
14 have consistently denied there is any documentary
15 evidence on brain damage. Whether you believe that or
16 not, I think there should be an audit done on the brain
17 damage. My Sophie is still classed as a success, even
18 though she cannot walk, see, talk, move, she can't do
19 anything for herself, but under their criteria, because
20 she lived for 30 days after her operation, she is still
21 counted as one of their successes, and I think that is
22 a travesty. I would hope that the Inquiry would be able
23 to ask for an audit to be done of the incidents of brain
24 damage at the BRI.
25 Q. I can actually assure you then, that this Inquiry
0101
1 intends to look at the whole question of not just brain
2 damage but other morbidity such as renal failure by
3 means of a proper analysis of the available information.
4 A. I am very pleased to hear that.
5 Q. That is what I said at the outset of this Inquiry and
6 that is what this Inquiry intends to do, so at least,
7 that will give you some satisfaction, but I cannot say
8 anything about what the results might be.
9 A. No.
10 Q. Do you have anything else to add?
11 A. No.
12 MR LANGSTAFF: Those are all the questions I am going to ask
13 but there may be some from the panel.
14 THE CHAIRMAN: Thank you. We do not have any questions, but
15 is there a re-examination?
16 MR LISSACK: Yes, please.
17 Re-examined by MR LISSACK:
18 Q. There are only three matters, sir, and they are
19 matters which are of importance to this lady to say.
20 Just three things. Firstly this -- this is
21 issue D, "referral", paragraphs 6 and 8 in the
22 statement, transcript 46, lines 1 to 4.
23 We know that the paediatrician that you saw at
24 Exeter was Dr Orme?
25 A. That is right.
0102
1 Q. As you say in your statement, and was touched upon
2 lightly in your evidence today, he changed after about
3 four years of caring for Sophie --
4 A. In fact in my statement it says four months, but it is
5 a mistake, it was four years.
6 Q. You changed to a new doctor, Dr Kinnaird?
7 A. That is right.
8 Q. Have you discussed with him the events at Bristol?
9 A. Yes, I have.
10 Q. And what was his practice from as long ago as 1991
11 so far as referral from Exeter to Bristol was concerned?
12 A. Dr Kinnaird told me, it must have been about last
13 summer, last year, when we were on one of our many
14 visits to the hospital, he actually said to me that he
15 had sent no children to Bristol for heart operations for
16 the past 9 years, and he said there was another
17 consultant at the RD&E who also had sent no children to
18 Bristol.
19 When I asked him why, he said that he had come
20 from outside Exeter and had always sent his heart
21 children to Great Ormond Street, so when he started work
22 at Exeter, he carried on that tradition, if you like,
23 and continued to send his children to Great Ormond
24 Street.
25 But he also said that he knew that the record at
0103
1 Bristol was poor and that is one of the reasons why he
2 did not send his children there.
3 Q. Thank you. The second matter, issue L, paragraph 11,
4 page 74 in the transcript, is to pick up on the answers
5 you gave Mr Langstaff about the fact that risks other
6 than the 50:50 or 80:20 chance of risk or survival or
7 death, depending how you look at it, was not discussed.
8 Suppose for a moment you had asked Mr Dhasmana
9 about his track record, if I can call it that, and he
10 had told you the truth. I would just like to know what
11 you would have done when faced with that information?
12 A. I would not have allowed him to operate on Sophie. If
13 he had told me he had done four of these operations and
14 all four patients had died, I would not have allowed him
15 to operate on Sophie.
16 Q. That answer probably being expected, it is really the
17 next matter I want your help with, please. If you were
18 faced with a situation where your daughter would remain
19 as ill as she was at the time and the surgeon who was
20 about to carry out the corrective procedures was
21 somebody you no longer felt appropriate, what would you
22 have done, practically? Do you know?
23 A. Practically, I think I would have spoken to the
24 paediatrician and voiced my fears, and asked to be
25 referred elsewhere.
0104
1 Q. And the third and last matter is this -- it is issue I1,
2 and it appears variously in the witness's statement,
3 paragraphs 15, 18, 20 and elsewhere and various places
4 in the transcript. I shall not trouble with a list of
5 references. The issue is this: what went wrong?
6 I want to try and bring the threads together,
7 because it may be of great materiality and assistance to
8 the Inquiry to hear your evidence on this point.
9 Firstly, have you ever been told by anybody what
10 actually has caused Sophie's present state?
11 A. No. The only information I have been given is what
12 Mr Dhasmana tried to say to me on the ward after her
13 operation.
14 Q. How important is it to you now -- we will deal with how
15 it would have been then -- now to know the answer to
16 that question?
17 A. I think it is very important to me.
18 Q. Why?
19 A. Because I cannot rest with myself. I still blame myself
20 all the time and I want to be able to think, no, it is
21 not my fault, it was something that was done that was
22 not right.
23 Q. I am sorry to press you on it, but it is important we
24 hear the reason for the next questions I ask you.
25 In fact, we know that at various points -- you
0105
1 have told us about it already -- members of the medical
2 profession, putting it generally, have spoken to you
3 about either the consequences of what went wrong or, in
4 one place, a guess as to what actually caused the
5 consequences.
6 I want to take them in order. You remember you
7 produced the photographs earlier on which the Inquiry
8 looked at?
9 A. Yes.
10 Q. You brought them with you today with the intention that
11 everyone should see them, obviously. The day following
12 the operation, did anyone from the BRI staff speak to
13 you about what could have gone wrong?
14 A. Not the day after the operation.
15 Q. When was the first time somebody did?
16 A. After we had seen Dr Schutt.
17 Q. What was it that was said?
18 A. I remember a ward sister and a young doctor coming round
19 the ward and stopping at her bed, and saying, "Of course
20 there was evidence that Sophie had neurological damage
21 before she had her truncus repair."
22 I said, "What do you mean by that?"
23 I have this photograph of Sophie, in her baby
24 bouncer, up on her cot, because I felt it was important
25 that people could relate to her as "that child", not
0106
1 just a sort of living organism on the bed, if you like.
2 I wanted them to realise that this was a child lying
3 there. They said to me that in this photograph Sophie
4 is 'fisting', meaning that she is going like that
5 (indicating with fists) and they said that shows that
6 she had neurological damage.
7 Q. Before the operation?
8 A. Yes. I was furious. I knew there was nothing wrong
9 with Sophie before she had that operation.
10 Q. Mr Langstaff has taken us through the notes very
11 helpfully.
12 A. Yes.
13 Q. We have seen what was reported at the time.
14 I then want to just move to what Dr Schutt said to
15 you, because it was passed over, if I may say so, very
16 briefly indeed in your evidence. I know it is
17 important -- because we talked before you gave your
18 evidence -- that you have this one chance to react to
19 what he said. Could you please tell us how the
20 conversation went?
21 A. We were told he wanted to talk to us and we were ushered
22 into a small room. There was my husband, there was me,
23 there was a ward sister, there was Dr Schutt, and we
24 were sitting in a very jumbly cluttered up room, and he
25 said to me, "How do you think Sophie is?"
0107
1 Because I still wanted to have hope, I suppose, or
2 was denying to myself that she was as bad as she was,
3 I was trying to find things that I thought were going
4 slightly better. I was saying, "Well, she's not quite
5 as twitchy as she was on the first day", and, you know,
6 "We played some music to her today and she did not
7 actually scream all the way through it, which was an
8 improvement".
9 He just looked at me as if I was an idiot, and he
10 said, "Well, I have examined Sophie. She can't see, she
11 can't hear, she has spastic quadriplegia (which means
12 she can't move any of her limbs), she will have severe
13 epilepsy. There is none of her brain left except the
14 brain stem, and nothing can be done for her. Just take
15 her home."
16 Then he said, "Have you got any questions?" I was
17 so shocked and distressed, I just could not think of
18 anything to say.
19 Q. It is an ordeal for you to have to tell us, but I know
20 you wanted to say that.
21 A. Then he just got up and walked out of the room and that
22 was the last time I saw him.
23 Q. Was anything ever said to you about Sophie's long-term
24 chances that was different to that that Dr Schutt said
25 to you in that conversation?
0108
1 A. I found it very difficult to accept, and I think for
2 maybe the first year, I kidded myself that Sophie was
3 going to get better, but I think deep in my heart,
4 I knew she was not.
5 Q. Did you ever discuss that with Mr Dhasmana, at all, or
6 not?
7 A. I never saw Mr Dhasmana again.
8 MR LISSACK: Thank you very much, indeed. Thank you, sir,
9 for allowing me to put those questions. They are
10 important to the witness.
11 MRS PLACKETT: I am sorry, may I say one more thing? It is
12 about the length of Sophie's operation. I have looked
13 at some of her records since, and it says that the cross
14 clamp time for her operation was 2 hours 45 minutes.
15 From what I understand of cardiac surgery, that would be
16 the actual time that Mr Dhasmana was working on her
17 heart, but she was in surgery for 8 hours, and I want to
18 know what was he doing for the other 5 and
19 a quarter hours. If the actual work on the heart was
20 finished in that cross clamp time, why did it take
21 another 4 and a quarter hours for her to come out of the
22 theatre?
23 THE CHAIRMAN: Mrs Plackett, thank you for coming to talk to
24 us. It has not been easy. We are grateful. You must
25 not regard this as being the only time you can get in
0109
1 touch with us. We shall be here for a while and if
2 there is anything else either that you would wish to ask
3 or can tell us, you can do so through letting us know
4 and we will take account of it, but for today, thank you
5 very much.
6 MRS PLACKETT: Thank you.
7 MR LANGSTAFF: May I add to those thanks for coming to give
8 your evidence?
9 Sir, because of the reference to the operation
10 times, I think it is probably appropriate that the
11 record should have with it a note of the operation,
12 because questions may arise at a later stage. The
13 record is 2206/43, on my screen only for the moment,
14 please. Can we please move it down below the address?
15 One can see the perfusion data which Mrs Plackett
16 was referring to, the cardiopulmonary bypass time of
17 2 hours 44 minutes, the aortic cross clamp, 1 hour 31
18 minutes. The operation note continues and goes on to
19 the next page, which ought to be released, 2206/44.
20 I think it is unnecessary to look at that in public now,
21 save to flash it on to the screen. Those will be made
22 part of the record in due course.
23 Sir, this afternoon we have Mrs Sheridan. It is
24 now just coming up to 20 to 2. I understand your
25 intention would be to have something of a three-quarters
0110
1 of an hour break?
2 THE CHAIRMAN: Yes. Shall we then reconvene -- I was trying
3 to do the mental arithmetic, Mr Langstaff and failing,
4 but let us say 25 past 2, to reconvene. Thank you.
5 (1.40 pm)
6 (Adjourned until 2.25 pm)
7 (2.25 pm)
8 MR LANGSTAFF: Mrs Sheridan, I think you were here this
9 morning when Mrs Plackett gave her evidence?
10 MRS SHERIDAN: Yes.
11 MR LANGSTAFF: You have seen we start with the oath. If you
12 would not mind standing, you will be asked by Saul to
13 repeat the oath after him.
14 MRS ELLEN SHERIDAN (Sworn):
15 Examined by MR LANGSTAFF:
16 Q. Mrs Sheridan, your full name is Ellen Sheridan?
17 A. That is right.
18 Q. You were born in Limerick but I think you have lived
19 most of your life over here?
20 A. That is right.
21 Q. You have not lost your Irish accent?
22 A. That is right.
23 Q. You are going to tell us about your son John, who
24 I think was born in March 1979. He under went two main
25 operations, the first of which was successful, and
0111
1 before our time of reference, Chairman, and the second
2 of which was not. I am going to ask you about those.
3 The second operation, on 2nd June 1986, when John was
4 seven years old?
5 A. That is right.
6 Q. Could I take you back to John's birth: 26th March 1979.
7 You were 24 at the time, I think?
8 A. That is right.
9 Q. Was that in Barnstaple in North Devon?
10 A. That is right.
11 Q. It was a full-term pregnancy?
12 A. Yes.
13 Q. A 24-hour labour?
14 A. Yes.
15 Q. And John was your first child?
16 A. John was the first child.
17 Q. I think since then you have had -- you have three other
18 children, have you?
19 A. That is right.
20 Q. Nora, born in October 1985, Patrick and David?
21 A. That is right.
22 Q. Did you have another child called David?
23 A. I did.
24 Q. Was he born in March 1982?
25 A. Yes.
0112
1 Q. He, I think, suffered from a heart problem when he was
2 born?
3 A. Yes, he did.
4 Q. Did he have care at Great Ormond Street in London?
5 A. Actually, he was transferred to Great Ormond Street. He
6 was born in King George's Hospital in London. I was
7 there at the hospital. Shortly after he had been born,
8 David was blue, he had blue lips and he was slightly
9 blue, so I said "Somebody had better come quickly and
10 see David, because I think there is something wrong with
11 him". So the nurse said, "We are going to get straight
12 on now and get a doctor". The doctor came pretty
13 shortly after. It would be a couple of hours after
14 David had been born, and a doctor came and she asked me
15 questions about John, so I filled her in with as -- as
16 much she asked me, I filled her in. "We will take him
17 now", she said, "to the baby unit and I will get a nurse
18 to sort you out now and go straight with David now".
19 Q. David went on to Great Ormond Street, did he?
20 A. They transferred him that night to Great Ormond Street.
21 Q. Unfortunately he did not survive?
22 A. David did not survive.
23 Q. I want to ask you about John. When John was born, did
24 you soon discover that there was a problem?
25 A. No.
0113
1 Q. Did any of the doctors say to you anything about John's
2 heart in the first couple of days he was alive?
3 A. The very next morning, I do not know whether it was
4 a doctor or a nurse, I think it was a doctor, said that
5 John had a heart murmur. John was my first child.
6 I never heard tale of heart murmur, I did not know what
7 it was or what they meant. I did know it was something
8 serious, when she said it was a heart murmur. So they
9 said they were doing some tests or something on John.
10 They brought me and John into a room and said "We are
11 doing some sort of x-rays". They put a machine down
12 over John and the lights went off, and they said we
13 would just have to wait and see.
14 Q. Did you speak to any doctor at that time about John and
15 what was wrong with him?
16 A. No. That is all they ever said: he had a heart murmur.
17 Q. You saw Dr Jordan?
18 A. They said Dr Jordan was coming the next day to see
19 John. Jordan came and me, Jordan and John, and maybe
20 there were other doctors and nurses, I do not know, but
21 he put a thing in his ears and he examined John. He
22 said "I am making arrangements for John to come to
23 Bristol as an outpatient in the next six weeks."
24 I think he gave me an appointment to see John in
25 six weeks time in Bristol.
0114
1 Q. Did he say why he needed to see John in Bristol?
2 A. No.
3 Q. Did he say anything about a heart murmur?
4 A. He said just John needed further tests and he would do
5 them in Bristol.
6 Q. You were travelling around at the time?
7 A. That is right.
8 Q. I think that is what you and your husband do?
9 A. That is right.
10 Q. You travel from town to town and your husband is in the
11 business of selling carpets or rugs door to door?
12 A. That is right.
13 Q. Obviously, when you had John you were in Barnstaple?
14 A. Yes.
15 Q. Was Bristol convenient for you?
16 A. It was not a point of convenient for us, it was the
17 point of convenient for John.
18 Q. Did you have any choice as to where he went?
19 A. No.
20 Q. That is just what was said to you?
21 A. It was.
22 Q. So did you go to Bristol for further examinations, or
23 not?
24 A. John was -- I was let go home the same day with John,
25 back to the caravan. As I was going out, I cannot
0115
1 remember who said to me, I think I was worried, really
2 worried about John, being my first baby and everything,
3 I was really worried, and somebody happened to mention,
4 I do not know who it was, I cannot remember, "Just watch
5 out for John going pale".
6 Q. So you did?
7 A. So we went back home, and I cannot remember how many
8 days later, but it was not very long after, two to three
9 days after, when I thought that John was pale, so
10 I called my mother up and my sister and they said
11 "I think he is fine, all little babies are pale", but
12 I was not happy with that. My husband was not there at
13 the time. As soon as he came back, I said "I think John
14 is pale". He said "I don't think so". I said "I feel
15 as if John is pale". So for my peace of mind, he took
16 me back to Barnstaple Hospital with John. I arrived
17 back into casualty and I begin to tell my story about
18 John. There was a nurse there, and she just took him
19 off me like this and she looked at him and took him out
20 of the room.
21 Q. How many days old was John at this stage?
22 A. He was about four days old at this time, three to four
23 days, I cannot remember for sure.
24 She just left us standing there. The next time,
25 I do not know how long after it was, it was not very
0116
1 long after, anyway, the doctor came in and he said,
2 "Mr and Mrs Sheridan, come with me". We kept on
3 saying, "Where is my child? What is wrong? What is
4 wrong? What is going on here?" He said "Come with me
5 now, I am taking you to see John". I remember them
6 putting gowns on us, over our mouths and over our shoes
7 and we arrived into intensive care. There were machines
8 on John and things I have never seen before in my life.
9 I remember him saying, "We have given John a special
10 injection, and we would like it if he stayed the
11 night". So we stayed the night. So he said, "We are
12 removing John in the morning to Bristol hospital".
13 I never asked why or why not.
14 Q. And they never told you why or why not?
15 A. No. So the next morning came. He said "John is going
16 in the ambulance. I would prefer if you give the
17 ambulance two hours of a head start". So at this time,
18 we just hooked up our caravan, gave the ambulance two
19 hours and took the caravan off to Bristol.
20 We found a place to park the caravan and members
21 of our other family were with us, and we went in and we
22 went to St Michael's Hill, because that is where they
23 told us he was going, to the Children's Hospital. We
24 arrived there, and we asked. They said John was in
25 intensive care.
0117
1 Q. Someone explained to you what they were going to do
2 to him?
3 A. As we went in, I remember asking what has happened and
4 what is going on with John. So somebody approached us
5 and said "Dr Jordan will be coming to see you". He came
6 and said he was doing a catheter -- I cannot pronounce
7 it very well.
8 Q. Putting a catheter in?
9 A. Yes.
10 Q. Did he tell what you a catheter was?
11 A. He said it was like a little camera they were putting up
12 through John's thigh and it would show up clearly in
13 John.
14 Q. Did that happen the next day?
15 A. That happened the next day.
16 Q. As a result of the catheterisation, the catheter going
17 up the leg, did Dr Jordan tell you what was wrong?
18 A. No. I cannot remember. He might have told me what it
19 was, but he did not explain to me so that I could really
20 understand.
21 Q. When the results came out, did anyone talk to you about
22 what John's difficulty was, what was wrong with John's
23 heart?
24 A. No.
25 Q. Was there any occasion when someone, for instance, sat
0118
1 down with a piece of paper and drew squares on it or
2 something like that and showed you what a heart looked
3 like?
4 A. Yes.
5 Q. Who did that? Who drew the four squares on a piece of
6 paper?
7 A. That was Wisheart.
8 Q. What was Mr Wisheart showing you when the four squares
9 were drawn? Do you remember?
10 A. He just drew on a piece of paper a square. He put
11 a line in the middle and say "That is where the hole is,
12 Mrs Sheridan", and drew a line across a part and said
13 "This is the part that is damaged and I am going to
14 repair".
15 Q. So he is going to repair the hole in the heart?
16 A. He said it was damaged, one section was damaged and he
17 was going to repair it.
18 Q. Mr Wisheart did that?
19 A. Yes.
20 Q. Was that the first time John was in the Children's
21 Hospital, or was that much later?
22 A. That was when he started planning open heart surgery,
23 the second operation.
24 Q. Let me take you back. John has gone into the Bristol
25 Children's Hospital in St Michael's Hill. He has had
0119
1 the catheter put up the leg, and when did you understand
2 that he was free to go, he would be all right to come
3 home?
4 A. After he had the catheter up, Jordan came back and he
5 said, "We know now what is wrong, Mrs Sheridan, and I am
6 putting John on some medicine and you can take him home
7 today or tomorrow". So he put him on, I am sorry, but
8 I cannot pronounce this word properly, Digoxin, so
9 I think it was either that day or the next day he let
10 John go home on that medicine.
11 Q. He told you what to do, what medicine to give him?
12 A. Yes.
13 Q. And you had to keep in touch, did you?
14 A. Yes. We had a 6-weeks outpatients appointment with
15 Dr Jordan.
16 Q. You came back after 6 weeks, and then after another
17 6 weeks, and so on?
18 A. Yes.
19 Q. Did you travel around and come back every 6 weeks?
20 A. Yes.
21 Q. Was that normally with Dr Jordan?
22 A. Normally with Dr Jordan.
23 Q. Sometimes with another doctor?
24 A. Another doctor. I do not know his name.
25 Q. Did they tell you what the problem was?
0120
1 A. No.
2 Q. So what happened at the consultations when you spoke to
3 them?
4 A. We came back for a 6-weeks check-up. We were waiting in
5 the waiting room. There were loads of children and
6 other people there. It was an outpatient clinic. When
7 John Sheridan was called in it, it was Dr Jordan. He
8 would put the things in his ears and examine his heart.
9 Sometimes he would take him downstairs and say it was
10 for x-rays. He would come back up and say "Everything
11 is fine, Mrs Sheridan. Now we are at the stage I only
12 need to see John every 3 months". We would make an
13 appointment at the desk for 3 months and that was it.
14 Q. How was John himself? Was he surviving well?
15 A. To me, he was.
16 Q. By the time he was about a year and a half old, what was
17 he like then?
18 A. John began to, before the year and a half was up, he
19 began to be getting a lot more short of breath and a lot
20 more bluer.
21 Q. Was he on his feet and running around?
22 A. He was. But when he ran too much, he would get very,
23 very breathless and very blue. He would have to sit on
24 his legs, so they told me the oxygen worked better, I do
25 not know.
0121
1 Q. So what did you do when you noticed John was getting
2 short of breath?
3 A. So his check-up was coming up, and I took him there for
4 his 3-months check up, and I told Dr Jordan, "John is
5 getting a lot more shorter of breath and a lot more
6 blue", so he said, I think he said, "Mrs Sheridan, we
7 will sort an operation out for John, and I would like
8 for you to see Mr Wisheart".
9 Q. What was the operation to be called?
10 A. It was called a shunt.
11 Q. So every 6 weeks you came back, or 3 months you came
12 back to Bristol. Could you have gone somewhere else?
13 Did you go in the course of your travels to London?
14 A. I was most of the time in London. I came from
15 Scotland. I came from Northern Ireland, I came from all
16 over England, back to that hospital for John's
17 check-ups.
18 Q. Did you ever think about perhaps seeing if they could
19 check him up somewhere else?
20 A. No.
21 Q. Why did you stay with Bristol?
22 A. Because I had heard if I change over to some other
23 doctors, they might just mess John around, mess him
24 about. He was with Dr Jordan since he was a baby. Now
25 he knows exactly what is wrong with him and he will do
0122
1 the best for John.
2 Q. So although Dr Jordan had not told you very much about
3 John's condition, you were happy and wanted Dr Jordan to
4 go on caring for him?
5 A. I did.
6 Q. You saw Mr Wisheart before he did the shunt operation?
7 A. I did.
8 Q. That was you, your husband, John, and obviously
9 Mr Wisheart himself?
10 A. Yes.
11 Q. What did Mr Wisheart say he was going to do?
12 A. He said he was doing, it was called a bypass, he said.
13 It was a shunt. He just described with his hands, they
14 were putting a tube in, he said, and it would divert the
15 blood. That was it.
16 Q. And how long was the conversation, roughly?
17 A. 10/15 minutes.
18 Q. Did you have a chance to ask questions?
19 A. No.
20 Q. Would you have wanted to ask questions?
21 A. I wanted to ask him a million questions.
22 Q. Why did you not?
23 A. I do not know why. The man always seemed to be in
24 a hurry.
25 Q. Mr Wisheart?
0123
1 A. Yes. He was sort of in and out.
2 Q. If you had the chance to ask him, what sort of things
3 would you have asked him that you did not?
4 A. I would have asked him, could he draw his -- show me
5 a much more definite thing, because the way he said it,
6 it was just a tube leading from one place to another.
7 I did not know what place it was leading from or going
8 to.
9 Q. You could not ask him because he was obviously in
10 a hurry, wanting to move on. When he left, did you
11 think to yourself, "Perhaps if I ask somebody else,
12 I will find out"?
13 A. No.
14 Q. Was this the first time you had met Mr Wisheart?
15 A. Yes, I think it was.
16 Q. Was this the occasion when had you drew the four squares
17 on a piece of paper?
18 A. No.
19 Q. That was later?
20 A. That was later.
21 Q. Having met Mr Wisheart and found he was a man in
22 a hurry, was he the man you wanted to do the operation
23 on John?
24 A. I left my child in his hands. I did not know anything
25 about hearts; I did not know anything about anything
0124
1 else. He was a good man. Everybody else was saying
2 Mr Wisheart, Dr Jordan, Bristol hospital, so I left my
3 child in their hands.
4 Q. Everyone else was saying what about Mr Wisheart and
5 Dr Jordan?
6 A. We would ask in the hospital or in Barnstaple Hospital,
7 and everyone was saying it is a good hospital, he is
8 under good care, under good doctors, and ...
9 Q. So he had the shunt operation. That went well, I think?
10 A. Yes.
11 Q. And you waited for him and in fact the operation took
12 rather less time than you thought?
13 A. Yes.
14 Q. You thought it was going to be three or four hours and
15 it was a bit less?
16 A. Yes.
17 Q. After that, John was on the ward, was he?
18 A. Yes.
19 Q. Did Mr Wisheart come to see you?
20 A. He did.
21 Q. What did he say about any future operations that John
22 would need?
23 A. He said something about, in the near future,
24 Mrs Sheridan, we will probably be discussing something
25 else.
0125
1 Q. You, I think, quite deliberately made sure you got a new
2 caravan which was warm, so that John would be kept warm?
3 A. That is right.
4 Q. And you went on having outpatient attendances at
5 Bristol?
6 A. That is right.
7 Q. Was that again with Dr Jordan?
8 A. Dr Jordan.
9 Q. At one of those occasions, I think it might have been in
10 1985, did Dr Jordan tell you that they were planning
11 another operation?
12 A. Yes, he did.
13 Q. Was that the first you knew about when the other
14 operation would be?
15 A. Yes.
16 Q. John would now have been five or six, that sort of age?
17 A. Yes.
18 Q. How was he as a lad?
19 A. John was fine. He was -- once he had the shunt put in,
20 which he was a different child. He could play around.
21 He was still a little short of breath, but not as much
22 as beforehand. But he was fine.
23 Q. You went back to Bristol and I think on one of the
24 occasions you went back to Bristol you saw Mr Wisheart
25 again?
0126
1 A. Yes.
2 Q. How long was that conversation?
3 A. The same thing: just in 15, 10 minutes and that was it.
4 Q. What did he tell you?
5 A. He said "Mrs Sheridan", he said, "we are now planning
6 open heart surgery for John". I remember saying to him,
7 "Why don't you just do another shunt in John, and it
8 will buy him more time and he will be bigger and
9 stronger and he will understand more and I will
10 understand more?" "No, Mrs Sheridan", he said, "that
11 will not work again".
12 Q. Why did you not want open heart surgery?
13 A. I cannot explain why I did not want it. I knew deep in
14 my heart it was more serious than the first operation.
15 I did know it was more serious. I just wanted to avoid
16 it, if it was possible.
17 Q. Because it was so serious?
18 A. Because it was serious.
19 Q. And so even though you knew the first operation was
20 a serious one, anything involving the heart must be,
21 this was even more serious than that?
22 A. Yes.
23 Q. Was it the way it was described, "open heart", did that
24 frighten you?
25 A. It did.
0127
1 Q. So he explained why open heart surgery had to be done,
2 did he?
3 A. He did. He said, "I cannot do the shunt because John is
4 too big now and it will not work", so we were saying,
5 "Is there anything else you can do besides open heart
6 surgery?" and he said "No, Mrs Sheridan, there is not".
7 He said "John will die if he does not have open heart
8 surgery, he will die."
9 I just looked at him and said, "Die?" He said
10 "Yes, Mrs Sheridan. John's heart will burst and he
11 will bring his heart up and he will die".
12 Q. Bring his heart up or blood up?
13 A. I remember him saying "He will bring his heart up".
14 Q. So that the choice was the operation or sooner or later,
15 John would die. Did you ask how long it would take?
16 A. He said his time was up.
17 Q. His time was up?
18 A. Yes.
19 Q. So you were living on borrowed time?
20 A. Yes.
21 Q. So there was really no choice for you but to have the
22 operation?
23 A. That is right.
24 Q. But although there was no choice, did he tell you
25 anything about the risks or the chances of John getting
0128
1 through the operation?
2 A. No.
3 Q. Did you ask?
4 A. I never.
5 Q. You realised that the operation was serious, more
6 serious than the shunt operation. You had had the
7 frightening name of an open heart operation. Did he
8 give it any other name?
9 A. No.
10 Q. Fontan's?
11 A. No.
12 Q. In any event, you knew it was a really serious
13 operation.
14 I would like, on my screen, please, 577/17. What
15 I am looking at, Mrs Sheridan, just a bit higher up,
16 please, is a letter from Mr Wisheart to Dr Edmund. Was
17 Dr Edmund one of your GPs, can you remember?
18 A. I cannot remember his name.
19 Q. He is writing to a Dr Edmund, who I think must have been
20 a GP in Bristol looking after you at a time when you
21 were at a caravan site in Patchway?
22 A. Could be, yes.
23 Q. The part of the letter I want to ask you about is this:
24 "The Sheridans attended the outpatients and were
25 seen by Dr Jordan and myself today. We have advised
0129
1 them [Mr Wisheart and Dr Jordan have advised you and
2 your husband] that the Fontan operation should be
3 carried out and have had a full discussion with Mr and
4 Mrs Sheridan, indicating both the risks and benefits
5 involved. They have accepted this advice and I am
6 placing John's name on the waiting list for surgery."
7 Do you remember a meeting with both Dr Jordan and
8 Mr Wisheart there together?
9 A. No.
10 Q. Was there an occasion when you saw Dr Jordan and
11 Mr Wisheart separately, but on the same day, that you
12 remember?
13 A. Yes. One in this room and we were sent in to Jordan, in
14 to Wisheart, but never the two of them together.
15 Q. On that occasion did both Dr Jordan and Mr Wisheart say
16 something to you about, in general terms perhaps, the
17 risks and benefits?
18 A. No.
19 Q. But something was said about there was a need for the
20 operation, or else?
21 A. Yes. Mr Wisheart clearly said John's time was up, and
22 he needed open heart surgery.
23 Q. And that was advice which you accepted?
24 A. Yes.
25 Q. And your husband?
0130
1 A. Yes.
2 Q. Because you would have talked about this?
3 A. Yes.
4 Q. And you were both worried about it, and you both thought
5 that was the right thing to have done?
6 A. Yes.
7 Q. The reason you thought it was the right thing to have
8 done was because there was no other choice for John?
9 A. That is right.
10 Q. Arrangements for having the operation must have been
11 quite difficult for you, because of your moving around?
12 A. That is right.
13 Q. So it was a case of your having to keep in touch with
14 the hospital, was it?
15 A. That is right.
16 Q. So you phoned up to find out when John should come in
17 for the operation?
18 A. They gave me Mr Wisheart's secretary's phone number, and
19 I phoned twice a week.
20 Q. Was it originally arranged for May 1986, and then had to
21 be put off for a couple of weeks?
22 A. It was cancelled for two weeks.
23 Q. Do you remember why that was?
24 A. They never said.
25 Q. It just happened?
0131
1 A. It just happened.
2 Q. Had you spoken to John about the operation?
3 A. No.
4 Q. Did he know he was due to go into hospital?
5 A. He did.
6 Q. Did he know something about why he was going in?
7 A. I think he had a fair idea.
8 Q. So you did not tell him the whole truth?
9 A. No.
10 Q. Because you did not want to frighten him?
11 A. I do not know, what could I say to him? He did question
12 me about it, the night before the operation. I think he
13 wanted me to tell him, he said what was going on next
14 morning, but I just could not tell him, I just did not
15 know what was going on, I did not know what to say to
16 him.
17 Q. He had only been to the hospital for check-ups, and he
18 knew why he went for the check-ups broadly, something to
19 do with his heart, did he?
20 A. That is right.
21 Q. So when he went in for the operation, he obviously knew
22 this was something a bit different?
23 A. That is right.
24 Q. You wanted to stay with him?
25 A. Yes. John was never left alone in any hospital or
0132
1 anywhere. He was never left alone, on his own, at no
2 time.
3 Q. Did something happen when you went into the Bristol
4 Royal Infirmary to have the operation?
5 A. He went in on the Friday, and we settled him in.
6 Everything was fine. It came Friday night, and my
7 husband said, it was about 11 o'clock, he said "I will
8 go on home now", he said, "and you stay with the
9 child".
10 So the nurses came and the sister came, and she
11 said "You can't stay here, Mrs Sheridan". I tried to
12 explain to her, "I am staying here because John will not
13 stay without me or his father, so I have to stay. He
14 will not stay here". So she would not listen. She
15 said:
16 "We have dealt with more than John", she said, and
17 "he will stay". I said "This is the place where I am
18 staying, I know my child is not going to stay without
19 me". But she insisted that I left. So I did leave. Me
20 and my husband.
21 Q. So there was an argument?
22 A. There was.
23 Q. What happened later on that night?
24 A. We just got down home and we were in bed about a half
25 an hour, when I could not sleep. I heard a noise
0133
1 outside. It was the police. They knocked on the door
2 and said "Are you Mr and Mrs Sheridan?" I said "Yes".
3 "You are wanted back in the hospital."
4 So we arrived back in the hospital, and she said
5 "You were right, Mrs Sheridan, you were right and I was
6 wrong. John will not stay."
7 Can we just have on the screen 577/36? Let us
8 scroll it up a bit. What we are looking at here,
9 Mrs Sheridan, is a nurse's report for 29th May 1986,
10 which is the day that John came into hospital.
11 THE CHAIRMAN: Forgive me, Mr Langstaff, do you want it to
12 be on general availability?
13 MR LANGSTAFF: Yes, please. I am grateful. It talks about
14 John and so on, and then, as we go across to the next
15 page, having identified what the document is, 577/37,
16 the very top of the page, the first few words are:
17 "Woke up distressed. Parents called, then
18 settled. Up and cheerful this morning."
19 So it appears to record the fact that John was
20 unhappy that you were not there, and you had to come in
21 some time during the night?
22 A. That is right.
23 Q. And both of you went in, did you?
24 A. Yes, we did.
25 Q. And stayed the night, having been called?
0134
1 A. Yes.
2 Q. Hence "parents called, then settled". The "then
3 settled", we see in the notes, must be John settling.
4 While you were there in the hospital, were you
5 shown round the intensive care ward?
6 A. Yes, I was.
7 Q. To see what John might look like after the operation,
8 and the tubes, the machines around him?
9 A. Yes.
10 Q. So that you were ready for that?
11 A. Yes.
12 Q. Did you see Mr Wisheart before he did the operation?
13 A. We seen Mr Wisheart the night before the operation.
14 Q. Again, how long, roughly?
15 A. We went into a little office, me and my husband, and it
16 was for signing a consent form, "Sign the form and the
17 operation will take six to seven hours tomorrow", and
18 that is all I can remember about that.
19 Q. The consent form, 577/33, please, you wanted us to have
20 a look at this. If you would scroll it down, please, to
21 the signature, can you put a yellow flag over the
22 signature line, please? Can you blow that up?
23 You just have a look at that signature. Is that
24 your husband's?
25 A. Yes.
0135
1 Q. And you wanted, I think, to see which of you had signed
2 the consent form, because you could not actually
3 remember?
4 A. That is right.
5 Q. When you signed the consent form, that was with
6 Mr Wisheart on the night before the operation, so he was
7 telling you something about the operation, was he?
8 A. He was not saying much about the operation. All I can
9 remember him saying is, "It will be six to seven hours,
10 and everything should go fine, Mrs Sheridan. As I said
11 before, he will not be a footballer, he won't be
12 a boxer, but he will be like any other child playing
13 around".
14 Q. Did he say anything about what might go wrong?
15 A. No, not that I can remember.
16 Q. Did you still think it was serious, if he was being so
17 optimistic about it?
18 A. I knew it was serious, deep in my heart, I knew it was
19 serious, but coming from Mr Wisheart, it did not seem
20 that serious.
21 Q. The next morning was the morning of the surgery. What
22 time roughly in the morning did John go for his surgery?
23 A. John was scheduled for the first thing that morning.
24 There was another little girl there, and they had
25 changed our plans. They said they were going to take
0136
1 her first and John in the afternoon.
2 Q. Did you speak to anyone that morning before the
3 operation?
4 A. My husband came in early that morning, and as I said,
5 John would not stay by himself with nobody, so my
6 husband came in and I went out and had a cup of tea.
7 The night before the operation, my husband met
8 Mr Wisheart, and he asked Mr Wisheart, he said, "When
9 last did you do an operation like this?" He said "Six
10 months ago, a little boy". My husband said "How did it
11 go?" "Everything went fine", he said.
12 Q. Was that a conversation that you heard?
13 A. No, I did not hear it. This was my husband.
14 Q. This is something your husband reported to you?
15 A. Yes, he told me later. The next morning, the
16 anaesthetist came and she was looking at the other
17 little girl who was going on before John, so she came
18 over and had a word with my husband.
19 Q. So a woman anaesthetist?
20 A. Yes. My husband said to her the exact same words he
21 said to Mr Wisheart, "When last did you do an operation
22 like this?" He said "6 months ago, a little boy". My
23 husband said "How did it go?" "I am sorry", she said,
24 "it did not".
25 Q. So how did you know that the anaesthetist was talking
0137
1 about the same operation as Mr Wisheart?
2 A. We did not know. When I came back up, my husband
3 explained to me, so we both choked up and looked at each
4 other, and that was it. We could not talk. We took it
5 for granted it was the same child both of them was on
6 about. When he explained it to me and she explained it
7 to my husband, he took it for granted it was the same
8 child the two people were on about. Wisheart said he
9 lived, and she said he died.
10 Q. Here John had not yet gone for his operation?
11 A. No.
12 Q. Between you and your husband, did you think that one or
13 other of the anaesthetist or Mr Wisheart was obviously
14 telling you something that was not actually right?
15 A. We both knew it, but we did not talk about it no more.
16 Q. Which of the two did you think had got it wrong?
17 A. I beg your pardon?
18 Q. Which of the two, the anaesthetist or Mr Wisheart --
19 they could not both be right if they were talking about
20 the same boy.
21 A. I remember my husband saying, I think he said
22 Mr Wisheart is lying. He said, "He said the child made
23 it, and she said he never made it", so all we could
24 think of at the same time is that there was somebody
25 lying there. All we were put out about was John. John
0138
1 was the only main thing here, and that is all we were
2 concerned about at the time.
3 Q. I am saying this really for the purposes of the record,
4 so that other people can read it and deal with it later,
5 but the Inquiry team has checked the surgeon's log, and
6 it may not, of course, be all the information that is
7 available, but Mr Wisheart's log shows that indeed there
8 was a Fontan's operation approximately six months
9 beforehand, 13th January 1986, whereas the operation on
10 John was on 2nd June 1986. In that earlier operation,
11 the child died nine days later. There was no other
12 operation in his log of the same sort when the child
13 survived, unless it was an operation in June 1983.
14 So your husband was feeling this about
15 Mr Wisheart. Did you not say to yourselves, "They must
16 be talking about a different operation"?
17 A. We never talked about it.
18 Q. You never talked about it?
19 A. No.
20 Q. Just your husband said "Mr Wisheart is lying", and that
21 was it?
22 A. And just sort of, you know one of them was lying, and my
23 husband said to me, "I think Mr Wisheart is lying". But
24 that was it. We never talked about it. I just choked
25 up, he choked up. We knew there was somebody lying.
0139
1 Afterwards, when John died, my husband said to me,
2 "I told you", he said, "He lied. I told you that man
3 lied to me".
4 Q. But there was another possibility: that they both might
5 have been accurate, but describing different patients,
6 two different operations, both about six months earlier?
7 A. They might have been on about two different children,
8 I do not know.
9 Q. Did that not strike you as a possibility?
10 A. We never talked about it. We just knew somebody was
11 lying.
12 Q. Because at this stage, you wanted to believe in
13 Mr Wisheart, did you not?
14 A. We did.
15 Q. And Mr Wisheart was John's chance of survival?
16 A. That is right.
17 Q. He had done the earlier operation on John, the shunt,
18 and that had worked?
19 A. Yes, it worked.
20 Q. And it had given John five and a half years of life?
21 A. That is right.
22 Q. So you had every reason at this stage, apart from what
23 had just been said, to have trust in Mr Wisheart, had
24 you not?
25 A. Yes.
0140
1 Q. Had you ever met the anaesthetist before?
2 A. Not that I can remember.
3 Q. In any event, John goes for the operation. You are
4 expecting it to last, what, six to seven hours?
5 A. Yes.
6 Q. You are told to go out so you are not waiting around?
7 A. That is right.
8 Q. That was difficult to do, I imagine?
9 A. We did not go out.
10 Q. You stayed in the canteen?
11 A. Around the hospital, around there.
12 Q. Did you go back to the ward to see what was happening?
13 A. What happened was, the sister approached us and she said
14 "Mr and Mrs Sheridan, go back to your caravan, have
15 a cup of tea, a change of clothes and" she said, "come
16 back. You will feel a lot better. Have a breath of
17 fresh air, and when you come back, possibly there might
18 be a bit more news". So we did.
19 There were members of our family within the
20 hospital with us, so we all went back to the caravans.
21 Me and my husband did what we were told. We did not
22 stay very long back at home, and we came back to the
23 hospital. I am dead unsure about the times, but I know
24 we came back to the hospital.
25 Q. Was it evening?
0141
1 A. Evening. It was coming on for the evening time.
2 Q. Coming on to the evening, so it was sort of teatime?
3 A. It was about 6, a quarter past or half past 6. It was
4 coming up for John's time, I remember feeling anxious
5 that John was about to come back. So it was the evening
6 time. So me and my husband came back to the hospital on
7 our own. There was a lift. We got into the lift and we
8 went upstairs, and we came out of the doors and there
9 were two doors in front of us, and as we were coming
10 a doctor was there. I assume he was a doctor. I do not
11 know who he was. He had all the gowns on that doctors
12 wear and he had one across his mouth.
13 As he held the door back as we were going in, he
14 said, "Have you got a child in the theatre?"
15 So we said "Yes, we have, John Sheridan". He said
16 "Oh, yes, John Sheridan. Well, I have good news. The
17 operation with John", he said, "has gone fine. It has
18 gone according to plan. They are tidying him up at the
19 moment, and he will be on the unit within half an hour
20 to an hour."
21 Q. What happened next?
22 A. So I said to my husband, "We will sit in here now in the
23 waiting room and we can't miss John. He has to pass us
24 coming in". So we were sitting there and we were only
25 about 10, 5 to 10 minutes sitting there, and the sister
0142
1 came, and she said -- she flew past the door at first,
2 and I saw her. She turned around and came back, she saw
3 us in there. She said "Come with me,
4 Mr and Mrs Sheridan, into my office, into my office", so
5 we said "No, no. What is wrong? What is wrong?" and
6 I remember shaking her and holding her. We were saying,
7 "What is wrong? What is wrong? Please tell us what is
8 wrong". She kept on saying "Come to the office". We
9 never did get to the office. She turned around and
10 said, "I am sorry to say, John is dying at the moment".
11 Q. You were devastated by the news?
12 A. I was.
13 Q. You screamed?
14 A. I screamed. I almost brought the hospital to
15 a standstill.
16 Q. And you went off for a moment or two and came back
17 I think later with your husband and his brother?
18 A. That is right.
19 Q. You waited while someone called a priest?
20 A. I waited and waited for any more news, but there was no
21 more news. About half 9, 9, they went for the priest,
22 some members of the family went for a Catholic priest,
23 and they asked, could a priest go down and give John his
24 last rites? He said "No". So I asked the sister, "Can
25 I go and see John?" She said "No".
0143
1 Q. When did you find out finally that he had died?
2 A. The sister approached me around 9-ish, between 9 and
3 half 9, and she shook me. She said "Mrs Sheridan,
4 please listen to what I have to say". So I held up my
5 head and said "What is wrong now?" She said "They are
6 going for a machine that brings the dead back to life.
7 Let us hope this works".
8 Within half an hour, she called someone in the
9 family and gave him the bad news, she said John had
10 died, so they came and told me.
11 Q. So the way she broke the news finally was to tell
12 somebody else that was close to you?
13 A. That is right.
14 Q. When she shook you, that was because you were in
15 a state, was it?
16 A. Yes.
17 Q. You asked again, did you, to see John?
18 A. My husband was taken out of the building, his brothers
19 took him out, so I asked the nurses, I cannot remember
20 seeing the sister any more, I asked the nurses, I wanted
21 to see my child so they said "No, you can't see your
22 child, Mrs Sheridan, that is it, you cannot see him".
23 So I started shouting. I said "Look, you have had my
24 child all day, he is mine. I want to see my child". So
25 they said they would have to get the doctor. At this
0144
1 stage, I did not know what doctor we were getting, but
2 I remember clearly Mr Wisheart came. He brought me into
3 the sister's office, there was nobody there, just me and
4 him, and he looked up at me like that, and he said,
5 "I am so sorry, Mrs Sheridan", he said, "because I have
6 lost John". He said "When I lose a child after so long
7 in this hospital, it is just like losing a part of me.
8 I am so sorry", he said. "Where is Mr Sheridan?"
9 I said "Mr Sheridan has gone out of the building". He
10 said "Promise me faithfully", he said, "that you,
11 especially Mr Sheridan, will come back to see me when
12 all is over". So I just looked at him like that, and he
13 said, "Because if you do not, I will be feeling guilty
14 for the rest of my life".
15 Q. Did he say anything about what had happened, apart from
16 the fact that John had died?
17 A. No.
18 Q. Have you ever found out?
19 A. From that day to this, I do not know what happened, why
20 he died. I never ever went back, to this town or to
21 Mr Wisheart, no more.
22 Q. Were you able to stay at the hospital beyond that?
23 A. He said "You can go down to see John", so I remember
24 a little nurse, she was crying. I came out, and she
25 touched me this way, with her hand. There was a priest
0145
1 and a few members of my family, my husband's sisters,
2 and we were going down to a very lonely place, very,
3 very lonely. It was very cold looking, smelled a very,
4 very funny smell. I remember going down and seeing
5 John. He had a little tube on his nose that was full of
6 blood.
7 Q. I am going to ask you to move on.
8 A. That was it.
9 Q. You did not go back to the hospital again, I think, but
10 your husband did, and they discussed with him the
11 question of a post-mortem?
12 A. That is right.
13 Q. Was your husband told that there had to be a post-mortem
14 because John had died during the operation?
15 A. Yes. They said they would take my husband to court.
16 He said, "You had him in the theatre all day, you did
17 what you had to do". They would not agree to that.
18 They said he had to have a post-mortem because he died
19 in the theatre. They wanted to find out if the doctor
20 did his job right, so they had no choice but to take him
21 to court and hold the body and they would still win at
22 the end of the day, so he signed it.
23 Q. Since then, you have had no counselling, I think?
24 A. No.
25 Q. Might it have helped if counselling had been offered?
0146
1 A. Probably would have.
2 Q. You left Bristol never to return until these events?
3 A. That is right.
4 Q. But your husband was particularly concerned, I think,
5 about where John's last resting place should be?
6 A. Yes.
7 Q. And was the upshot of that that he had John's body
8 exhumed with the permission of the government and taken
9 back to Ireland?
10 A. That is right.
11 Q. Because your husband comes from Ireland as well?
12 A. Yes.
13 Q. Were you ever told what happened to John's heart and
14 lungs?
15 A. Nobody told me nothing. I was looking at the television
16 and it said about this case in Bristol, babies being
17 robbed of their hearts. Eventually, I got a letter and
18 that tells me that John's heart and lungs and other
19 tissues has been held in the hospital.
20 Q. No-one had ever mentioned that possibility to you?
21 A. No way.
22 Q. So tell me, how did you and your husband react to that
23 news?
24 A. I just looked at him and he just looked at me. He said
25 "No way, this could not be possible. They could not do
0147
1 this to us".
2 Q. If they were going to do that, you would expect them to
3 ask, would you, first?
4 A. Yes, you would.
5 Q. If they had said something to you about John's heart and
6 lungs being useful in learning valuable lessons for
7 other little children in the future, if something like
8 that had been said at the time, would you have said
9 "Yes, you can keep the organs", or "No, you can't"?
10 A. "Certainly not, no way".
11 Q. Because you would never have given permission?
12 A. I would never, ever, give permission.
13 Q. So you feel particularly upset about not having been
14 told?
15 A. Yes, I do.
16 Q. One matter I just want to go back on for a moment, if
17 you do not mind. You told us how you did ultimately --
18 you did in the end see John?
19 A. Yes.
20 Q. At first the nurse would not let you?
21 A. That is right.
22 Q. When you first asked the nurse, that was straight after
23 the end of the operation, as you understood it. Do you
24 think perhaps the reason why she said, "Well, you can't
25 see John", was that at that time the nurses and others
0148
1 may have been tidying John up from surgery to make him
2 look a bit better?
3 A. When the sister approached us and said that John was
4 dying at 7 o'clock, it would have been after that,
5 I asked -- the family asked "Why can't the parents go
6 down and see John, if he is dying?" and they refused and
7 said "No". "The Catholic priest has to go down and give
8 John his last rites". They refused. So she approached
9 me and said "We have found a machine which brings the
10 dead back to life". Then the next approach was, they
11 said John was dead. I asked again, and they said no.
12 Then Mr Wisheart came and said what he had to say, and
13 did not let me see John. The nurses would not let me
14 see him, no way.
15 Q. But no reason given to you why not?
16 A. No.
17 Q. It is a long time from 1986 until now. You have told us
18 that it was after the operation that your husband said,
19 "Well, I told you Mr Wisheart was a liar"?
20 A. From that day to this, he always said to me, "I told you
21 that man lied".
22 Q. How did he know just from the result of the operation
23 that Mr Wisheart had lied?
24 A. He got the feeling. He just got the feeling in his
25 heart, that she told the truth, the anaesthetist, and he
0149
1 told a lie.
2 Q. Nothing more than that, because that was all there was
3 to go on?
4 A. That is all there was.
5 Q. Apart, obviously, from the sad fact of John's death.
6 Did you try and put John's death behind you as
7 best you could?
8 A. As best we could, we picked up the pieces. John's death
9 will never be behind us, never.
10 Q. I understand that, but did it come into the front of
11 your minds again as a result of things that people were
12 saying about Bristol recently?
13 A. The first I ever heard of this -- as you know, I cannot
14 read and I cannot write. The first I ever heard of
15 anything going on about Bristol, my brother-in-law
16 approached me and he said, "In the wireless today, there
17 was an awful thing going on", he said, "about the
18 Bristol hospital, about the heart specialists and the
19 heart surgeons". So I just looked at him and said "It
20 may not be the same heart specialist and it may not be
21 the same surgeons". He said "I think it is. I can
22 remember the names".
23 So I felt as if I wanted to know was it the same
24 doctors that operated on John? I wanted to know, and
25 I did not want to know.
0150
1 Eventually, me and my husband, he said "Pop across
2 the road". We went across the road. There were members
3 of our family there. And there was this gentleman,
4 a total stranger that I had never seen before in my
5 life, and he was reading from a newspaper. As I passed,
6 I remember seeing Wisheart's photo, so I walked over to
7 the gentleman and he read the paper out to me. As soon
8 as he said "Mr Wisheart", I just broke down and cried.
9 That is the first I ever heard of it.
10 Q. That is the start of how it was you came forward to tell
11 your story?
12 A. Yes.
13 Q. I have taken you through your story as I hope you would
14 want to have it said. Is there anything you think
15 I have missed asking you which you want to tell us
16 about?
17 A. No.
18 Q. You have said it all?
19 A. I think I said it all.
20 MR LANGSTAFF: I have asked you all the questions I am going
21 to ask. The panel may have some further questions for
22 you.
23 THE CHAIRMAN: Mrs Sheridan, we have no questions. Is there
24 any re-examination?
25 MR LISSACK: No, thank you.
0151
1 THE CHAIRMAN: I am grateful. Mrs Sheridan, thank you for
2 coming to tell us John's story. We are very grateful.
3 I am happy that Patrick and David, I assume they were
4 able to see it also. Thank you very much.
5 MRS SHERIDAN: Thank you very much.
6 MR LANGSTAFF: Thank you for coming. You are free to go.
7 If there is anything you remember you want to tell us
8 about as time goes by, do not hesitate to get on the
9 telephone and phone someone here.
10 MRS SHERIDAN: Thank you very much.
11 (The witness withdrew)
12 MR LANGSTAFF: Sir, tomorrow I assume you will wish to start
13 at 9.30 prompt, and I hope I will not delay you on this
14 occasion. We expect to have the evidence of Linda
15 Burton, Alice Thomas and Kenneth Darbyshire.
16 THE CHAIRMAN: Thank you, Mr Langstaff. Yes, at 9.30
17 tomorrow. We will adjourn now.
18 (3.32 pm)
19 (Adjourned until 9.30 on Tuesday, 23rd March, 1999)
20
21
22
23
24
25
0152
1
2
3
4 I N D E X
5
6
7 HOUSEKEEPING ......................................... 1
8
9 POINT RAISED BY MR LANGSTAFF ABOUT HOSPITAL RECORDS .. 3
10
11 MRS PAULA JORDAN (Sworn).............................. 4
12 Examined by MISS GREY............................. 4
13 Examined by THE PANEL ........................... 38
14
15 MRS PENELOPE PLACKETT (Sworn) ....................... 39
16 Examined by MR LANGSTAFF ........................ 39
17 Re-examined by MR LISSACK ...................... 102
18
19 MRS ELLEN SHERIDAN (Sworn) ......................... 111
20 Examined by MR LANGSTAFF ....................... 111
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Published by the Bristol Royal Infirmary Inquiry, July 2001
© Crown Copyright 2001