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Daily transcripts
Hearing summary
19 July 1999
Today the Inquiry began its final week of oral evidence before the
summer recess with evidence from retired Medical Director and Cardiothoracic Consultant
Surgeon at United Bristol Healthcare NHS Trust (UBHT), Mr James Wisheart. The
morning’s questions focussed on Mr Wisheart’s professional commitments in
addition to his clinical workload. These included membership of various hospital and
regional committees and his responsibilities as Chairman of the Hospital Medical
Committee, Associate Clinical Director for Cardiac Services and Trust Medical Director. Mr
Wisheart described the increasing pressure of workload and the division of paediatric and
adult surgical work between the three cardiothoracic surgeons at the Bristol Royal
Infirmary (BRI), himself and Mr Dhasmana undertaking all the paediatric work between them,
as well as an adult caseload. He said that the appointment of a fourth consultant in 1989
eased the situation in the short term but ultimately led to a further increase in demand
for the service. He said that attempts to attract a dedicated paediatric cardiac surgeon
to the position of Chair of Cardiac Surgery were unsuccessful and confirmed that there
were also problems recruiting paediatric cardiologists to Bristol. Mr Wisheart then
answered questions about waiting times and the implications for patients waiting an
extended length of time for surgery. The issue of the split-site was discussed, with Mr
Wisheart stating that the situation was not ideal and that in principle the quality of the
service may have been affected as a consequence of the need to transfer children from the
Children’s Hospital to the BRI for open-heart surgery. He then commented on the
separation of the role of Medical Director and Chairman on the Hospital Medical Committee
when the time commitment to fulfil the responsibilities of Medical Director increased. He
concluded today’s hearings by commenting on the relationship between consultants
(surgeons, anaesthetists and intensivists) involved in the care of patients who had
undergone cardiothoracic surgery, especially during their stay in ITU.
Mr Wisheart will continue his evidence tomorrow morning from 9.30 a.m.
|
FULL TRANSCRIPT
1 Day 40, 19th July 1999
2 (10.40 am)
3 THE CHAIRMAN: Good morning, everyone. Good morning,
4 Mr Langstaff.
5 MR LANGSTAFF: Sir, good morning. This morning, as is
6 obvious from the number of people that we have in the
7 hearing chamber, it has been very well advertised that
8 Mr Wisheart will give the first part of the evidence
9 which he is to give to us.
10 Can I emphasise, as I have done on a number of
11 occasions already, and I am pleased to see that the
12 local news bulletin on the television this morning for
13 those who were watching echoed it, Mr Wisheart will not,
14 at this stage of the Inquiry, be asked about the
15 adequacy of his surgery directly, nor will he be asked
16 about the figures in any comparative sense, how they
17 compared with other institutions in the United Kingdom,
18 or the United Kingdom as a whole. He will not be asked
19 about the expression of concerns. Everyone, I suspect,
20 in this room, knows that Mr Wisheart, his registration
21 was removed by the General Medical Council following
22 a hearing of some length, and I shall not be asking him,
23 at this stage, about the concerns, the expression of
24 those concerns, and the way in which they led to the
25 decision that the GMC took.
0001
1 His lawyers know that. He knows that. The
2 lawyers acting for various other participants,
3 interested parties in the Inquiry, know that as well.
4 I am grateful for their support in understanding why the
5 Inquiry is taking this particular approach.
6 We have on a number of occasions said that we will
7 bring back witnesses to deal with issues which touch
8 upon the development of the concerns during the 1990s in
9 Bristol. We will explore those, I hope every bit as
10 fully and as thoroughly as we have explored the issues
11 thus far, but I do not want it to be misunderstood when
12 anyone who might be waiting and watching for a question
13 in that area does not hear one over the next two days.
14 With that introduction, Mr Wisheart, would you, as
15 other witnesses have done, please, stand to take the
16 oath?
17 MR JAMES WISHEART (SWORN):
18 Examined by MR LANGSTAFF:
19 Q. Mr Wisheart, on the screen to your right you should,
20 I hope, see in a moment what we have WIT 120/1. Is this
21 the first page of a statement of evidence which you have
22 given to this Inquiry?
23 A. It is.
24 Q. If we go to page 90, and scroll down to the bottom, is
25 that where that statement finishes with your signature?
0002
1 A. It is.
2 Q. At page 91 do we see a statement on issue H, the split
3 site, and if we go through to page 111, to your
4 signature, is that where we find your signature to that
5 statement?
6 A. Yes, that is.
7 Q. At page 112 do we find a statement of evidence that you
8 have given to this Inquiry as to referrals. Again, at
9 page 120, at the foot, there is your signature to that
10 statement?
11 A. Yes.
12 Q. You have further given us statements, page 121, on the
13 pre-operative management of cases, which you sign at
14 page 152, a statement on management of surgery beginning
15 at page 153, and ending at page 177?
16 A. Yes.
17 Q. A statement on post-operative care beginning at 178
18 and ending at 224?
19 A. Yes.
20 Q. At 225, a statement dealing with treatment of the
21 families, including the bereaved, which ends with your
22 signature at page 240?
23 A. Yes.
24 Q. That statement is then followed by one in relation to
25 issue J, about which this Inquiry has been hearing
0003
1 evidence and will continue to hear some evidence this
2 week, page 241, finishing at page 254 with your
3 signature?
4 A. Yes.
5 Q. Have you, in addition to giving the Inquiry those
6 statements, made formal responses to the written
7 statements of others, as asked by the Inquiry, at
8 WIT 75/25, a response which consists of two pages, to
9 the written statement of Mr Roger Baird?
10 A. Yes.
11 Q. At WIT 79/308, a written response to the written
12 statement of Mr Stephen Boardman?
13 A. Yes.
14 Q. At 86/33, a written response to the statement by
15 Mr Peter Durie?
16 A. Yes.
17 Q. At 89/57, a written response to the statement of
18 Rachel Ferris?
19 A. Yes.
20 Q. At 85/37, a response to the statement by Sister
21 Sheena Disley?
22 A. Yes.
23 Q. At WIT 114/47, a response to the statement by
24 Fiona Thomas?
25 A. Yes.
0004
1 Q. Have you further given us, at WIT 120/264,
2 a supplementary statement as to the questions arising in
3 respect of the retention of tissue?
4 A. Yes, I have.
5 Q. Do you, for the purposes of this Inquiry, adopt as
6 true and accurate the contents of your several
7 statements and your comments on the statements of
8 others?
9 A. To the best of my knowledge, they are true and
10 accurate.
11 Q. You will be relieved after that to know that I am not
12 going to ask you in detail to go through the content of
13 some 264 pages of statement, quite apart from the
14 various other responses which you have made to the
15 statements of others.
16 We shall take in this Inquiry those statements as
17 your evidence, so that anyone who wishes to see, as
18 a coherent and comprehensive account, that which you are
19 saying, will be able to go to those statements and see
20 what you have to say and what the Inquiry has heard from
21 you.
22 My purpose in asking you questions concerning the
23 issues which I have already mentioned is to supplement
24 that evidence, it may be even to deal with some areas in
25 which you say little in your statements, so that the
0005
1 Inquiry may benefit from hearing more from you.
2 May I have on the screen, please, UBHT 189/152?
3 Can we scroll down, please?
4 I do not invite a comment for the moment, but it
5 appears to be the view expressed in 1994 by Dr Laszlo
6 that when you ceased to be Chairman of the Hospital
7 Management Committee you had always demonstrated a high
8 degree of tact, diplomacy, integrity, impartiality and
9 IQ, "combined with the vocal resonance of Brian
10 Mawhinney".
11 That latter, I think, is not so much to do with
12 politics as with your origin in Northern Ireland?
13 A. That is correct.
14 Q. I do not ask you, for reasons of modesty, to say whether
15 you agree wholeheartedly with the description of
16 yourself, but do you at least recognise that that was
17 the view others had of you in 1994, at any rate?
18 A. I would like to think so. They did not tell me anything
19 differently.
20 Q. No doubt that impression may have owed in part to
21 the hours that you worked?
22 A. I think anyone who accepts the role of being Chairman of
23 the Hospital Medical Committee in a teaching hospital
24 accepts that they will be working quite hard for those
25 two years, accepting the additional workload that comes
0006
1 with that appointment over and above their own clinical
2 workload.
3 Q. Can we have a look, please, at UBHT 174/11? This comes
4 from the 11th October 1988, and it is the foot of the
5 document to which I wish to refer.
6 The author of the letter is talking about -- let
7 us go to the top of the letter to see the heading of it:
8 "Appointment of fourth cardiac surgeon ..."
9 It is arguing a case for having an additional
10 surgeon.
11 The reasons, if we scroll down to the last
12 paragraph:
13 "We are now operating on a planned 15 operations
14 a week apart from emergencies, that is approximately 725
15 patients per annum. Whereas at the present time we are
16 able to achieve this, it is only with the greatest
17 difficulty, for the three surgeons in post [that would
18 be yourself, Mr Keen and Mr Dhasmana] are working very
19 hard, and my two colleagues, who also do paediatric
20 cardiac surgery at the Children's Hospital, Mr Wisheart
21 and Mr Dhasmana, are working all hours, day and night,
22 and their weekends are rarely free. This really cannot
23 continue, for even should these numbers be achieved
24 during normal working periods, there is no way that this
25 volume of work will be sustained during the summer ...
0007
1 when one or other of the cardiac surgeons is away."
2 Is it right that in 1988, at any rate, you were
3 working all hours, day and night and your weekends were
4 rarely free?
5 A. I think there is a measure of licence in this letter,
6 sir.
7 Q. You mean it exaggerates to make a point?
8 A. I think so, yes. I mean, we did work hard. I think it
9 will be clear that in a service which is growing, as
10 ours was, you can only increase the number of surgeons
11 one at a time, then there are times when the workload of
12 each individual is greater and then when a new surgeon
13 is appointed it is eased, but as the work continues to
14 grow, so it tends to be a little bit like that. We
15 accepted that, because there was no other way it could
16 be, but it was important to appoint the fourth surgeon.
17 Q. Your prime interest, we have seen in some of the
18 documents before the tribunal, was in surgery rather
19 than in administration?
20 A. That is correct.
21 Q. The reference in this document here is to your work as
22 a surgeon?
23 A. That is correct.
24 Q. We have heard from one of the parents who gave evidence
25 to us that it had been reported to her that your white
0008
1 Volvo was very rarely out of the carpark?
2 A. It was out of the carpark for quite substantial periods
3 at a time, sir.
4 Q. We have seen what the letter says in 1988. Mr Baird,
5 when he gave evidence, said this of you:
6 "How did Mr Wisheart, your predecessor, manage?"
7 His answer was:
8 "By working very hard over the whole of his time
9 until he retired. You saw his car in the hospital
10 carpark probably more than anybody else's. You would
11 ring up his wife and say 'Janet, I would like to speak
12 to James'. 'Oh, you'll find him in the hospital'. That
13 is where he was."
14 Before I continue with what Mr Baird then had to
15 say, do you accept that as a description of yourself?
16 A. In the sense that my hours of work were not from 9 to
17 5. The day tended to begin at 8, or between 8 and 8.30,
18 and I suppose it would frequently go to 7 o'clock,
19 8 o'clock, or sometimes 9 o'clock on quite a few
20 evenings of the week.
21 Q. Mr Baird went on -- I will come back to it, but since
22 I have the transcript open in front of me, for those who
23 want to pick it up, it is Day 29, page 74. I asked:
24 "Would it be fair or unfair to say in consequence
25 of fulfilling that role, he was probably overworking?"
0009
1 Mr Baird's answer:
2 "I do not know, you will have to ask him."
3 I will do in a moment or two.
4 I then asked for his view, because he did the job
5 after you, the Chairman of the Hospital Management
6 Committee. He said:
7 "Well, I think in the end he found himself in an
8 impossible position."
9 I am not asking you for a comment at the moment,
10 but let me set that comment, which obviously covers
11 a period of time when you were Chairman of the Hospital
12 Management Committee, against what we can see of the
13 holidays that you took.
14 How many holidays per year were you entitled to?
15 A. We were entitled to six weeks holiday a year, and if one
16 had worked on Bank Holidays, or been on call on Bank
17 Holidays, then one was entitled to additional days in
18 lieu of that. Then, of course, there was study or
19 professional leave as well.
20 Might I just say, sir, you referred to the
21 Hospital Management Committee --
22 Q. I meant the Medical Committee, but you are absolutely
23 right to correct me. So if we can have, please, on the
24 screen JDW 7/215, this is a personnel document which
25 records holidays, and gives the date of your first
0010
1 employment. We can see by flicking through this and the
2 pages which follow -- let us have a look at page 216,
3 page 217, dealing with 1984/85 here, 218, 219. Just
4 pausing there: these, from the early 1980s, might
5 suggest you did not take all the holidays that were open
6 to you?
7 A. My impression was that consistently I took, to within
8 a day or two, all the holidays that were open to me.
9 I have not retrospectively checked that out in any way,
10 but that was certainly my impression at the time.
11 Q. When you say "to within a day or two", you were then
12 somebody who took every last hour of holiday?
13 A. It may or may not have been every last hour, but broadly
14 speaking it was the full entitlement. At least, that is
15 what I thought I was doing. I may say that I enjoyed my
16 holidays very much and they compensated for the
17 long hours at other times.
18 Q. Can we have a look again at some of the travelling and
19 subsistence claims and what they may tell us? Shall we
20 have a look, please, at JDW 7/187.
21 I just really want to explore with you how typical
22 this was in respect of a month. This is October 1992.
23 It is not easy to read, but what you did, because you
24 had a number of entries to make, I think, was at the top
25 of each of your sheets you wrote, did you, "Home to BRI
0011
1 to home, 1; Home to BRI to home, BRI to BCH, to BRI, 2."
2 That way, if we follow the numbers down the
3 left-hand margin, we can see the moves that you carried
4 out by car for which you then were able to claim
5 transport rates.
6 The purpose is set out in the right-hand column.
7 If we take a look at October 1992, 1st October, there is
8 no particular call-out. 2nd October, you go to Taunton,
9 to attend outpatients. 3rd October, that is a Saturday
10 call and there appear to be two call-outs on the
11 Saturday. The 4th, a Sunday, two Sunday call-outs. The
12 5th, a night call. The 6th, a night call. The 7th, no
13 particular call. The 8th, a night call. The 9th and
14 10th, nothing; and then two Sunday call-outs on the
15 11th. The 12th, there is a night call. Nothing on the
16 13th or 14th. 15th, there is a night call. Then we go
17 to 185 (JDW 7/185)to complete the month and we can see the rest of
18 October: a Saturday call, a Sunday call, a Sunday call,
19 a night call. There is a gap between the 20th and 25th,
20 a Sunday call, the 26th, a night call, the 27th a night
21 call, the 29th, a night call.
22 In the 31 days of October, I make that 11 days
23 when there was no call-out, either during the weekend or
24 at night.
25 I have selected that pretty much at random. Is
0012
1 that in fact fairly typical of the working pattern that
2 you were doing in the early 1990s?
3 A. I think that is quite difficult to answer because again,
4 I never calculated them and I do not have an average
5 number in my head, but I would like to point out that
6 a call does not necessarily mean that I was in for
7 a number of hours carrying out an operation. If I had
8 operated on a child on a Monday, I would come in to see
9 them on the Monday evening before bed-time, and that
10 might be 10 minutes, it might be 20 minutes. It was
11 whatever it needed, but it could be shorter or it could
12 be longer.
13 So often these calls were to simply pop in and out
14 and see the patient, and of course at other times, they
15 would have been for some emergency operation and that
16 would have been much longer. But there would not have
17 been a large number of those each month.
18 Q. Each of those calls that I have shown to you would have
19 involved actually going from home to the hospital and
20 back?
21 A. At nights and weekends, yes.
22 Q. If you were routinely going to see a child who had
23 finished surgery or an adult who had had his surgery,
24 you would no doubt try and do that before you went home
25 at half past 7 or 8, whenever it was in the evening that
0013
1 you went home?
2 A. Yes, I would normally do that.
3 Q. So each and every time we see a night call, it would
4 be something other than the routine check on the patient
5 before you go home?
6 A. It would be more towards bed-time.
7 Q. And that is your bed-time?
8 A. That is my bed-time.
9 Q. So just to get the picture, you would have done your
10 full day's work at the hospital, starting at 8, 8.30,
11 working through until the early evening, come home, and
12 then there would have been a call-out, presumably?
13 A. It would usually have been a visit that I would have
14 voluntarily done; it would not have required a telephone
15 call to trigger it.
16 Q. So you would have said to your wife, "I have had my
17 dinner and I had better pop down to the hospital and
18 check on X"?
19 A. Yes. I mean, that would only have been done for
20 a child who I had operated on that day, or for some
21 other patient who I felt had a particular need and whom
22 I did not wish to leave for a 12 to 14 hour period
23 without having been seen.
24 Q. So far as the Sunday and Saturday calls are concerned,
25 you would have been on call-out at the weekend,
0014
1 presumably?
2 A. At this time in 1992, Mr Dhasmana and I shared the call
3 for children so we were on call on alternate weeks. For
4 adults, it varied. In 1992 I think there were four of
5 us, so it would have been one week in four for adults,
6 but again, our practice was that if we were in town, we
7 looked after our own patients, so, for example, even if
8 I had not been on call, I might have popped in on
9 a Saturday morning or reasonably early on a Sunday
10 morning to see my own patients, or at least my patients
11 in intensive care, and that might have taken half an
12 hour; it might have taken an hour. It would not have
13 been the whole morning, usually. That was simply our
14 style of working.
15 Q. So the visit may or may not have been because you were
16 on call that weekend?
17 A. That is correct.
18 Q. Those weekends when you were on call, you simply could
19 not go very far?
20 A. Again, it varied as to whether we had pagers or how
21 sophisticated the pagers were, but, yes. I mean, you
22 could not go walking in the mountains, that sort of
23 thing.
24 Q. The general pattern that you had in terms of operating
25 sessions from the early 1980s onwards was, was it, one
0015
1 session at the Children's Hospital per week and six or
2 possibly seven at the Royal Infirmary?
3 A. Yes. I think I had two sessions on alternate weeks,
4 which is exactly what you say, at the Children's
5 Hospital. The Infirmary varied. It is an expression of
6 the same development of the work as we referred to with
7 the number of surgeons. As the work grew, when there
8 were three surgeons, then we tended to operate on more
9 days but when a fourth surgeon was appointed, then at
10 that point the same number of operating sessions were
11 divided amongst the four surgeons, so it did vary from
12 time to time.
13 Q. Can we have a look, please, at UBHT 113/326? I will
14 show you where it begins. It begins at 325 so we had
15 better look at 325 (UHBT 113/325)first.
16 This is 1989, 5th July, the Bristol & Weston
17 Health Authority. 326, please.
18 Can we scroll down to "Consultant in cardiac
19 surgery ..."
20 "Mr Wisheart tabled a statement of need for
21 a fourth cardiac surgeon (copy filed with the minutes).
22 He emphasised that the heavy workload sustained by the
23 current surgeons could not be maintained and it was
24 intended that the existing workload would be
25 redistributed. He assured the committee ..."
0016
1 It goes on.
2 So here you are emphasising to the district at the
3 time -- this being 1989 -- that some further surgeon was
4 needed in order to spread the load?
5 A. That is correct.
6 Q. And to spread the load because essentially it was too
7 heavy for each of the three of you -- Mr Keen,
8 Mr Dhasmana and yourself -- to continue doing the work
9 adequately?
10 A. That is correct.
11 Q. If we look, please, at HA(A) 35/10 again, it is July
12 1989. This is the statement of need to which reference
13 is made in that last minute, as we saw.
14 If we can just scroll down, please, and see first
15 of all the context in which this is put:
16 "Cardiac surgical services in Bristol have
17 developed in a step-by-step fashion during the last
18 decade, increasing the number of open heart operations
19 performed annually from 253 in 1980 to a predicted 675
20 to 700 in 1989."
21 It sets out the staffing. It notes that if the
22 number was to go up to 675, it was recognised that an
23 additional surgeon would probably be needed.
24 The middle paragraph:
25 "While the three surgeons have managed to
0017
1 sustain this heavy workload over the winter months of
2 1988/89, it is not a load which could be carried
3 indefinitely. In particular, it would almost certainly
4 be impossible to maintain the volume of work during the
5 holiday season simply due to lack of sufficient surgical
6 hands."
7 This is your writing, I think, your statement of
8 need, your drafting?
9 A. It may be. I am not sure at this moment who drafted
10 this statement.
11 Q. The last sentence:
12 "The exceptionally heavy load borne by consultant
13 staff over the winter months has undoubtedly contributed
14 to unsociable hours of working for the whole team,
15 medical, technical and nursing, and this would be better
16 avoided."
17 Those are words, are they, which although they
18 were making a case, were appropriate?
19 A. I think it was appropriate to say them because cardiac
20 surgeons, as a race, are quite enthusiastic to do the
21 work, and of course we were faced with a great need to
22 do more work and we were keen to develop the service.
23 This was foreseen as is set out in the first paragraph.
24 The need for a fourth surgeon was anticipated, but of
25 course nobody, at that point, knew when he would be
0018
1 needed, and what we were doing here, really, is to
2 trigger --
3 Q. Could I just stop you. I think it has been remedied;
4 we were just losing your voice a little bit.
5 A. I am sorry.
6 Q. It is not your fault, the microphone is fairly
7 sensitive, but sometimes if people sit back it loses it
8 and it is important that people hear what you have to
9 say. If I stop you again, you will understand.
10 A. Yes.
11 Q. I am sorry.
12 A. I am not sure that I can repeat what I said.
13 Q. Let me tell you what you said. You said that it was
14 appropriate to say those words "because cardiac
15 surgeons, as a race, are quite enthusiastic to do the
16 work, and of course we were faced with a great need to
17 do more work and we were keen to develop the service.
18 This was foreseen as is set out in the first paragraph.
19 The need for a fourth surgeon was anticipated, but of
20 course nobody, at that point, knew when he would be
21 needed and what we were doing here, really, is to
22 trigger --", that is where I stopped you.
23 A. Yes, to trigger the anticipated need for a fourth
24 surgeon. In the Health Service, to appoint a new
25 consultant in the 1980s was really quite a difficult
0019
1 task. There were many hurdles to get over before a new
2 appointment could be made. This particular appointment
3 perhaps was a little less difficult because it was
4 already incorporated in the plan for the development of
5 cardiac surgery, but an effort still had to be made, and
6 still we were recognising that we had got to the point
7 where that was needed.
8 Q. Looking at the wording:
9 "The exceptionally heavy load borne by consultant
10 staff". So "exceptionally" was a word which was
11 justified in the circumstances, was it?
12 A. It was a heavier load than would normally have been the
13 case, and in that sense, I think it was justified, yes.
14 I think everybody was just contributing that little bit
15 extra at that point, because that is what the
16 circumstances seemed to need.
17 Q. "Exceptionally" is hardly the word one uses for
18 "a little bit extra". It is a word of hyperbole.
19 A. I guess the truth lies somewhere between "a little bit
20 extra" and recognising that there may be a little bit of
21 licence in this letter. I do not actually think
22 I drafted this statement.
23 Q. What about the unsociable hours of working for the whole
24 team?
25 A. Well, that reflects a situation where operations may
0020
1 have lasted longer than had been planned and therefore
2 all members of the staff in the operating theatres might
3 not have got away from work at the time they had
4 anticipated, and that would have happened from time to
5 time.
6 Q. It is talking about late nights, some weekends, that
7 sort of thing, is it not?
8 A. Well, yes. I mean late nights in the sense that the
9 work might not have been finished at 5 o'clock or
10 6 o'clock but might have gone to 7 or 8 o'clock.
11 I think emergency work that would have to be done at
12 weekends or in the middle of the night is a different
13 issue. I think this is reflecting the overall pressures
14 which really came from the development of the total work
15 and I think the unsociability of dealing with
16 emergencies, I do not think was the issue here. I think
17 it was the unsociability that stemmed from just
18 prolongation of the working day.
19 Q. We saw that this was put in the context of 675
20 operations. If we look -- this is 5th July -- to
21 9th August 1989, UBHT 113/296, the starting point of
22 it. I am going to take you a page further on, but let
23 us see where it starts so you can see what it is. These
24 are minutes of the Bristol & Weston Health Authority, so
25 it is the same body that looked at the question of the
0021
1 appointment of the fourth surgeon a moment ago.
2 9th August 1989. If we go to the next page(UHBT 113/297), please,
3 shall we move down? Can we go into the minutes again.
4 It is at the very bottom of the page, "Consultant in
5 cardiac surgery", so it picks up the minute we were
6 looking at a moment ago:
7 "Dr Thomas reminded members that all chairmen of
8 divisions had approved this post, provided that it led
9 to no increase in workload."
10 Just pausing there, we mentioned a moment ago the
11 difficulty in securing a further consultant appointment,
12 at least in the 1980s. There were a number of hoops you
13 had to go through, were there?
14 A. There were.
15 Q. Funding?
16 A. Yes.
17 Q. Who would provide the funding?
18 A. In this instance, the Regional Health Authority.
19 Q. What was the difficulty in getting the funding out of
20 them for a particular post?
21 A. Because if they had funds for a certain number of new
22 consultant appointments in the region, they probably had
23 applications for two, three, four times that number of
24 new consultant posts, and therefore it was a matter of
25 competition, prioritisation.
0022
1 Q. So there was competition. The post had to be justified,
2 and no doubt it was important that other potential
3 competitors said, "Well, all right, they can have one in
4 cardiac surgery" or "thoracic surgery", or whatever the
5 discipline might be, because they, too, would recognise
6 the need?
7 A. Yes. To some extent, that hurdle had been got over at
8 the earlier planning stage for the development of the
9 service, when it was recognised that a fourth surgeon
10 would be needed, but it was still necessary to actually
11 achieve it and that is what we were doing.
12 Q. But the chairmen of divisions -- that would be the
13 Division of Surgery and the various other divisions,
14 presumably, that is referred to?
15 A. Yes.
16 Q. "Had approved the post provided it led to no increase in
17 workload."
18 They seemed to be regarding it as a means of
19 easing the burden on each of the three consultants doing
20 the 675 operations?
21 A. Yes.
22 Q. So that instead of each having an average of 225
23 operations, it would be down to 150, 160, that sort of
24 region?
25 A. Whatever the arithmetic is, yes. Dr Thomas was an
0023
1 anaesthetist and in a sense, that illustrates what he is
2 saying here, because when a new consultant is appointed,
3 it tends to increase the amount of work for the
4 anaesthetic department, the x-ray department and all the
5 other hospital departments, and he is saying that this
6 appointment should not lead to such an increase. So at
7 the moment of making the appointment, it was exactly as
8 you have just said: the same amount of work was being
9 divided between -- at least, the proposal was that it
10 would be divided between the four surgeons instead of
11 the three surgeons.
12 Q. The justification you had been putting forward was "We
13 are doing too much, we need to do a bit less each"?
14 A. Yes.
15 Q. So it was consistent with having a fourth pair of hands
16 to ease the burden?
17 A. Yes.
18 Q. Am I right in thinking what actually happened was when
19 the fourth surgeon was appointed, the Trust decided that
20 now was the opportunity to increase the throughput to
21 1,000 operations or more per year?
22 A. The Trust was not in existence in 1989/90 --
23 Q. No, but by the time the fourth surgeon came, the
24 opportunity was taken to actually increase the number of
25 operations?
0024
1 A. I think that decision came a little bit later, but that
2 decision came with, if you like, the funding that was
3 necessary to provide the increased activity in all the
4 various areas, but the fact that the fourth surgeon was
5 there was one of the considerations that enabled it to
6 happen.
7 Q. But if one were to look at the load on each individual
8 surgeon, I suggest to you -- I will back it up with
9 documents if you wish me to do so -- but no sooner does
10 the fourth surgeon arrive than the number of operations
11 goes up, so it is not long before you are back in the
12 same position of each surgeon doing the same numbers
13 that had led to the complaints back in 1989?
14 A. That is correct.
15 Q. So if one were to describe the position, looking at the
16 surgical workload alone, as "chronic overload", how far
17 off the mark might that be?
18 A. I do not think the surgeons regarded it that way. As
19 I say, cardiac surgeons are quite keen to be doing the
20 work and we were under pressure of great demand because
21 patients were being referred to us who needed surgery,
22 and as you know, the history of our facility in Bristol
23 is that it was under-resourced and that we were --
24 Q. Can I just stop you? I think what you are going on to
25 do, in your answer, is actually to justify the workload,
0025
1 the level of workload, rather than accept, which is the
2 proposition I am putting to you for your comment, that
3 there was a chronic overload. You are saying "that is
4 what cardiac surgeons are there for, because people need
5 to be treated, there are serious cases and therefore we
6 do the work". But that is justification for overload.
7 I am asking whether the recognition of overload in the
8 first place is or is not accurate?
9 A. My view is that at times there was overload, that is,
10 prior to the appointment of a new surgeon, and then
11 after the appointment of the new surgeon, that was not
12 the case, but it tended to come again in a cyclical
13 manner. I think that is the way it happened.
14 Q. Not all, I suspect, of the other cardiac surgeons were
15 perhaps doing quite as much in terms of hospital
16 administration as you may have been.
17 You were, were you, Chairman of the Division of
18 Surgery from 1985 onwards, at least for a while?
19 A. For a two-year period.
20 Q. So from 1985 to 1987, you were Chairman of the Division
21 of Surgery. That was a task additional to your clinical
22 commitments?
23 A. Correct.
24 Q. No doubt, given the description of you which we have
25 seen and I began the questioning with, that was
0026
1 a commitment you took seriously?
2 A. Oh, indeed.
3 Q. You would have to spend some time to fulfil that?
4 A. Yes. It varied a bit. It was not an enormously onerous
5 task, not compared to the tasks I undertook in the
6 1990s, but it certainly took some extra time and effort.
7 Q. Tell us briefly what the Chairman of the Division of
8 Surgery did, so we can all understand.
9 A. The consultants in the group of hospitals were grouped
10 into different groupings, so there was the Division of
11 Surgery, there was the Division of Child Health, there
12 were paediatricians, the Division of Radio Diagnosis for
13 the x-ray doctors, and so forth. The divisional
14 meetings were advisory and not executive; they did not
15 have a management function. So they were mainly
16 concerned with the professional responsibilities of the
17 group.
18 In the case of surgeons, the sort of training
19 would be an important issue and the facilities for
20 training, the arrangements for the trainees and so
21 forth, those were issues that would be discussed.
22 The allocation and use of the resources which we
23 as a group of surgeons had, the operating theatres and
24 so forth, and whether one surgeon should have a session
25 or another surgeon, and so forth.
0027
1 Those are just two of the issues that spring to
2 mind immediately. So the division met monthly to
3 discuss issues of that sort. There would be minutes to
4 approve or amend; there would be some letters to write
5 and from time to time, there might be a larger task to
6 be undertaken. I do recall that within my time, that
7 task happened to be the writing of a 10-year strategy
8 for the future work of the hospital, which is a way of
9 concentrating the mind, looking ahead.
10 Q. The role you have described is partly training, partly
11 in a sense management, which surgeon does what, where,
12 and also strategic. Inevitably, as with any
13 chairmanship, you would have a role in setting the
14 agenda, would you, for a meeting?
15 A. Yes. I would normally set the agenda, and I would be
16 happy to be prompted by any of my colleagues in that
17 matter.
18 Q. And you would have to deal with matters that arose
19 between meetings that needed any urgent input? You are
20 nodding; the reason I say that is simply --
21 A. I am thinking, really, rather than -- yes, I would not
22 say it was particularly onerous, but clearly as Chairman
23 of the division you were the person somebody would come
24 to if they had something that needed considering or
25 something they wanted advice about.
0028
1 Q. More than once you have said it was not particularly
2 onerous. How many hours per week are we talking about,
3 on average?
4 A. I would be surprised if it were as much as two or
5 three hours per week. Perhaps two or three hours
6 a week.
7 Q. Perhaps two or three hours a week?
8 A. Yes.
9 Q. Later on in the 1980s, did you become a member of the
10 Regional Hospital Medical Advisory Committee?
11 A. No, I did not.
12 Q. But you attended it?
13 A. No. The Regional Hospital Medical Advisory Committee?
14 No, I was not a member of that group and I did not
15 attend meetings of that group, that I can recall.
16 Q. Can we have a look at UBHT 113/299? It begins at 296.
17 I will show you this in a moment. 9th August 1989, it
18 is the Steering Committee, with chairmen of divisions of
19 the Bristol & Weston Health Authority. You were
20 a member of the Steering Committee?
21 A. Yes, I was.
22 Q. Can we go to 299, and can we scroll down. Four persons,
23 we are told there, have been suggested as suitable
24 nominees for membership of the principal Medical
25 Advisory Committee to the RHA: Mr Wisheart, Dr Berry,
0029
1 Mr Horrocks and himself. It meant setting aside "one
2 day a month for a meeting with three hours reading
3 beforehand, occasional projects to undertake and
4 position papers to write."
5 It did not come your way, that post?
6 A. No, Dr Thomas was the representative.
7 Q. You were nonetheless prepared to be considered for such
8 a post?
9 A. It looks as if I was, yes.
10 Q. That would be volunteering yourself, because there would
11 be no advantage in terms of reduction of work or
12 increase in money, I take it, for this post?
13 A. No.
14 Q. It would mean volunteering yourself to set aside one day
15 a month with three hours reading beforehand, occasional
16 projects and position papers to write.
17 In 1989, despite what else you were and had been
18 doing, you would have been willing to undertake that,
19 would you?
20 A. So it would seem, yes.
21 Q. You say that with a certain amount of surprise?
22 A. I do not have a very clear recollection of that.
23 Q. You were at the meeting?
24 A. I was, I know. That is absolutely correct.
25 Q. You did not put up your hand in shock/horror and say,
0030
1 "Not me, I am doing too much already"?
2 A. I think I was reasonably confident that Dr Thomas
3 would be the successful person.
4 Q. So you had the status of being the losing nominee?
5 A. Yes. Satisfaction.
6 Q. You did, however, in 1990, I think, become an appointee
7 from the Hospital Medical Committee to the
8 Bristol & Weston Health Authority purchaser committee.
9 We can pick that up from HA(A) 141/41. You see your
10 name there in attendance?
11 A. Yes.
12 Q. In the attendance section rather than the observers
13 section. The very first note:
14 "The committee reports that it has welcomed the
15 decision of HMC to nominate Mr Wisheart to attend and
16 advise the committee."
17 So that, again, was something you obviously were
18 willing to have your name put forward, or at least, not
19 so unwilling that you rejected the appointment?
20 A. Yes. That is so. I clearly regarded what was happening
21 at this time, namely the division into the
22 purchaser/provider split, if you like, to be important
23 for all of us and therefore I was prepared to be
24 involved in how that developed.
25 I think it was quite a short-lived commitment.
0031
1 Q. This is June 1990. What sort of commitment in terms of
2 time was that?
3 A. I think very little. I may have attended some meetings
4 and the work that I recall in this area was work to do
5 with the development of contracts and the placing of
6 orders within those contracts. I do not recall having
7 responsibilities much beyond that.
8 Q. Also in 1990, you became, I think, a member of the audit
9 review group?
10 A. I think that was an ad hoc group who were preparing
11 proposals for the Medical Audit Committee for what was
12 to be the Trust. Audit, at that time, was, if you like,
13 a new activity which had been put forward in the White
14 Paper which the government published a year or two
15 before, and which was welcomed by the medical
16 profession, and so the review group you refer to
17 consisted of Dr Thomas, Dr Watt and myself, and we were
18 preparing proposals for the terms of reference and
19 membership of the Medical Audit Committee, which was
20 a sub-committee of the Hospital Medical Committee.
21 Q. So you met, you discussed, you talked, you spent time
22 doing the job --
23 A. Yes, that was one-off. It was either one or two
24 meetings, and that was a very important task.
25 Q. You remember in September 1990 the Cardiac Services
0032
1 Working Party?
2 A. There were constantly cardiac services working parties
3 throughout the whole period.
4 Q. And you would almost always be a member them?
5 A. Absolutely, yes, very important work. That was the most
6 important work that I was committed to, really.
7 Q. On 18th October you became the Associate Clinical
8 Director of Cardiac Surgery?
9 A. Yes.
10 Q. That post, presumably, involved quite a commitment?
11 A. That post involved quite a commitment, particularly
12 at the beginning when the question of defining the
13 directorate and its role and setting up its initial
14 structures had to be accomplished.
15 Q. So initially quite a lot of time that you had to spend?
16 A. Yes. Again, it might have been a number of hours
17 a week. I mean a few hours a week, I am sorry.
18 Q. How many is "a few" or "a number"?
19 A. I am really guessing, to be honest. I do not have
20 a precise answer.
21 Q. It has to be an average, because some weeks no doubt
22 there would be very much more than others?
23 A. I think that at the beginning this might have required
24 for a number of months 3, 4 or 5 hours a week, but once
25 it was up and running, we would have been back to 2 or
0033
1 3 hours per week, probably.
2 Q. In 1990 you were a member of the Health Policy Committee
3 of the Bristol & Weston Health Authority, or attended
4 it?
5 A. I think I attended it on one or two occasions.
6 Q. The Contracts Quality Monitoring Committee?
7 A. I think that is the work that I referred to a moment
8 ago when I referred to the development of the
9 purchaser/provider role and the development of contracts
10 or service agreements and the place of audit within
11 those, and again, that was a series of, if you like,
12 ad hoc meetings which were directed to a particular
13 purpose.
14 Q. The District Audit Committee?
15 A. That was the medical committee which came into being as
16 a result of that review group that we discussed a moment
17 ago.
18 Q. In 1991; so the review group led to the District Audit
19 Committee of which you were a member?
20 A. I think I became a member of the Audit Committee in an
21 ex officio capacity because I was the Chairman of the
22 Medical Committee.
23 Q. So what sort of time did membership of the District
24 Audit Committee involve?
25 A. I think it met once every two months. I had no leading
0034
1 role in that committee, so I attended. The members of
2 the committee for the next year or two had the
3 responsibility to "supervise", for want of a better
4 term, the performance of audit in a particular area and
5 my area was the Division of Children's Services, so that
6 was really the only work that I did outside the
7 committee itself, and that was only occasional work;
8 that was not regular work.
9 Q. You attended the District Health Authority meetings
10 from 1990 onwards?
11 A. Again, that was very short-lived because the District
12 Health Authority ceased to exist in 1991. I am sorry,
13 it ceased to exist in the form it had existed before,
14 I beg your pardon. It existed as a purchasing Health
15 Authority and I was not a member of that.
16 Q. So up until at least 1991, when there was the division
17 into Trust and District, you attended those meetings
18 too?
19 A. I attended some. I do not recall it as a major regular
20 commitment, but I do recall attending a small number of
21 meetings.
22 Q. In 1992, did you become the Chair of the Clinical Care
23 Advisory Group?
24 A. I cannot recall now.
25 Q. Let us look at UBHT 36/14, which is where it starts.
0035
1 This is 31st July 1992.
2 "Minutes of the meeting of the ... Trust ...
3 31st July."
4 Can we go to page 16?(UBHT 36/16) It is the first three
5 lines?
6 A. I can report to you, sir, that that group never came
7 into being.
8 Q. So at least that was one poisoned chalice that passed
9 from your lips.
10 On 2nd September 1992, did you become the Chair of
11 the Steering Committee of the Chairmen of Divisions?
12 A. That happened on 1st April, sir, because the Chairman of
13 the Medical Committee also chaired the Steering
14 Committee.
15 Q. I was going to ask whether it was effectively
16 ex officio. So by being the Chair of the Hospital
17 Medical Committee, you were also the Chairman of the
18 Steering Committee of the Chairmen of Divisions, and
19 I do not know, in your capacity as Associate Director of
20 Cardiac Surgery, did you, in that capacity, attend the
21 South Western Regional Cardiac Specialist Sub-committee?
22 A. Any cardiac consultant was entitled to attend that
23 committee but it always occurred on the day I was
24 operating and I think in my career I attended it about
25 twice.
0036
1 Q. So you went if you could?
2 A. I went if I could.
3 Q. In September 1992, you, I think, set up or suggested the
4 setting up of the Clinical Care Committee?
5 A. Is that the one we have referred to?
6 Q. No the Clinical Care Advisory Group is what is on the
7 screen. Perhaps you can tell me if there is
8 a distinction between that, which obviously was set up
9 in July 1992, and what we pick up in the minutes on
10 18th September the same year, 1992, UBHT 34, it starts
11 at page 211. Again, it is the Executive Committee of
12 the Trust.
13 Can we go to page 214(UBHT 34/214), please?
14 A. I believe that this is referring to the same proposed
15 committee as the one we discussed a moment ago, and
16 which did not come into being.
17 Q. Mr Wisheart, one last question before we take a break.
18 Do you recognise, in any of the questions that I have
19 been asking you about the various roles that you did
20 fulfil -- leave aside what we have yet to come to, which
21 is the Chairmanship of the Medical Committee and your
22 role as Medical Director -- that perhaps you may have
23 been doing too much?
24 A. I did not think I was doing too much, sir, no.
25 MR LANGSTAFF: Shall we, on that note, it is an
0037
1 appropriate note really, take a break?
2 THE CHAIRMAN: Mr Langstaff, yes, 15 minutes, so we
3 come back at 5 past 12. Thank you.
4 (11.50 am)
5 (A short break)
6 (12.05 pm)
7 MR LANGSTAFF: We have not yet, Mr Wisheart, really
8 explored the work that you then went on to do as Medical
9 Director. Can you just remind us first how many hours
10 per week on average the Chairmanship of the Hospital
11 Medical Committee would involve you in?
12 A. I have never thought of it that way. I am really not
13 quite sure, but we were given two sessions within which
14 to do the work, so it was unlike any of the other tasks
15 that we have been discussing. But this one was of
16 course much more onerous, so two half days per week were
17 allocated for the Chairman of the Medical Committee to
18 do that work.
19 Q. And you got nothing extra for being Medical Director --
20 no extra relief in terms of time?
21 A. Initially that is correct.
22 Q. So initially -- let us take that stage first -- when you
23 were both Chairman of the HMC and Medical Director of
24 the Trust, what sort of commitment in terms of time --
25 I know you say you did not look at it that way, but if
0038
1 you were to, what would it amount to?
2 A. I would have thought that one would be talking of
3 anything up to 10 hours a week, but, you know, again,
4 I am guessing. Obviously, it varied from week to week.
5 Q. Whilst you were Medical Director initially, at any rate,
6 no earmarked support in terms of support staff?
7 A. I had a secretary at all times.
8 Q. But you had had that secretary throughout as
9 a consultant?
10 A. I always had a clinical secretary who looked after my
11 clinical work, but I had an additional person at Trust
12 headquarters who helped me with all my work as Chairman
13 of the Medical Committee and Medical Director.
14 Q. If we skip ahead towards the beginning of 1994, at this
15 stage you had been both Medical Director and Chairman of
16 the Hospital Medical Committee since the Trust began to
17 operate, effectively. At 14th January 1994, UBHT 20/7:
18 can we scroll down a little bit? It is the "Chairman's
19 Remarks."
20 "The Chairman also welcomed Dr Gabriel Laszlo who
21 would take over as Chairman of the Hospital Medical
22 Committee from the beginning of April. Until now the
23 roles of Chairman of the Hospital Medical Committee and
24 Medical Director had been combined, but over the three
25 years since becoming a Trust it had become evident that
0039
1 with clinical commitments, the combination of the two
2 roles was becoming [his word, no doubt] untenable."
3 The word "untenable" appears to relate to the
4 pressure of time, given your clinical commitments. Have
5 I read it right?
6 A. I think that the combination of the two roles, together
7 with one's clinical commitments, had become too heavy,
8 yes. But I think he believed that that would probably
9 apply to any active clinician who also had the
10 chairmanship of the Medical Committee and the Medical
11 Directorship to carry out.
12 Q. The present Medical Director, we have heard, I think has
13 seven sessions?
14 A. That is some years later, yes.
15 Q. Everyone else who has done this task has had more relief
16 or support than you had, as an historical fact?
17 A. Well, the first Medical Director was Mr Dean Hart, who
18 was an eye surgeon. He worked under the same
19 arrangements as myself.
20 Q. I have omitted him in my description, I accept that.
21 A. But I think there is an important factor here that
22 enables one to understand how this role evolved and how
23 the allocation of time to it evolved.
24 I could say, I think with accuracy, that when
25 I began as Medical Director it would have been very
0040
1 difficult to identify what work I had to do as Medical
2 Director that was different from my work as Chairman of
3 the Medical Committee, but by the end of the two years
4 in 1994, a whole portion of work had developed which had
5 not existed two years earlier, and I think it was the
6 development of that work that led to the position which
7 Mr Durie is describing in this minute. So the change
8 that has been proposed here is a recognition of that
9 development.
10 Q. The role of Medical Director, you tell us, was not
11 recorded in writing or any job description that you ever
12 had?
13 A. Not until --
14 Q. Much later?
15 A. Much later.
16 Q. Let us look at GMC 5/15, shall we? This is a document
17 which I think comes from 1996. The job description of
18 the Medical Director. What I want to explore with you
19 is how far the responsibilities which are here set out
20 were your responsibilities whilst you were Medical
21 Director, and plainly, if they have changed over time,
22 I would hope that as we go through them you will
23 indicate that.
24 Responsible to the Chief Executive. We see that
25 the obligation of the Medical Director is to liaise with
0041
1 Clinical Directors, all consultant staff, the Chairman
2 of the Hospital Medical Committee, executive directors
3 and medical staffing personnel.
4 Was that always part of the function of the
5 Medical Director?
6 A. In as much as one was open to and accessible to all
7 those people, it was. In an active way, I think it
8 evolved alongside quite a number of the issues that
9 developed, that were not there at the beginning.
10 Q. "Main responsibilities: (1) Providing advice to the
11 Chief Executive on the full range of medical and
12 clinical issues in the Trust."
13 That was a role that was there from the beginning?
14 A. That was not there at the beginning. That is what
15 I was told my role as Medical Director was: to give
16 advice to the Board -- well, the Chief Executive and
17 Chairman of the Board.
18 Q. "(2) ..."; what about that?
19 A. I would link 1 and 2 together, I think.
20 Q. (3) ...?
21 A. These committees need to be considered separately. The
22 consultant appointment committees had historically been
23 set up by the Chairman of the Medical Committee but that
24 became one of the tasks which the Medical Director
25 undertook subsequently. So up until about 1996 --
0042
1 I would not be quite sure of the date -- it would have
2 been a question of nominating the appropriate people to
3 be members of any given committee, but I myself would
4 not normally have gone to committees other than those
5 which had a particular interest to my clinical
6 activities.
7 The Patient Care Standards Committee --
8 Q. Can I just ask you to pause there for a moment, so
9 I am clear on your answer? The role of the consultant
10 appointment committee was, you are saying, for the
11 Chairman of the HMC?
12 A. Yes.
13 Q. So whilst you were Chairman of the HMC until 1994, you
14 were fulfilling that role --
15 A. Yes.
16 Q. -- as it happens, but in the capacity, with your hat on,
17 as it were, as Chair of the HMC rather than your hat as
18 Medical Director?
19 A. That is how I understood it at the time.
20 Q. Does it follow that after the beginning of 1994, when
21 you ceased to be Medical Director following the view
22 that it was untenable for you to go on --
23 A. Ceased to be Chairman of the Medical Committee.
24 Q. I am sorry, Chairman of the Medical Committee and
25 remained a Medical Director; that you did not have this
0043
1 role actively?
2 A. At that point it was, if you like, allocated to the
3 Medical Director. When we divided the tasks, the
4 Medical Director took that role.
5 Q. So throughout you retained that particular role?
6 A. Under one hat or another, yes.
7 Q. You were going to go on now to deal with the Patient
8 Care Standards Committee?
9 A. Those were direct subcommittees of the Trust Board
10 chaired by a non-executive member of the Trust Board.
11 I did not actually attend any of those committees until
12 1994 or 1995. I mean, not in a regular manner. I might
13 have as a one-off, but I did not regularly attend those
14 committees from 1992 to 1994.
15 Q. Why was it that you began going to the Patient Care
16 Standards Committee?
17 A. I think it was in relation to the development of audit
18 towards clinical audit and the responsibilities of the
19 Medical Director for clinical audit. It was in that
20 context.
21 Q. Before you went regularly, but only went now and again,
22 as you told us --
23 A. Perhaps.
24 Q. -- you would get the minutes?
25 A. The minutes would have come with the papers of each
0044
1 Trust board meeting, so they would have been part of
2 those papers.
3 Q. If anyone had wished advice, it would have been your
4 role to provide it, would it?
5 A. If I had been approached, yes.
6 Q. The Marketing and Development Committee?
7 A. That was a committee which considered marketing in the
8 sense that, were we showing ourselves to the public and
9 to the purchasers in the best possible light? and which
10 also considered developments within the Trust and their
11 differing merits and how to choose or prioritise between
12 them. Again, I cannot recall playing any part, really,
13 in the deliberations of this committee during those
14 first two years, 1992 to 1994. I played some part
15 subsequently because one of the roles that evolved as
16 Medical Director was to assist groups of colleagues who
17 felt that there should be some development in their work
18 and so I worked with them to try to work out a proposal
19 and to bring in the people who would be able to help and
20 assist them in the preparation of that proposal, and
21 subsequently, that proposal might be considered at this
22 committee. But that was later on.
23 Q. Paragraph 4. Can we scroll down a bit?
24 A. This was written in I think early 1996; is that
25 correct?
0045
1 Q. Yes.
2 A. I think that this is really an expression of a role
3 that I might have to play if necessary. I had
4 previously played a role before I was Chairman of the
5 Medical Committee in setting up a liaison committee with
6 general practitioners in Bristol. I had had occasional
7 dealings with the Health Commission in relation to
8 contracting, but these were occasional and one-off.
9 I had really not had any dealings with the other
10 bodies -- well, I might have, I am sorry, yes, I beg
11 your pardon, again, there were colleagues who wanted to
12 develop their work in ways which involved approval from
13 the NHS Executive, and again, there were two instances
14 that I can immediately recall where I assisted them with
15 the preparation of their proposals. Apart from that,
16 I had no dealings with those bodies.
17 Q. Number 5. Let me just ask you to stop there for
18 a moment. The Department of Health: you had some
19 dealings, I think, with the Department of Health in your
20 capacity as Associate Clinical Director of Cardiac
21 Surgery, at least up until Mr Dhasmana took over in
22 1993, because they were concerned, were they not, with
23 the supra-regional services part of paediatric cardiac
24 services?
25 A. Yes. I had occasional and not very many dealings with
0046
1 them in that context.
2 Q. In that context, I shall ask you some questions later.
3 Paragraph 5. (Pause).
4 You may wish to break it down into each of the
5 subsets?
6 A. Can we deal with it one by one?
7 Q. 5(a)?
8 A. "5(a) The approval of consultant job plans", I think
9 this is referring to the job plan which consultants in
10 the post had and which from time to time were reviewed
11 and changed. When Dr Roylance was the Chief Executive,
12 those plans were agreed with him and I really was not
13 involved in that. In fact, subsequently, with Mr Ross,
14 I do not recall being involved in any instance of that,
15 but clearly this document is saying that I might be, so
16 all I am saying was, I was prepared to be, but in
17 practice, I was not.
18 Q. So the content of 5(a) did not differ really before or
19 after?
20 A. No, and it did not really amount to anything.
21 The attendance at meetings, those were meetings
22 I attended really throughout.
23 Q. (c) ... ?
24 A. I think that this is the recognition of the new advice
25 that was coming from the GMC at around that time. Prior
0047
1 to that, one's consciousness of responsibilities in the
2 area would have been much less clear and would have been
3 related to the function of the "three wise men" or to
4 the general principles that one had, and one had always
5 had, throughout one's professional life in relation to
6 conduct and competence.
7 Q. Let me just explore that particular one a little bit
8 further. I am going to take you away from this document
9 and take you to UBHT 6/200, which is where the document
10 starts. 21st May 1993. Then page 205 (UBHT 6/205), towards the
11 foot, (g) at the bottom, a well-known name:
12 "The implications of the publicity of Beverley
13 Allitt were discussed. Mr Wisheart felt that UBHT
14 should seek to establish a framework within which any
15 health care worker having contact with patients knew to
16 whom they could turn for advice if they were worried
17 about a colleague's behaviour. Within medicine there
18 existed the 'three wise men' procedure ..."
19 Back in 1993, albeit towards the end of 1993, you
20 were actively concerned, it would seem, with responding
21 to the Beverley Allitt affair and its implications for
22 hospital services generally?
23 A. That is correct.
24 Q. Can we go back now to where we were, GMC 5/15: "(c) To
25 develop and maintain Trust policies concerning medical
0048
1 staff", I appreciate the Beverley Allitt reference was
2 not just medical staff but clinical staff, "conduct and
3 competence, bearing in mind guidance from the Chief
4 Medical Officer and the GMC."
5 Tell me: again, this was something which developed
6 throughout the time, was it?
7 A. There had always been structures in place for dealing
8 with issues of conduct and competence. There were
9 a number of pathways which had been present, but in the
10 mid-1990s, the General Medical Council was really --
11 well, they were making proposals that every doctor had
12 a professional duty if they felt a colleague was in some
13 respect not "up to the mark", to basically report that
14 view.
15 This was creating a change in the way people
16 thought about those issues. There of course had been
17 the previous structures, but there were changes, and
18 then, shortly after that, there emerged -- again, I am
19 not sure of the exact date, just off-the-cuff, but there
20 was a document from the Department of Health and the
21 Chief Medical Officer concerning medical excellence
22 which was really a euphemism for dealing with issues of
23 conduct and competence and which was requiring each and
24 every Trust to ensure that it had methods and policies
25 for dealing with any such problems.
0049
1 So that is what is being referred to there. In
2 that sense, it is a new and evolving responsibility of
3 the medical directorate.
4 Q. "(d)" seems to be linked to "(c)", the same answer?
5 A. Yes. There had been the existing pathways which were
6 working and which had worked constructively on a number
7 of occasions within my experience, and indeed, my
8 remarks about Beverley Allitt were advocating that
9 a similar structure might be available to other staff
10 members of the Trust in addition to doctors.
11 Q. (e) ... ?
12 A. The substance of that provision was that I was involved
13 from time to time with the Director of Personnel in
14 away-days with Clinical Directors, in running short
15 courses concerning management for Senior Registrars, and
16 if you like, a number of one-off activities of that
17 sort. That was the substance in my time.
18 Q. Did that substance vary much throughout the years?
19 A. When the directorate system began in 1991, it was of
20 course a new system, so there were a number of
21 away-days, training days, whatever you would like to
22 call them, for the new Clinical Directors, to help them
23 understand their role. As Clinical Directors changed
24 and time went on, there were similar days. I worked
25 with the Director of Personnel either in planning them
0050
1 or occasionally in participating in them.
2 So I would say that that developed to a degree
3 over the period in question.
4 Shall I go on?
5 Q. Yes.
6 A. The induction arrangements for newly appointed
7 consultant staff may have been carried out occasionally
8 in the early 1990s, but essentially was a new activity.
9 In the past, really, induction arrangements had been
10 vestigial or non-existent, but in the early 1990s they
11 were introduced for junior doctors who took up new
12 appointments and it quickly became clear that it was
13 both a useful and constructive thing to do, and within
14 a few years, similar arrangements were seen to be
15 desirable for consultants, and we implemented that.
16 Q. Returning for a moment to "(e), the training and
17 development of medical staff and managerial roles",
18 obviously a consequence of the Clinical Directorate
19 system -- I say "obviously"; I assume --
20 A. In part.
21 Q. And the need for such training would be greatest, one
22 might think, when the system first began. How far would
23 you accept that?
24 A. Only to a very limited extent. I think the need for
25 such training is constant. For example, Clinical
0051
1 Directors occupy the role for a number of years and then
2 new ones come along, so they may wish to have some
3 training.
4 Secondly, the role of the Clinical Director, of
5 course, evolved and developed because it was uncharted
6 water for everybody at the beginning. So, again, there
7 was a role for away-days, courses, teaching, if you
8 like, for that reason.
9 Then there were others who were not Clinical
10 Directors but who had an interest and who wanted to know
11 more, so for quite a number of reasons -- I mean, it was
12 not just a one-off function at the beginning, and again
13 for doctors in training who wanted to prepare themselves
14 for a role as consultant, they wanted to know a bit
15 about it as well, so that was a continuing requirement.
16 Q. I do not think I was -- I hope I was not suggesting it
17 was a one-off need at the beginning, but rather that, if
18 you know the expression "front-end loaded", that at
19 least at the beginning there was a very clear need for
20 Clinical Directors, those who had not been involved in
21 management, because they had been clinicians, to be
22 trained, even though, plainly, training needs
23 continued. It was that that I was asking you to comment
24 on.
25 A. Yes, but, I mean, that of course is correct, but, you
0052
1 see, there were two things happening at this time. One
2 was the division between providers and purchasers which
3 brought in contracts, service agreements and so forth.
4 The other within the UBHT was the development of
5 directorates, which was a completely new idea. Both of
6 these evolved and developed and the interactions between
7 the two evolved and developed. So it really was an
8 ongoing requirement. I apologise for the use of the
9 term "one-off", that really was not appropriate, but it
10 was a continuing requirement.
11 Q. It would follow, a requirement that was there
12 throughout the time that you fulfilled the Medical
13 Director post?
14 A. I think that my involvement in it probably increased,
15 because I was really in the same boat as everybody else
16 at the beginning. I was learning about these new
17 structures, and it was later that I became involved in
18 participating in and planning these sort of events.
19 Q. Shall we turn overleaf(GMC 5/16)? (g) ... ?
20 A. (g) is something that began very late in the day. It
21 obviously had begun when this document was written, so
22 it must have begun in late 1995, I suspect, so that was
23 new.
24 Q. (h) ... ?
25 A. This was one of the very major items that caused the
0053
1 Medical Director's role to increase. This is the report
2 known by the name of Sir Kenneth Calman, the then Chief
3 Medical Officer, which concerned the training of doctors
4 for hospital specialties. It really ushered in
5 something close to a revolution in the way that hospital
6 doctors were trained, so the implementation of that
7 while maintaining the ability to provide a service
8 required a great deal of work which developed during the
9 years 1992 to 1994 and was probably at its maximum in
10 1995 and the next few years. It was a very big task.
11 Q. So developing up until 1995, but there in 1992?
12 A. No. I forget which year the report was published, it
13 might have been in late 1992 or 1993, but it was
14 something that began during that period and then grew.
15 At first people's understanding of what was required was
16 very limited, but it eventually was all made relatively
17 clear and we had to work with it through a period of
18 really very radical change, and it was very difficult.
19 Q. (6) ... ?
20 A. It was always the view of the Trust that they should
21 work closely with the Faculty of Medicine of the
22 University of Bristol and that they had a lot of common
23 responsibilities, so there were a number of committees
24 and groups which met to try to encourage and nurture and
25 promote that high degree of co-operation.
0054
1 The meeting that I attended regularly was
2 a 2-monthly meeting which lasted an hour at 8 o'clock on
3 a morning, and then there were other occasional ad hoc
4 meetings.
5 Q. That remained the same, did it, from ...
6 A. I think that that grew. I think, as I have indicated,
7 I did not attend all the meetings that might be listed
8 under this heading. Certainly, 1992 to 1994, that was
9 so, and I think probably in 1995, but around 1995 or
10 1996, I did begin to attend another one that was really
11 related to day-to-day issues that arose in the context
12 of teaching medical students within the hospital.
13 Then, at the very end of the period, there was
14 another group, the name of which I do not remember,
15 which met about once a month or thereabouts for an hour
16 or so. So that one, in terms of my personal
17 involvement, again, grew.
18 Q. Number (7)?
19 A. This is another one in which my involvement grew for
20 a number of reasons. If we are now considering audit as
21 a Trust activity and not a cardiac surgical activity,
22 I had been a member from the beginning of the Audit
23 Committee, as we discussed earlier, but that was just
24 a matter of attending. Things really changed for me in
25 relation to audit Trust-wide where, around the time
0055
1 medical audit became clinical audit, that is to say,
2 audit was not just carried out by doctors alone but by
3 doctors in collaboration with nurses, the professions
4 allied to medicine, whoever was involved in the team
5 providing the service. It also extended to general
6 practitioners and so forth.
7 So that was a very major change in the way people
8 had to think about audit and undertake audit.
9 At the same time, Dr Thomas, who had really
10 accepted the leading role in audit at the beginning,
11 stepped down from the chairmanship of what had been the
12 Medical Audit Committee, and initially a successor could
13 not be found. So, for a short period I was, if you
14 like, the interim chairman of the Clinical Audit
15 Committee until Dr Jill Bullimore became, if you like,
16 the proper Chairman of that committee. That was
17 a period of six months or more.
18 Q. You have anticipated one of the questions I was yet
19 to ask you, which was how on earth one would fit in the
20 various roles you were doing with taking on the burden
21 of being the Chairman of the Clinical Audit Committee as
22 well, but I will come back to that.
23 I suspect the answer might be that you had been
24 involved in audit and nobody else was willing to put
25 their name forward as Chairman. Have I got it about
0056
1 right, or not?
2 A. That is exactly the situation at the time.
3 Q. So there was a need --
4 A. There was an absolute need.
5 Q. And you met it, because there was a need?
6 A. As Medical Director, it was in a sense my
7 responsibility and the need was there, and I could not
8 duck it.
9 Q. Even though it meant more time that you had to spend
10 doing something when you already had a committed week?
11 A. I accepted it in the hope and understanding that it
12 would be a short-lived responsibility.
13 Q. And it lasted, I think, at least six months?
14 A. Something of that order, yes, but in fact, I mean, as
15 Medical Director, I was quite seriously involved in the
16 promotion, if you like, of the change and various other
17 issues in relation to audit.
18 Q. I will talk to you about audit and the policies in
19 relation to that in a moment. The purpose of taking you
20 through the job description is really to identify what
21 changes there had been over time so that the Panel can
22 form a view as to how far it is that your workload may
23 have increased dramatically, or gently, or a little, or
24 not at all, from 1991 to 1994, and then again to 1996.
25 That is the purpose of the present questions. So if we
0057
1 just scroll down a page --(UBHT 6/206)
2 A. May I summarise (7) just in a word and say that my role
3 in that really became significant after 1994.
4 Q. (8) ... ?
5 A. There are two issues there. It says "claims arising
6 from ...", but in fact, if there was an incident of
7 gravity -- and I can recall one or two -- then according
8 to the nature of the incident, I might have been
9 involved in a group investigating it. In a sense, that
10 is even more important than what this document strictly
11 says about claims.
12 Q. That would have been a task throughout for the Medical
13 Director, would it?
14 A. Yes, but it was an ad hoc task.
15 Q. I was going to say, it all depends when incidents arise?
16 A. Exactly.
17 Q. Again, it is one of those things when, if it happens,
18 you cannot duck?
19 A. Yes, but sometimes it would have been the Director of
20 Nursing who would have been involved rather than
21 myself. It very much depends on the nature and the
22 gravity. Sometimes it was dealt with at directorate
23 level, so there were a number of incidents that I do
24 recall being involved in. There were others I knew of
25 but was not directly personally involved in.
0058
1 Q. So if we were to take, as it were, a snapshot at any
2 moment in time from 1991 through to 1996, we might have
3 seen you either having no work to do under (8) or
4 suddenly have, as it were, land on your desk a problem
5 which would have to be looked at, responded to, dealt
6 with, investigated, perhaps, as a matter of some
7 urgency, people spoken to, time spent?
8 A. There were only two or three incidents over the whole
9 period that I was personally and seriously involved
10 with. But this is separate from clinical risk
11 management and is really quite different -- well,
12 I mean -- yes, it is different, because clinical risk
13 management was really a question of trying to promote
14 a way of thinking in my colleagues and across the Trust,
15 and it was an issue that arose, I would have thought, in
16 1996 rather than 1995, as a Trust responsibility, and it
17 was all to do with the movement of indemnity to Crown
18 indemnity, the setting up of the NHS litigation
19 authority, and so forth. Somewhere along the course of
20 the development of that, Trusts were really required to
21 take a much more formal approach to this and a much more
22 proactive one, and that is what that is referring to.
23 Q. So that is a new development in 1996, or thereabouts?
24 A. Or thereabouts.
25 Q. Number (9): always a function?
0059
1 A. In principle, always a function. The handling of
2 complaints through the period, as I am sure you know,
3 did change, and there was a very important change,
4 I would guess in 1994 or 1995, which made it much more
5 formal, involved a Trust Board non-executive member as
6 the Chairman of the group, and so forth.
7 In fact, my involvement was like clinical
8 accidents, an ad hoc one from time to time, and in fact,
9 it was very rare, because complaints were generally
10 dealt with at Directorate level.
11 Q. Can we scroll down the page, please? (10): always
12 a function?
13 A. Yes. It was always a function, and the preparation of
14 strategic reviews in my experience was something that
15 happened from time to time rather than being
16 a continuing constant activity. You will recall that
17 I mentioned a strategic review way back in the 1980s in
18 the Division of Surgery.
19 There was a very formal work carried out in,
20 I should say, mainly 1996 going on to 1997, in the
21 preparation of a strategic review and plan for the
22 Trust's activities, and I was involved in that, so in
23 practical terms and in time terms, in my time as Medical
24 Director, that was towards the end.
25 Q. Just an aside before we go on to (11) and (12): you
0060
1 mentioned there the formulation of a high level
2 strategy. Who else by name or by post was involved in
3 that?
4 A. In 1996?
5 Q. In the contribution that you described under (10)?
6 A. There were a very considerable number of people. My
7 recollection is that there was a core group which farmed
8 out tranches of work to, if you like, subgroups, and so
9 in total, there were a substantial number of people,
10 many of them would have been Clinical Directors. The
11 executives, some of them would have been involved.
12 Other senior people, be they medical, nursing,
13 management, really depending what the issue was, anybody
14 would be involved. The names that come to mind are
15 Dr Monk, the anaesthetist, who I think now has a role as
16 an Associate Medical Director for Planning; Miss Janet
17 Maher --
18 Q. We have heard her name pronounced "Marr" by others. Is
19 it "Maher"?
20 A. I think the pronunciation varies depending on where
21 you come from.
22 Q. It is the same person, anyway. I am sorry, you
23 mentioned Janet Maher?
24 A. Yes. She again; Ian Barrington was involved when
25 paediatric services were being considered. People like
0061
1 Ian Watt, Jill Bullimore were seriously involved, and
2 I am sure if I am given a moment, I could think of other
3 names.
4 Q. (11), (12) ... ?
5 A. (11) looks very general to me. I am just trying to turn
6 it into something real. You could apply it, I presume,
7 to the changes in the NHS in 1991. I can just think of
8 two other instances. Also associated with the name of
9 Sir Kenneth Calman were changes in the delivery of
10 oncology services, and again, we are talking of 1996 or
11 thereabouts. That involved quite a lot of work and
12 preparation in which I played only a peripheral role; it
13 was largely the oncology people who did it.
14 Another example would be the changes in paediatric
15 intensive care, to take a very specific one, which again
16 were promoted by the Department of Health around 1995
17 and 1996. It was really quite a major step forward.
18 I was not, myself, involved in the work that we did,
19 again except quite peripherally, but changes of that
20 sort.
21 Q. (12) ... ?
22 A. (12) became a role for me after Mr Ross came. Prior
23 to that, Dr Roylance had chaired the group who
24 considered the applications and the decisions about
25 which applications were successful. Of course, the
0062
1 issue here, as with all such things, is that there was
2 a finite amount of money and the requests would have
3 over-subscribed that by three or four times each year.
4 Q. So you are advising who succeeded and who failed?
5 A. Sadly, and so --
6 Q. And what you are saying is that Dr Roylance, being
7 a medical man, could do that for himself?
8 A. Interestingly, it had been one of the roles that he had
9 had from before the time that he was the General Manager
10 in the mid-1980s, and he continued to have that role.
11 He had great familiarity with the ins and outs of the
12 role.
13 Q. The point is made, I think by you amongst others, that
14 Dr Roylance, of course, was unusual as a Chief Executive
15 in being a medical man. The suggestion is certainly
16 made that because he was succeeded by a non-medical man,
17 the role of Medical Director took on the greater onus.
18 Item (12) is the first time you have actually
19 mentioned that specifically in respect of any one of the
20 items. Is it the only specific aspect in respect of
21 which Dr Roylance's medical qualifications gave him an
22 advantage over Hugh Ross's lack of them?
23 A. I mean, as we have gone through this list, it is the
24 first time it has become explicit, if you like, but it
25 would certainly be correct to say that because of the
0063
1 fact that he was a doctor, because of the fact that he
2 knew the consultants well and knew the hospitals and
3 their framework well, that people often went to him --
4 I mean by "people" consultant colleagues, doctors --
5 who, in another institution might have gone to the
6 Medical Director, just to chat, discuss whatever was on
7 their mind and so forth.
8 So I think at that informal level, of advising,
9 counselling, whatever word one likes to use for that, he
10 did play a very significant role --
11 Q. Just pausing there: if that be right, then you would
12 have seen a difference in the time before Hugh Ross was
13 appointed as Chief Executive and after, in the number of
14 people who beat a path to your door for advice,
15 consultation, a chat, who otherwise might have gone to
16 Dr Roylance.
17 Did you in fact have a substantial increase in the
18 number of consultant or other medical colleagues coming
19 across your threshold?
20 A. I would say there was some increase. I imagine people
21 probably went to a variety of people instead of
22 Dr Roylance. They might have gone to the Clinical
23 Directorate, the Chairman --
24 Q. What we are talking about is not where they might have
25 gone but the role of the Medical Director.
0064
1 A. I think there was an increase, but I do not think it was
2 enormous. I can think of instances.
3 Q. If we had to put a qualitative term on it: slight,
4 moderate? What would the ranking be?
5 A. Perhaps between slight and moderate. No more than that.
6 Q. (13) I imagine has always been a duty of anyone's post.
7 Essentially, it appears to suggest that whatever else
8 you can think of, you ought to do?
9 A. Yes.
10 Q. I imagine that has always been a part of any task you
11 have ever undertaken?
12 A. Yes. There is one important one that interestingly has
13 not featured in the list, although I am sure it should
14 have come in under some heading but it has been missed,
15 and that was the issue of junior doctors' hours, which
16 was on the agenda when I became Chairman of the Medical
17 Committee. It was in fact one of the first major items
18 that occupied my time through that early period and
19 through the period when I was Medical Director, and
20 there was a considerable amount of work to be done to
21 achieve the requirements of the government in that area.
22 Q. Was that a feature of the job which was perhaps heavier
23 in terms of workload towards the beginning of your
24 period of directorship than it was towards the end?
25 A. Yes, I would say that it was heavier in the early part,
0065
1 but continued through. I mean, it did not disappear
2 altogether.
3 Q. So having been through each of them one by one, the
4 items which we picked out, the one big change that you
5 have identified at the top of this page, if we go back
6 up to it, in (h) at the top, everything else is a matter
7 of perhaps degree, reflection, in the case of those
8 tasks which involved ad hoc demands, when the ad hoc
9 demand might occur, I suppose with the only other
10 exception being the question of advising the Chief
11 Executive on equipment, which would have arisen when you
12 were asked to take over.
13 A. No, I think there was more than that, with respect.
14 I think the clinical risk management was very much at
15 the end, and I think that my personal involvement in the
16 promotion of audit trust-wise was after 1994.
17 Q. So that was developing and growing.
18 A. I had an interest in it, but actually personally working
19 hard, committing time to it, was after 1994. So I think
20 there were actually a number of items there.
21 Q. At the beginning of the period when you were Medical
22 Director and Chairman of the Hospital Medical Committee,
23 you were also, I think, Associate Clinical Director of
24 the Division of Cardiac Surgery?
25 A. I think I handed that over to Mr Dhasmana about October
0066
1 or November 1992.
2 Q. I thought it was 1st January 1993, but it was a matter
3 of months.
4 A. In which case, I am sure that is correct, but I was just
5 speaking from memory.
6 Q. So for a period of a year, a year and a half,
7 thereabouts, you were carrying on all three roles?
8 A. No, no. I became Chairman of the Medical Committee and
9 Medical Director in April 1992, and if we accept your
10 date of 1st January, that was when I handed that over,
11 so 8 months. But it was largely up and running then and
12 it was not as onerous in the Associate Clinical
13 Directorate as it had been at the beginning.
14 Q. That carrying on or taking such a workload with the
15 degree (or lack of it) of hours, time off in lieu and
16 support that you have described: how do you think that
17 taking on such roles might, in general terms, tend to
18 affect the clinical work of any surgeon?
19 A. I think the first thing I should say is -- no, I am
20 sorry, I should answer your question, I beg your
21 pardon. Excuse me.
22 Obviously it does impinge on the clinical role of
23 the surgeon. It may impinge on his daily clinical work
24 because there are other activities competing for its
25 interest. It may occupy his time and energies early in
0067
1 the morning or at the end of a day's work, so that is
2 correct --
3 THE CHAIRMAN: May I just interrupt for a second? By all
4 means answer Mr Langstaff's question, but if there are
5 other things you want to add, remember that it is all
6 for the purpose of our understanding, so if you want to
7 add something in addition to the reply, feel free to do
8 so.
9 A. Thank you.
10 MR LANGSTAFF: Perhaps I should take you back to what you
11 were going to say. The question that I asked was how do
12 you think that taking on such roles might in general
13 terms tend to affect the clinical work of any surgeon.
14 You then said, I think, "The first thing I should say
15 is...", and then you said, quite rightly and properly,
16 that the first thing you should do is answer my
17 question.
18 A. What I was going to say was that when it was proposed
19 that my name should go forward to be Chairman of the
20 Medical Committee, I of course talked with my immediate
21 colleagues as to whether they were agreeable to that,
22 because clearly, if I did that, it would impinge upon
23 them and their activities.
24 From 1992 onwards, whereas previously I had been
25 operating usually in the Infirmary three days a week and
0068
1 most of my colleagues usually were operating three full
2 days a week, I subsequently operated on two days a week
3 only and my colleagues continued to operate on three
4 days a week. Of course, the consultant staff was
5 growing again at that time.
6 Secondly, they supported the fact that I should
7 allow my name to go forward to be Chairman of the
8 Medical Committee by saying that they would also be
9 prepared at times to help out, if you like, so if I had
10 a conflict between a clinical duty and another duty and
11 I felt obliged to attend to the managerial one, they
12 would help out on the clinical side. That happened
13 occasionally, not a great deal, but the knowledge that
14 I could depend upon them to help was, of course,
15 absolutely fundamental, and without it I could not have
16 undertaken the tasks.
17 Q. Being a surgeon involved in complex surgery involves
18 concentrating for hours at a time, does it not --
19 concentrating on the surgery?
20 A. Yes.
21 Q. I think you are nodding?
22 A. Absolutely, yes.
23 Q. And concentrating in conditions which may be very hot?
24 A. Generally manageable.
25 Q. Where you cannot, as one might have the luxury in other
0069
1 professions such as my own, lose concentration for
2 a moment, really, without there being a potential
3 effect?
4 A. That is correct. I mean, that was not a problem because
5 when I operated, I was doing exactly what you describe
6 and I enjoyed that because I did not have to think about
7 the other things, and I could not be got at.
8 Q. In the back of your mind, was the problem of the day,
9 a difficulty that had arisen as Medical Director or
10 Associate Clinical Director or the Chairman of the
11 Hospital Medical Committee, or the chairmanship of the
12 Clinical Audit Committee, not buzzing around there
13 somewhere?
14 A. No. Those were put out of one's mind and they waited
15 until the operation was complete or it was sufficiently
16 complete for me to leave. I can really say that going
17 to the operating theatre was my refuge.
18 Q. Do you think perhaps that, had you been responsible for
19 some other surgeon and you recognised, let us suppose,
20 in that other surgeon, a degree of commitment to
21 clinically-related matters, administrative matters
22 rather than to surgery, you might be concerned to ensure
23 that that particular surgeon did not suffer any
24 ill-effects in the surgery which he was principally
25 employed to do?
0070
1 A. Well, it would be a question to ask, but I do not recall
2 it ever being a concern in relation to any other
3 surgeons, including those who worked extremely hard in
4 many areas.
5 Q. I asked you as a hypothetical question. We have heard
6 from more than one person that they recognised, or say
7 that they recognised, that you were carrying an enormous
8 workload. Did anyone raise that issue with you?
9 A. I can think of one person who asked me a question about
10 that.
11 Q. When?
12 A. I am not sure, but it was relatively late in the period
13 under discussion.
14 Q. Roughly?
15 A. I honestly do not remember.
16 Q. Who was it?
17 A. It was Gordon Stirrat.
18 Q. So Gordon Stirrat raised the issue of potential overload
19 with you; no-one else?
20 A. I cannot recall any other person raising that issue.
21 Q. So when Mr Dhasmana took over as Associate Clinical
22 Director and therefore he was the director of the
23 Directorate, part of the Directorate in which you
24 worked, he never raised the issue with you?
25 A. No.
0071
1 Q. And Dr Roylance, who would have seen what you did,
2 indeed, has told us his own views of it when he gave
3 evidence. He never raised the question with you?
4 A. No.
5 Q. And you never raised the issue with yourself?
6 A. I reviewed my position in my own mind from time to
7 time. I was satisfied that I could cope with those
8 responsibilities which I had accepted at that particular
9 time. I do not regard myself as being in any way
10 different from a significant number of my colleagues who
11 worked equally hard in one area of their professional
12 life or another. I just happened to choose to do my
13 work where it was rather visible within the Trust and
14 within the NHS.
15 Q. If you do not wish to answer this question, please say
16 so and I shall respect your answer: did your wife ever
17 raise with you that you might be overworking?
18 A. There were issues of what time I returned home from time
19 to time. But your question specifically said an issue
20 of, "Are you doing too much and more than you can cope
21 with?" I do not think that that was raised, no.
22 Q. And put in the way of, "Well, James, you are doing so
23 much, is it affecting your surgery?", for instance?
24 Anything along those lines?
25 A. That was the question Professor Stirrat put to me.
0072
1 MR LANGSTAFF: Sir, it is just coming up to 1.15 where we
2 would normally have a break. Again, it is an
3 appropriate topic, perhaps, to end the morning session
4 on. I think we would normally wish to begin again at
5 2 o'clock in the afternoon.
6 THE CHAIRMAN: Yes. We will break for 45 minutes now and
7 reconvene at 2 o'clock. Thank you.
8 (1.15 pm)
9 (Adjourned until 2.00 pm)
10 (2.00 pm)
11 MR LANGSTAFF: Mr Wisheart, just before the break I was
12 asking you whether you had ever reviewed, yourself,
13 whether you might be doing so much by way of
14 administration, so much by way of meetings, et cetera,
15 that it might have affected your clinical work.
16 You said you did on a number of occasions review
17 in your own mind whether that was the case.
18 It has been pointed out to me over the break that
19 you did not say when it was that you carried out this
20 introspective personal review. Can you help us?
21 A. Asking myself the question would, I think, have been on
22 the occasions when I was asked to do something that
23 I had not been doing and therefore I was just mentally
24 reviewing my commitments, what I had accepted, what had
25 stopped happening, what I could do. So I mean, I could
0073
1 not give you a date, but that would have been the time
2 when I asked myself the question.
3 I also asked my colleagues on one or two
4 occasions. We have already mentioned one of those, in
5 the 1992 time, before I became Chairman of the Medical
6 Committee. But in relation to the document that we went
7 down point by point, which of course was a document
8 about me changing to have six sessions as Medical
9 Director in order to do all the things listed on that
10 document, that of course, conversely, meant a change in
11 my clinical commitment, and I asked the Clinical
12 Directors who were relevant to my clinical work whether
13 they thought that that was appropriate, that is to say,
14 Professor Vann Jones, Mr Hutter and Dr Monk. They
15 expressed the view that it was appropriate and
16 I supported that.
17 Q. I want to put this morning's questions and answers
18 into the context in which you were in relation to
19 paediatric cardiac surgery and the demands on the
20 service from 1984 through to 1995.
21 At the start of 1983, there were two cardiac
22 surgeons at Bristol, were there?
23 A. Yes, Mr Keen and myself.
24 Q. And the work which each of you did was largely adult?
25 A. No, that is not correct.
0074
1 Q. One of you only, I think, did any paediatric work?
2 A. That was myself.
3 Q. In terms of the numbers of open heart surgical
4 operations on infants and neonates, there is I think
5 some disagreement by one, as to whether in the year 1984
6 it was three or whether it was four. I think I can help
7 you with that. If we go to JDW 8/56 -- I am sorry, that
8 is the wrong reference. You will have to forgive me.
9 I cannot immediately help you with that, it seems, but
10 I will do. I will come back to it. The numbers of
11 operations that were being done when you were appointed
12 in 1975, which is what you have here -- let us scroll
13 down a bit, please, and turn over -- can you go back?
14 This is the total workload, which for some years has
15 been an average of three open heart operations each week
16 and that was adults and children?
17 A. Correct.
18 Q. That would be 150 per year?
19 A. No, it was less than that. The weeks it was done it may
20 have been three a week, but it was not 50 weeks a year
21 because the total number was of the order of 110 plus or
22 minus a few for the preceding years and for 1975.
23 Q. From that time onwards, there was, was there,
24 a consistent and gradual expansion of the numbers of
25 surgical cases, both adult and paediatric, which were
0075
1 performed in Bristol?
2 A. The total number of operations performed increased
3 nearly every year.
4 Q. There was not, I think, any other surgeon who did
5 paediatric work as a consultant until Mr Dhasmana was
6 appointed in 1986?
7 A. That is correct for practical purposes. As there were
8 only the two of us, Mr Keen of course provided some
9 cover for me when I was taking my six weeks holiday each
10 year, but --
11 Q. Or not!
12 A. -- so in that respect only, was any paediatric work
13 being done other than by me.
14 Q. The first time that a full-time paediatric surgeon was
15 appointed was in 1995, was it, when Mr Pawade began?
16 A. That is correct, yes.
17 Q. So at no stage until the last few months of the period
18 with which we in the Inquiry are concerned was there
19 a "dedicated" -- I use that word in the sense that
20 should be apparent -- paediatric surgeon?
21 A. That is correct. Mr Dhasmana and I each devoted
22 approximately half of our clinical time to paediatric
23 work.
24 Q. So you were half adult, half paediatric?
25 A. Yes.
0076
1 Q. So was he?
2 A. Yes.
3 Q. And Mr Keen was fully adult, dedicated adult, was he?
4 A. Yes. In the early days, from 1975, he was part cardiac
5 and part thoracic and at some point in the early 1980s,
6 I do not remember which year, he withdrew from thoracic
7 work and became entirely cardiac.
8 Q. And Mr Hutter, when he began --
9 A. Was entirely adult work. He began in 1990.
10 Q. And Professor Angelini, such clinical work as he did was
11 entirely adult?
12 A. Entirely adult, and Mr Bryan also.
13 Q. So the paediatric work, bar the very odd one or two
14 cases which might in an emergency be performed by some
15 other surgeon because needs must, had to be shared
16 between you and Mr Dhasmana and you had to provide cover
17 for each other from 1986 onwards, and between you and
18 Mr Keen, such cover as he could give you before that?
19 A. That is correct.
20 Q. The service that was provided plainly had the support of
21 cardiologists, but there were problems, were there, in
22 the mid-1980s in seeking to recruit a specialist
23 paediatric cardiologist?
24 A. I do not recall a problem in the mid-1980s. Dr Jordan
25 was there when I began and Dr Joffe was appointed around
0077
1 1979 or 1980. Dr Martin was appointed in 1988 -- it
2 might have been 1989, but I think it was in 1988.
3 Q. He began on 1st February 1989.
4 A. Thank you. I cannot recall that within that there was
5 a particular issue in that area in the mid-1980s, but it
6 may be you can remind me of something. I am not sure.
7 Q. Let us have a look at UBHT 92/26. 16th March 1987. It
8 speaks for itself, the heading:
9 "Consultant in paediatric cardiology, new
10 appointment in connection with the cardiac surgery
11 expansion programme."
12 The first paragraph, realising that manpower
13 approval for a Senior Registrar in Cardiology is not
14 likely to ever materialise, "it has been agreed that two
15 consultants in cardiology are to be appointed. The
16 first post is to be a paediatric cardiologist and
17 I enclose the first draft of the job description ..."
18 So at that stage, approval has been given that the
19 expansion which is envisaged requires a new paediatric
20 cardiologist. Shall we move on from that to 30th March
21 in the same year: UBHT 92/16:
22 "The above appointment will be advertised in the
23 BMJ and Lancet on Saturday 11th April, the closing
24 date ... 15th May ... interviews will take place on
25 18th June ... The position will be funded from money
0078
1 allocated for the cardiac services expansion programme."
2 That conveniently takes us on to 4th September
3 the same year, 62/330, the foot of the page. The second
4 paragraph:
5 "Part of our discussions dealt with the unfilled
6 consultant paediatric cardiologist post and I am writing
7 to you now about this since the need to provide adequate
8 cover for our present load, let alone any further
9 expansion, is becoming acute."
10 It goes on to discuss the possibility of having
11 somebody from abroad on a locum basis.
12 So we can see the authorship of this, let us go
13 down to the bottom of the page, and over(UBHT 62/331). You can see
14 that it is Dr Joffe.
15 What plainly had happened, it appears from the
16 document -- tell me if I have it wrong -- is that the
17 Department advertised for a paediatric cardiologist.
18 The advertisement went out in the BMJ and the Lancet and
19 there was no response?
20 A. That is correct. I had quite forgotten about that
21 episode. There either was no response or there was no
22 suitable response. If I might comment, it really
23 reflects the fact that in a very, very small specialty
24 such as this, there are not always trainees ready for
25 a consultant job, and I think that it was a reflection
0079
1 of that situation.
2 Q. I think when Dr Martin began as a consultant, it was
3 suggested that his appointment be delayed for some 6
4 months so that he got adequate experience in paediatric
5 cardiology?
6 A. I think it was actually in areas of paediatrics, and
7 that is why I was uncertain about 1988/89. He in fact
8 came in 1988 and he did work in paediatrics, I think in
9 neonatology, which enabled him to fulfil his
10 requirements for training. He then began his work as
11 a consultant paediatric cardiologist. I think that is
12 what happened.
13 Q. For a period, at any rate, of the best part of a year --
14 by all means, if you want to see it I can trace it
15 through the documents with you -- there was a need for
16 a paediatric cardiologist which was unmet?
17 A. I think it was filled by a locum called Dr Benatar.
18 Q. Did that put pressure, as you saw it, upon the service?
19 A. I think it meant that Dr Jordan and Dr Joffe were
20 working very hard. I think the situation would have
21 been similar to the one that we have discussed for the
22 cardiac surgeons as the work increases, and I suppose we
23 are talking of a delay of a year in acquiring
24 a consultant colleague. Clearly they had to maintain
25 the work. I mean, I cannot remember exactly when
0080
1 Dr Benatar came and went, but I would presume that that
2 alleviated the pressure upon them to some extent.
3 Q. Was there consistent and repeated difficulty in staffing
4 the increasing workload as it went up from the days of
5 1975 to the days of 1996?
6 A. Do you mean in the field of paediatric cardiology?
7 Q. No, the entire field of giving the paediatric cardiac
8 services to children?
9 A. I must admit, I had forgotten about the delay on this
10 one until you drew my attention to it, but Dr Joffe was
11 appointed when -- I do not recall there being a delay
12 there. I do not recall a delay when Dr Jordan was
13 replaced by Dr Hayes in 1993, and on the surgical side,
14 the appointments, well, it was really only Mr Dhasmana,
15 then Mr Pawade and the adult surgical appointments were
16 made when we were able to advertise them.
17 So I do not think that the availability of staff
18 was an issue, apart from in the sense that we have
19 discussed.
20 Q. You had hoped, had you, in 1991/92, to attract
21 a paediatric surgeon as a candidate for the post of
22 Professor for the Chair of Surgery?
23 A. Yes, for the chair, we had, yes.
24 Q. Martin Elliott, who was of course a paediatric cardiac
25 surgeon, was someone who either had expressed or was
0081
1 encouraged to express some interest in applying for the
2 post?
3 A. We approached him and invited him to have an interest
4 in it and we worked with him over a considerable time.
5 He considered it very seriously.
6 Q. But he turned it down?
7 A. Yes.
8 Q. So your reference to difficulty in attracting the staff
9 you wanted has to be read at least subject to that?
10 A. Yes. I was thinking of the NHS appointment.
11 Q. So we have difficulty in attracting a paediatric
12 cardiologist in the 1980s -- there may have been
13 a shortage of them nationally, we have been told.
14 A. I would not be able to say off-the-cuff when there were
15 shortages, but I think they would be able to recognise
16 that in a very small specialty, there can be problems of
17 attracting trainees into it and having trainees ready
18 for consultant posts at the irregular intervals when
19 they become available. It is quite difficult. I think
20 that was a problem for paediatric cardiology. The
21 problem with the chair was that Martin Elliott was
22 really the only paediatric surgeon who was, if you like,
23 a viable candidate at that time.
24 Q. I will come back to his appointment later, if I may. At
25 the moment I am exploring with you the question of
0082
1 staffing and difficulties that there may have been in
2 general terms. Can we look at UBHT 170/66, is where it
3 begins. I am going to take you to page 68(UBHT 170/68).
4 This is 12th May 1989. This is one of the cardiac
5 surgery working parties. If we just scroll down,
6 please, we see that you were present at the meeting.
7 Can we go to 68?
8 "In terms of nursing, Miss Evans reminded the
9 Working Party that the Region had not agreed to the
10 hospital's original bid for nursing staff. This had led
11 to a situation where there was considerable difficulty
12 in providing appropriate staffing for the agreed
13 workload."
14 So far as the nursing side was concerned, was
15 there, throughout the period, a continuing and
16 consistent difficulty in providing adequate staffing?
17 A. Are you asking me a question, please, about paediatric
18 cardiac surgery, or cardiac surgery generally?
19 Q. Let us take cardiac surgery generally, first.
20 A. There are clearly others who can speak with more
21 authority than I on the subject, but in general, my
22 impression was that we were nearly all the time able to
23 recruit nurses for Ward 5, and I think that the
24 retention of staff was reasonably good.
25 Within that, I think there was a problem which
0083
1 was a fairly consistent problem in the 1980s and into
2 the 1990s, of attracting paediatric nurses, that is,
3 paediatric trained nurses, because they were reluctant
4 to work on a ward where, from time to time, they would
5 be invited to look after adults.
6 So, in summary, the overall numbers could
7 generally be recruited but within that it was difficult
8 to recruit people who were trained paediatric nurses.
9 Q. We have just been looking at a document from 12th May
10 1989. If we take it a month further on, 28th June 1989,
11 six weeks further on, UBHT 170/56 is the start of the
12 document. It is "Notes of a cardiac surgery meeting".
13 You are present, amongst others.
14 The next page(UBHT 170/57), please.
15 "Review of staffing: 3.1 nursing, ward staff and
16 theatre. Considerable problems relate to difficulty of
17 recruitment of experienced staff."
18 You were saying in your last answer that you did
19 not think there was any difficulty of recruitment of
20 experienced staff?
21 A. I thought that generally through the period that was
22 so. This, of course, represents a point where there was
23 quite a significant development and the numbers of
24 nurses had increased. The numbers of nurses needed had
25 increased over the last few years. So it may be that
0084
1 there had been a problem at this point. My impression
2 looking back is that there had always been much greater
3 problems recruiting and retaining nurses in the
4 Children's Hospital. I had always been led to believe
5 that nationally there was a shortage of paediatric
6 trained nurses and this was particularly so in intensive
7 care. I was conscious generally of a much lower level
8 of difficulty in Ward 5.
9 Q. What you may be saying, I think, is that if it was
10 difficult for cardiac surgery generally, it must have
11 been more difficult still for paediatric. I put a spin
12 on it, but that essentially would be the proposition
13 that would follow from what you have just said, would it
14 not?
15 A. I think that there was a shortage of paediatric
16 intensive care nurses generally, and I think it was
17 difficult for us to recruit them into Ward 5 for the
18 reasons stated. I mean, I am trying not to create the
19 wrong impression anyway, and it is certainly possible
20 that my recollections of this could be slightly hazy,
21 but I think the general remarks I am making are correct.
22 Q. We have been looking at 1989 in respect of nursing
23 plainly for cardiac surgery generally, which shows
24 a difficulty in May and June of that year.
25 A. Yes.
0085
1 Q. If we can go forward to UBHT 183/47, to identify the
2 document, the date of it is 9th July 1991. It is the
3 next page(UBHT 183/48): the Directorate of Surgery meeting. It says:
4 "Financial report, last year, agency nurses
5 overspent."
6 What might emerge from that -- tell me if I am
7 right or wrong -- is that may have been difficulties
8 filling permanent full-time posts, and therefore one had
9 to go out to the bank?
10 A. That is certainly what that would suggest, but of course
11 there can be fluctuations even when you think you have
12 a full establishment or a near full establishment, with
13 holidays and sickness, and I think in amplification of
14 what I said earlier, if I may, I would certainly want to
15 say that there were periods from time to time when the
16 nursing numbers were a bit short, but I was trying to
17 make a general remark earlier.
18 Q. Yes. So from time to time the nursing was a bit short,
19 which must obviously have added to such pressures as
20 there may have been?
21 A. Yes.
22 Q. Can we have a look now, please, at UBHT 138/18 -- I am
23 sorry, let me change that. I will go to that later.
24 UBHT 170/42, please: 7th February 1990. It is a letter
25 to Mrs Peacock and you will see it is from the
0086
1 anaesthetists who are named at the bottom, copied to
2 you. It reads:
3 "On Friday, 26th January 1990, the duty cardiac
4 anaesthetist agreed to undertake one extra cardiac case
5 to help the surgeons reduce their waiting lists.
6 "The same afternoon, a major cardiovascular case
7 presented for emergency operation ... At this stage,
8 because the extra case had been undertaken, staffing
9 levels were reduced below an acceptable minimum for safe
10 patient care. The senior sister in the suite and the
11 senior cardiac surgeon both requested extra staff ...
12 but the minimum request of one student nurse was not
13 forthcoming".
14 The anaesthetists said, "We will not do it unless
15 there is adequate cover."
16 The position there described, is that a one-off,
17 or was that something which represents part of the
18 problem that was bumping and grumbling along?
19 A. I would say the specific circumstances described here
20 would have been very uncommon, that is, of an emergency
21 coming in just after everybody had agreed to do an
22 additional case for the reasons stated, and clearly such
23 a development is going to place pressure on the
24 available staff. It is inescapable, because the cardiac
25 theatre nursing complement is a finite number of nurses
0087
1 and they were already committed, and then suddenly here
2 was an emergency, so that is a problem which people
3 sought to address by asking for help from other areas,
4 which, in the event, was not forthcoming.
5 Q. So the answer to my question is that this was a one-off
6 rather than an exemplar of the general problem?
7 A. These specific circumstances would be very uncommon.
8 Q. But the position the circumstances appear to illustrate
9 is an apparent shortage of nursing staff, at any rate,
10 available, albeit in unusual circumstances, but
11 a shortage of nursing staff which one might be forgiven
12 for thinking was more general? That is the purpose
13 behind my question.
14 A. No. I think this reflects a different problem. I think
15 that this reflects a problem that when there is a sudden
16 extra demand, the usually available number of nurses
17 were unable to reorganise themselves to meet that. So
18 I think that this represents a demand over and above
19 what would be normally expected, and the flexibility, be
20 it of people or in the mind, I do not remember, was not
21 there to cope.
22 Q. So it is much more the one-off than the exemplar?
23 A. Yes, I think so, yes.
24 Q. Can we look at UBHT 23/124, please? This is 3rd June
25 1991. This is a letter which, as we see, is addressed
0088
1 to Mrs Maisey. It begins:
2 "Thank you for asking me to list the main problems
3 with cardiology, following our meeting with the
4 Chairman.
5 "We are faced with difficulties which have
6 gradually built up over the years as district and
7 regional demands for cardiological services have rapidly
8 increased, outstripping local resources and regional
9 funding. The problems are interrelated and are listed
10 below."
11 Shall we scroll down to "Beds" at the top of the
12 page, please.
13 What it talks about under "Beds" is severe
14 shortage. Just stopping there, a shortage of beds is
15 the same as saying there is a shortage of staff, is it
16 not?
17 A. No, not quite the same. "Beds" represent a physical
18 resource of space and the actual bed and so forth, and
19 you can have the physical resource and be unable to
20 recruit the staff. I think it represents a different
21 sort of resource.
22 Q. Plainly one might think of a bed as a metal frame with
23 a mattress on it, but in the hospital context, it is
24 obviously not just that and the space to put the frame
25 and mattress, but also the staff to man it?
0089
1 A. It could mean either of those things, but I think what
2 Dr Rees is referring to in this paragraph is that there
3 were insufficient actual physical beds available to
4 him. There may be an additional problem that there are
5 beds but no nurses to look after patients in them, but
6 I think what he is saying -- and I know that it was
7 a long-running problem for cardiology; this is adult
8 cardiology -- was that they had insufficient beds
9 dedicated to cardiology. They just did not have access
10 to the beds.
11 Q. Indeed, he makes the point at the end of the first
12 paragraph which would support what you are saying:
13 "There is a need for protected beds to be
14 allocated for cardiology within the general medical
15 area."
16 So the "beef" he is making is: "We cannot cope
17 with the demand, given the available resources". That
18 seems to be what he is saying?
19 A. Yes. The sentence about "protected beds" means that the
20 beds which the cardiologists had which were inadequate
21 to begin with could actually have been all filled with
22 general medical emergencies so they would have been
23 unable to admit their cardiological patients.
24 Q. The spin-off for cardiac surgery, presumably a number of
25 patients would come to you for cardiac surgery, having
0090
1 been through the hands of the cardiologists first?
2 A. They virtually all passed through the hands of the
3 cardiologist first.
4 Q. So a delay with the cardiologist dealing with a planned
5 case might presage a delay in the delivery of cardiac
6 surgery, if required --
7 A. To that patient.
8 Q. -- to that patient?
9 A. It could indeed.
10 Q. So what we are looking at here on the screen is not
11 a problem reflected for cardiology on its own, it is
12 something which affected the delivery of cardiac
13 services to the population that needed them?
14 A. That is correct.
15 Q. A division, in the directorates that dealt with cardiac
16 services at this time, the delays in dealing with adults
17 because of a lack of facilities to treat adults would be
18 bound to have some knock-on effect, would it, when it
19 came to dealing with children?
20 A. The particular problem that you are addressing here
21 would not directly affect the position of children.
22 Q. Indirectly?
23 A. Well, that would then be very speculative. I mean, the
24 reality for both children and adults -- and I apologise
25 because it is not exactly an answer to your question,
0091
1 but the reality is that there was really always
2 a substantial waiting list for surgery under both
3 headings, so that while you are absolutely right to say
4 that the difficulty we are discussing in the letter from
5 Dr Rees might have delayed the investigation of an adult
6 and therefore delayed the progress of that adult towards
7 a surgeon and an operation, there was really always
8 a substantial waiting list of adults waiting for
9 operations.
10 So there is not, I think, a clear direct
11 relationship between this letter and the services
12 available to children.
13 Q. If, let us suppose, you, or for that matter Mr Dhasmana,
14 had no waiting list when it came to adults, then
15 presumably your available time would be spent reducing
16 the waiting list that there was for children?
17 A. If there had been no adults, yes, I expect that is
18 correct. There would have been other limitations,
19 because not all anaesthetists, for example, anaesthetise
20 children. But if everything else were equal, then what
21 you say would be correct.
22 Q. So there is a balance between one and the other. One
23 would not have an enormous waiting list in one area, the
24 children's area, and a small waiting list on the adult
25 side; the one would have repercussions upon the other,
0092
1 would it not?
2 A. Yes, they would. So should I say how we sought to
3 address that?
4 Q. In a moment, because I want to examine the question of
5 waiting lists with you in perhaps slightly greater
6 detail. But can I ask you to look at HA(A) 119/35? In
7 fact, can we scroll down, please? It is the second
8 paragraph in this letter. The date of it, going back up
9 to the beginning to check the date, is 4th June 1987, so
10 we are back in the mid-1980s, June 1987. It is written
11 in relation to paediatric cardiac surgery. The second
12 sentence:
13 "I thought I should let you know that I have
14 recently had occasion to accompany two young parents
15 from Gwent whose 3 and a half years old child died
16 following cardiac surgery in Bristol last December, at
17 an interview with one of the paediatric cardiac
18 surgeons, a Mr Wisheart. The child had been referred to
19 Bristol when a few months old and the parents had had to
20 take him to the outpatient clinic every 12 weeks
21 initially. The frequency was then increased to every
22 6 weeks. The child was also seen by a paediatrician
23 in ... Gwent every 12 weeks.
24 "In November 1985, the parents were told that the
25 time had arrived for surgery to be undertaken and that
0093
1 it was hoped to admit the child in January or February
2 1986. In the event, the child was not admitted until
3 December 1986. In spite of repeated requests by the
4 parents and several letters from the Royal Gwent
5 paediatrician expressing concern at the boy's condition,
6 he was not reviewed in Bristol during this 10 to 11
7 month delay in admission. During the interview,
8 Mr Wisheart said that the delay in admission was
9 entirely due to the pressure of demand faced by the
10 department and the inadequacy of resources to meet that
11 demand. He said that it was impossible to determine
12 whether the delay had had any seriously adverse effect
13 on the baby's prospects ..."
14 It then deals with the parents' understandable
15 feelings.
16 But there, there is recorded, and apparently
17 accepted, it would seem, by you, if the author of the
18 letter is right, that there had been something in the
19 region of a 10 to 11 month delay in admission beyond the
20 optimal time of surgery for this particular child. An
21 explanation, in June 1987, that this was entirely due to
22 the pressure of demand faced by the department and the
23 inadequacy of resources to meet that demand.
24 Is it right that there were such pressures on the
25 department in respect of not only adults but of children
0094
1 in 1986/87, that a child might have to wait 10, 11,
2 possibly more months, in order to get surgery when the
3 optimal time would have been 10, 11 months earlier?
4 A. I would have to make reservations about when the optimum
5 time was and how long the optimal period might have
6 been. I do not know who told the parents January or
7 February 1986, but with that reservation, I would
8 certainly agree that there were delays, significant
9 delays, in surgery for both adults and children at that
10 time and probably at all times during my consultant
11 career. We were working constantly to try to change
12 that by increasing the facility. You will have noticed
13 that this was immediately prior to the significant
14 expansion of the facility in 1987/88.
15 Q. Certainly, at about this time -- can we look at
16 UBHT 92/6? This is 26th March 1987. It is addressed to
17 Dr Jordan from you, "wanting to let you know that at the
18 present time my paediatric waiting list stands at 74
19 patients."
20 Those would be surgical cases, would they?
21 A. Yes.
22 Q. So this is 74 patients all waiting for operation.
23 "This represents a good year's work, but of
24 course many patients will not have their operation for
25 more than a year in view of the urgent cases who will
0095
1 inevitably present during that period."
2 The result of a waiting list like that, with you
3 and Mr Dhasmana -- Mr Dhasmana's waiting lists were
4 presumably fairly similar, were they not?
5 A. I think there is a letter somewhere in that same folder
6 in which he states his number, but of course, having
7 begun just over a year prior to March 1987, it is
8 possible that it was not quite as large at that time.
9 Q. Let us have a look at it. I think you have in mind
10 JPD 1/5. It is not very well photocopied, I am afraid,
11 but if I read it, I will take it slowly so you can
12 follow it:
13 "Further to Mr Wisheart's letter dated 26th March
14 [the one we have just been looking at] I write to add
15 that I have got about 30 paediatric patients on my
16 waiting list for routine open heart procedures. On my
17 present schedule I cannot operate on more than one
18 paediatric case per week. That means already a 7 and
19 a half months waiting list has developed. Combining
20 these with Mr Wisheart's, our waiting list for
21 paediatric cases at this centre stands at more than 100
22 cases. Even with the expansion, I do not foresee the
23 possibility of operating on more than 3 or maximum
24 (rarely) 4 cases a week without affecting the adult
25 cardiac surgery."
0096
1 That is partly why I asked you about the effect
2 that the one had on the other, which he appears to
3 recognise, in that.
4 "As you are all aware, the plans for any future
5 project take a long time to implement. It may be
6 feasible to look into the prospect of open heart surgery
7 at the Children's Hospital now rather than in the
8 distant future ..."
9 He goes on to make a case for that.
10 So in early 1987 he is recording, together with
11 your figures, 100 surgical cases and a fairly
12 substantial waiting list.
13 If we go ahead to September 1987, the same year,
14 just concentrating on that for a moment, UBHT 154/220,
15 it is from you to Dr Rees and Dr Vann Jones. You deal
16 with the waiting lists. The bottom one:
17 "There are 55 children of whom 21 went on the
18 waiting list before 1st January 1987."
19 So 21, it is about 40 per cent of the children who
20 have been waiting for more than 9 months.
21 Can I take it in stages and ask you the questions
22 that I want to ask you about this? This was far from
23 ideal, was it?
24 A. Definitely.
25 Q. This could not have had any positive beneficial effects
0097
1 upon the children concerned, save in the most
2 exceptional case. Am I right?
3 A. Beneficial effects? No, it would not have had
4 beneficial effects.
5 Q. The reverse is true?
6 A. Not in every case, no, it is not.
7 Q. Not in every case?
8 A. No.
9 Q. But the generality?
10 A. For some of the patients, the question of timing and the
11 optimal timing varies. For an emergency case, the
12 optimal timing is now. For an urgent case it will be
13 within the next few days, a week or two. For those sort
14 of patients, those requirements would be met, or at
15 least, something very close to them.
16 Then there are a group of patients who are not as
17 urgent as that and who would generally be called
18 elective, and amongst those there will be some for whom
19 the timing is really not particularly critical and there
20 will be others at the other end of the spectrum for whom
21 it will not be urgent but it should probably be
22 within -- or at a particular time, plus or minus a few
23 months.
24 So it is really quite variable as to the effect it
25 would have on the child. The ones, of course, who wait
0098
1 are those who are in the elective group, and most of
2 those who would wait longer are those for whom the
3 timing is less critical, but I would be unable to say
4 that that was the case entirely. In other words,
5 I cannot say to you that there were not some children
6 who would have suffered, for want of a better term, from
7 the extra delay.
8 Q. Can I just follow up that last answer? On 28th February
9 1989 -- so we are looking, and you have made the point,
10 the 1987 documents are before the expansion of surgical
11 facilities at the Bristol Royal Infirmary, 1988. 1989
12 is obviously after that.
13 If we have a look at UBHT 179/141, this is
14 a letter to you from Mr Dhasmana. If we just scroll
15 down, please:
16 "... in response to your memo of 21st February
17 with the relevant information regarding my waiting
18 list."
19 The number of patients, adult 35, children 25, and
20 in part 2 of that, there are 3 children, he says in the
21 third line, waiting longer than one year. He describes
22 them. In one it was intended to operate after a year or
23 so when the child had grown big enough for a Fontan
24 procedure. The second is VSD, the symptoms have changed
25 and the patient has improved. The third has ASD with
0099
1 few symptoms at the present time.
2 "Death on the waiting list:
3 "In 1987, 8 patients died while waiting for
4 surgery on my list."
5 He deals with that.
6 "Unfortunately, during that time my waiting list
7 was approaching between 7 to 9 months."
8 He does not say whether they were adult or
9 children, which is the first point one must make.
10 Secondly, so that there is no misinterpretation
11 given to this, we do not have, do we, from this letter,
12 any information which says in terms that they died
13 because they were waiting and would have survived if
14 they had been operated on earlier, which I think is the
15 point you were making a moment ago.
16 A. I think under number (2) -- it does not say and I do not
17 know categorically from my own knowledge that this is
18 so, but it would be my belief that under (2) Mr Dhasmana
19 is talking entirely or predominantly about adults
20 because I think that he makes clear the situation with
21 children in the paragraph above and he adds a dimension
22 to what I said earlier on that.
23 Q. He is dealing with different things because in the
24 paragraph above he is dealing with the present position
25 in 1989 and says in effect there are reasons that one
0100
1 can excuse the wait for the 3 children who have been
2 waiting for more than 9 months. He then goes on to look
3 historically back in time to 1987, when he is saying, in
4 1987 these patients died. He does not say whether they
5 are adults or children.
6 A. Yes, but the reason I am able to make the comment is
7 that I do not believe that many children died, if any,
8 on the waiting list, and this was a phenomenon that
9 occurred amongst adult patients.
10 Q. If we move forward to 28th February 1991, UBHT 157/60,
11 to identify the document first, it is the South West
12 Regional Cardiac Specialist Sub-committee, 28.2.99. It
13 is the next page(UBHT 157/61):
14 "91/4 ... Possible projects were discussed. It
15 was agreed the most urgent was an analysis of the
16 mortality and morbidity associated with the long waiting
17 lists for cardiac investigation and surgery ..."
18 A number of individuals were asked to prepare an
19 audit proposal.
20 This may well have been dealing principally with
21 adults --
22 A. It was.
23 Q. Was the audit actually carried out?
24 A. It was dealing principally with adults, and I cannot
25 recall whether or not it was carried out. You will
0101
1 recall that I went to very few of these particular
2 meetings. But I can say that it was a national problem
3 at this time. There are quite a number of published
4 studies in this area and of course it led up to
5 government action which sought to no longer have
6 patients waiting over a year for coronary artery
7 surgery. But I can say that this was an adult surgical
8 issue and all these people were adult cardiologists or
9 adult surgeons.
10 Q. The need for the analysis might suggest, as, if I may
11 comment, some of your answers earlier might suggest,
12 that no-one actually knows what the effect of keeping
13 a given patient, or patients in general, on the waiting
14 list, actually is in terms of morbidity or mortality?
15 A. There was certainly very limited knowledge available.
16 I think you said this was 1991?
17 Q. Yes. It is 1991, 28th February.
18 A. I imagine there was some published information by that
19 time, but I think there was quite a lot more in the
20 years that followed this, in the early 1990s. I think
21 it reflects the fact that there were more patients out
22 there needing surgery than the facilities had the
23 capacity to cope with. Hence the waiting times.
24 Q. I follow that. What I was asking you, really, was, does
25 anyone know with any degree of precision what the effect
0102
1 of keeping cardiac patients, whether child or adult, on
2 a waiting list for periods in excess of 4, 5, 6 months,
3 actually is in terms of patient health?
4 A. I think what one can say in relation to adults is that,
5 be it valve disease or coronary disease, it is
6 a progressive disorder, and therefore with the passage
7 of time it is likely that the effects of that disorder
8 will increase, and therefore that will lead to both
9 mortality and morbidity. That will happen whether we
10 are talking about a delayed referral, a delay on the
11 waiting list, or any other delay. That is just
12 something that happens in the natural history of the
13 disorder.
14 With children the issue is slightly different. It
15 is one which became more clearly recognised through the
16 1980s than it had been before that.
17 If we set aside those children who need urgent or
18 emergency treatment and consider those who are not in
19 immediate need of surgical treatment, the congenital
20 abnormality which they suffer from will have an effect
21 that secondary changes will develop in the heart and in
22 the lungs, and possibly in other organs, but in most
23 children, in all of them in the heart, in many in the
24 lungs also, and in some, elsewhere.
25 So that, if a child early in life has an
0103
1 abnormality of the heart but is relatively free of the
2 secondary effects, whereas N years later they may still
3 be alive but in addition to the abnormality of the
4 heart, they will have these secondary effects.
5 The importance of this is that whereas in the
6 1970s, say, and also in the early 1980s, people,
7 surgeons and cardiologists, preferred to delay
8 operations because they felt children would be operated
9 on more safely when they were a little bit older, people
10 came to realise and accept that, indeed, they should be
11 operated on sooner in order to prevent the development
12 of these secondary effects which, in essence, were
13 complications -- additional complications.
14 That, then, is the thinking underlying the trend
15 towards earlier operating. I am actually trying to
16 answer your question, but it is a little indirect.
17 So the effect of a child waiting, again, whether
18 they are on a waiting list or not, is best understood
19 within, I think, that set of ideas.
20 So, for some children, an extra wait will be of
21 very little significance; for others it will be of some;
22 for some it may be quite important, but whether or not
23 they are on the waiting list is not the crucial factor;
24 the crucial factor is that time is passing.
25 Q. The longer the waiting list, the more time will pass.
0104
1 A. Yes, absolutely. Nobody wants a longer waiting list.
2 Q. And a waiting list -- let us have a look, I think, at
3 the way you yourself described it in 1990, JDW 1/333,
4 underneath the table. This is 30th November 1990.
5 It is a document which is making proposals:
6 "The present facilities at the Infirmary and the
7 Children's Hospital are fully occupied and there is
8 pressure to increase the number of patients treated,
9 particularly adults ..."
10 Then a number of bullet points:
11 "Waiting lists of unacceptable length, up to 12
12 months (dependent on consultant)."
13 A. Yes.
14 Q. The word "unacceptable" is right, I take it?
15 A. Yes. I think in principle it is right. It was
16 a constant battle. We were constantly engaged in it, to
17 try to increase the facilities to deal with that
18 problem.
19 Q. So throughout the period that we have been looking at
20 from 1987, which was the earliest document I showed you
21 in relation to this, through here to the end of 1990 and
22 the beginning of 1991, if one is to look at the proposal
23 to analyse the effects of being on a waiting list, it
24 has been recognised that there is or were lengthy
25 waiting lists for cardiac surgery both adult and
0105
1 paediatric?
2 A. Yes.
3 Q. Recognised for the reasons, the physiological reasons,
4 you give, that waiting will do harm to a greater or
5 lesser extent?
6 A. Yes.
7 Q. To a child.
8 A. Or an adult.
9 Q. Or an adult. That, therefore, attempting to reduce
10 waiting lists, cope with the demand, if you like, is
11 essential?
12 A. Absolutely.
13 Q. In 1993, for instance, if not before, the paediatric
14 waiting list was addressed, I think, by carrying out
15 Saturday morning surgery?
16 A. The paediatric waiting list?
17 Q. The paediatric waiting list.
18 A. In 1993?
19 Q. UBHT 247/183. 22nd January 1993, addressed to you as
20 Medical Director:
21 "Dear James, I wish to make a constructive
22 criticism of the waiting list initiatives that the UBHT
23 is presently undertaking and their effects upon the
24 Directorate of Anaesthesia".
25 If we scroll down, we see it is from Mr Monk. It
0106
1 is the paediatric waiting list, I am sorry.
2 A. That was general paediatric surgery.
3 Q. That was general paediatrics?
4 A. Yes.
5 Q. If we go on to UBHT 85/89, May 1993, this is cardiac
6 services. Can we scroll down, please?
7 "It was agreed that a 9-month wait for routine
8 surgery was a clinical priority for the additional
9 investment from Bristol & District Health Authority.
10 The imperative to avoid over 1 year waiters for
11 catheterisation was widely debated".
12 This is talking about I suspect principally
13 adults; but plainly the waiting list issue, as you
14 acknowledged a moment ago, did not go away?
15 A. It never went away.
16 Q. And it remained at this level, at or about the
17 unacceptable, throughout?
18 A. Throughout my consultant life, that is correct. I mean,
19 when we were doing 100 a year it was too long. When we
20 were doing 1,000 a year, it was still too long. So
21 although we were running faster and faster, we never
22 actually caught up.
23 Q. One of the comments that you have made on other
24 evidence was to the effect, "How could we, as
25 a department, increase the number of neonatal and infant
0107
1 cardiac surgical operations, the number of referrals?"
2 the point being, it is a function of general
3 demographics that you get proportionately the same
4 number of operations from the same congenital heart
5 disease because it is the same congenital problem, and
6 this in the context of those in the Supra Regional
7 Services Advisory Group who gave evidence to us saying
8 "We encouraged those at Bristol to try and do more
9 congenital heart surgery in neonates and infants". Do
10 you remember the passages?
11 A. I remember the passages.
12 Q. Is it right that in terms of the population that might
13 be referred to Bristol, both in neonatal and infant
14 cardiac services and the bulk of paediatric cardiac
15 work, that the level for a given population is likely to
16 be fairly constant in cases per year?
17 A. The frequency of congenital abnormalities within
18 a population is relatively constant from year to year.
19 That is correct. So that the total number of operations
20 arising due to congenital abnormalities is likely to be
21 quite constant.
22 I think to complete the answer to your question,
23 the important thing that altered over the period, or
24 perhaps beginning a little before 1984 through this
25 period, were views on the most appropriate age at which
0108
1 operations should be carried out, which in a word, were
2 that the trend was towards operating earlier, for the
3 reasons I have stated.
4 So, as regards, therefore, the total number of
5 children in the first year of life on whom one might
6 operate, it was really a function of those two
7 considerations.
8 Q. So in terms of, as it were, planning a service for those
9 under 1 year of age, looking at the number of operations
10 for that group which might be done, one would, for the
11 reasons you have mentioned, have a slowly increasing
12 probable number of operations?
13 A. Yes, due to that trend, by which I mean the trend to
14 operating at an earlier age. That is correct.
15 Q. And that would be, if I have understood it correctly,
16 a slow and steady development throughout the 1980s?
17 A. Yes. I think that is correct, as a generalisation.
18 Q. The demand for adult surgery, on the other hand, is
19 a function of a number of features.
20 We keep on being told, as lay people, the number
21 of factors that may affect, for instance, coronary
22 artery disease. Am I right in thinking that the demand
23 for some form of coronary arterial surgery was well in
24 excess of the available facilities at Bristol for the
25 region which might be served by it throughout the period
0109
1 with which we are concerned?
2 A. Yes, that is correct.
3 Q. So we have an expansion of the number of operations for
4 adults being done by the Bristol Royal Infirmary from
5 somewhere round about the 200 open heart operations in
6 the early 1980s, to over 1,000 now, and still the demand
7 is not satisfied?
8 A. That is correct.
9 Q. So the picture is, is it, a large number of adult cases
10 waiting to be done, increasing demand, and a much
11 smaller but steadily increasing, gradually increasing,
12 number of paediatric cases throughout the same period,
13 especially under 1?
14 A. Do you wish me to comment on the increasing paediatric
15 cases?
16 Q. Yes, please.
17 A. Prior to 1980 and in the early 1980s, we had been
18 undertaking a total of about probably on average between
19 60 and 70 operations for congenital abnormalities each
20 year.
21 By the end of the 1980s, we were doing about
22 double that number, namely, 140 to 150.
23 One might ask, well, how come that the total
24 number increased when you have the same number of
25 abnormalities occurring in the community, give or take
0110
1 a little bit? I think that at the time we thought some
2 came from South Wales, and that was undoubtedly true but
3 it was not the whole answer, so I do not know the whole
4 answer to that question.
5 The second thing that changed was that the number
6 of infants having open heart surgery increased much more
7 dramatically: from numbered around the 10, plus or
8 minus, each year in the early 1980s, they increased to
9 about 50 each year to 1991 or so, and I believe that
10 that reflected the implementation of the viewpoint that
11 we have discussed a moment ago.
12 I would acknowledge that we were relatively
13 conservative about moving to a younger age and in
14 particular to the first year of life, in children who
15 did not need to have the operation in the first year of
16 life, so we were not leading the movement in this
17 direction, but we were there following the trend.
18 While we were always conscious that it would in
19 a sense be better if we were doing more operations in
20 the first year of life, we had to make a decision for
21 each child on what we considered and believed to be the
22 best interests of that child, and therefore it would not
23 have been acceptable to us to make a decision simply in
24 order to increase the numbers of operations in the first
25 year of life.
0111
1 So the numbers carried out in the first year of
2 life therefore reflected what we believed to be in the
3 best interests of that individual child at that time.
4 Q. What I want to ask, arising out of that, is whether the
5 fact, as it was, that you and Mr Dhasmana were both
6 surgeons who did adult work in respect of which there
7 was the great expansion you have spoken of, as well as
8 paediatric work, and plainly had waiting lists in both,
9 whether the fact of your doing both in effect meant that
10 children had a longer waiting list than might have been
11 the case had one or other of you been a dedicated
12 paediatric cardiac surgeon, perhaps with some cover from
13 a surgeon who did both?
14 A. Your question is, would there have been such a long
15 waiting list if there had been one full-time paediatric
16 cardiac surgeon instead of two half-time? Did
17 I understand that correctly?
18 Q. Effectively, yes. If the relationship between the adult
19 and the paediatric -- we have, I think, established in
20 the question and answer that there has been, that the
21 one has an effect which is not entirely independent of
22 the other. Given the need to cope with, throughout this
23 period, the great demand for adult work, the fact that
24 by the design of others you and Mr Dhasmana both spent
25 some of your time dealing with children, some with
0112
1 adults, it may be that in Bristol the waiting list for
2 paediatric cardiac surgery was longer than it might
3 otherwise have been, had there been, let us suppose,
4 a dedicated paediatric surgeon throughout. That is the
5 question.
6 A. I think it is a very difficult question, and of course
7 there are --
8 Q. That is part of why I ask it.
9 A. There are hypothetical elements in it.
10 Q. Would you like time to think about it and return to it
11 after a break?
12 A. If that would be fine, thank you.
13 THE CHAIRMAN: That is a sensible suggestion, if I may
14 say so. Why do we not take 15 minutes now and that
15 means we reconvene at 25 to 4.
16 (3.20 pm)
17 (A short break)
18 (3.40 pm)
19 MR LANGSTAFF: Mr Wisheart, you have had some time, I hope,
20 to think about the question. If I rephrase it, it was
21 essentially: did the fact that you and Mr Dhasmana were
22 both called upon to deal with adult cardiac surgery mean
23 that, in effect, the paediatric suffered in a way they
24 would not have done had one dedicated paediatric surgeon
25 been appointed?
0113
1 A. Thank you. Can I make a couple of points in response to
2 that, please?
3 I believe that, had there been one full-time
4 paediatric surgeon rather than the two of us, and that
5 that one surgeon had been working in the Infirmary as we
6 were working, that he would have had a number of
7 allocated operating sessions to use for his paediatric
8 work in exactly the same way as Mr Dhasmana and I used
9 sessions for our paediatric work.
10 So I think that in that context -- and it is all
11 hypothetical -- a full-time paediatric surgeon would
12 have made a marginal difference.
13 If we consider an alternative context, secondly,
14 namely, that the full-time surgeon was able to operate
15 in the Children's Hospital and had, if you like, full
16 control of his operating and post-operative care
17 resources, then I think that that would probably have
18 made a substantial difference.
19 But may I say this, and I had better speak for
20 myself, I think, at this point and not Mr Dhasmana.
21 Over the period as a whole, the constant pressure to
22 increase adult work did of course impinge on me because
23 I was constantly involved in efforts to increase the
24 facility, but in terms of my operating, the number of
25 adults I operated on obviously fluctuated from year to
0114
1 year, but broadly stayed the same over the whole period
2 of time.
3 In other words, the proportion of my time that was
4 devoted to children was nearly protected.
5 The sessions which Mr Dhasmana and I did devote to
6 children amounted to three a week -- I do not mean three
7 half days; there were three operations a week of
8 whatever length, at least, which were children, so that
9 meant that we could achieve 150 a year, plus or minus,
10 and in that sense, we were actually meeting in full the
11 demand that we understood to exist for paediatric
12 cardiac surgery each year.
13 That could never be said for the adult work.
14 I suppose the final point I would like to make is
15 that there is a difficulty about having one single
16 surgeon, even if he is full-time, and that is the
17 obvious one, that it means he is on call all the time
18 when he is present, but when he is away, then there is
19 nobody in town to look after that work.
20 Q. You come back to the question, then, of the total
21 numbers of such cases being done and whether one would
22 have one or two and so on, but that is a matter which
23 I will take up with you when I come to deal with the
24 question of supra-regional services designation.
25 Before I ask you to look at the next document,
0115
1 arising out of the answer you have just given me, what
2 you are saying is, "We had enough sessions, in effect,
3 to deal with the paediatric demand but the waiting list,
4 of course, still remained"?
5 A. Correct.
6 Q. If there was enough time available and enough resources
7 available to cope with the demand -- to cope with the
8 demand and no more -- the only way of reducing the
9 waiting list will be to have some form of waiting list
10 or additional time spent on attacking the waiting list,
11 presumably?
12 A. Or else the ability to be more flexible and to operate
13 from time to time on children in sessions when one would
14 have normally operated on adults. But, I mean, we are
15 not just talking of access to an operating theatre. The
16 ability to operate on a child requires a whole package.
17 You need to have a paediatric cardiac anaesthetist.
18 Most of the nurses in theatre would have been able to do
19 the work with a child, but some were certainly better
20 than others, and again, as the nurses will describe to
21 you, they tried to have nurses with experience looking
22 after children in intensive care.
23 So the whole package has to be provided and not
24 just access to an operating theatre slot.
25 Q. Can we look at JPD 1/2, please? This is 27th January
0116
1 1987, from Mr Dhasmana to Dr Johnson, the Chairman of
2 the Division of Anaesthesia, and what Mr Dhasmana is
3 writing to say is, he is asking for an extra session at
4 the Bristol Children's Hospital. The reasons he gives
5 in the second paragraph: designation as a supra-regional
6 specialty centre dealing with paediatric cardiac
7 problems, has resulted in an increasing amount of work
8 from all parts of the South West and from South Wales,
9 between you and he, you had operated on more than 120
10 infants and children. Then:
11 "Having been given only one half-day list in
12 a fortnight, my waiting list to deal with these problems
13 has progressively lengthened and in many of these cases
14 I have been operating as an emergency in the evenings or
15 during the weekend. Some of these would have been
16 operated during the routine hours if I had an operating
17 session allocated to me during the week."
18 He seems to be saying "the waiting list has got
19 longer, given the time allocated to us", he says, and he
20 is asking for an extra session .
21 If he did an extra session at the Children's
22 Hospital, he would presumably do one less adult session.
23 You do not like that point?
24 A. I do not think he would have, although I think you would
25 need to ask him, because it would depend on the details
0117
1 of his programme at that time, but I think he is
2 actually saying that he has the freedom to operate at
3 whatever time he is proposing.
4 I would like to say, this is of course closed work
5 we are talking about now, not open heart work, and
6 I mean, he only had one half day alternate weeks,
7 I think.
8 Q. Yes.
9 A. Had he had more, then some of his other operating could
10 have been accommodated on it, but of course, emergency
11 work by its nature does not occur in proximity to your
12 planned operating sessions.
13 Q. He seems to be suggesting in the second paragraph --
14 A. Well, some of it does, but --
15 Q. -- that some that are described as "emergency" could
16 have been done during routine hours. Perhaps there is
17 an element of flexibility about the definition?
18 A. Some of it, but that certainly was a problem, because
19 for each of us, in the Children's Hospital there was
20 a much higher proportion of work that was urgent or
21 emergency than in the Infirmary, amongst children, and
22 it was work that did have to be done within a day or
23 two, frequently, and so it was not uncommon to operate
24 in the evening or at the weekend. It had to be done.
25 That was the need of the child. Certainly, if that
0118
1 could have been reduced, that would have been a very
2 good thing.
3 Q. Given the fact of the waiting lists, given the demands
4 upon the two of you, what efforts were made to improve
5 the situation?
6 A. In the Children's Hospital?
7 Q. And at the BRI, to reduce the waiting lists?
8 A. In the Children's Hospital, first, a number of things
9 happened. The first one was that some time after this
10 I gave him one of my sessions, because I had additional
11 duties elsewhere. But perhaps the more important thing
12 was that the number of closed heart operations that we
13 did peaked around this time and subsequently became
14 less, and there were two reasons for this -- at least
15 two reasons. The first one was that the cardiologists
16 developed the ability to carry out certain interventions
17 as a non-surgical procedure, in other words, as part of
18 the cardiac catheterisation, so that some procedures
19 that we had done at surgical operations were carried out
20 at the time of catheterisation, so that reduced the
21 number of operations. The second thing is that the
22 trend towards earlier total correction of intracardiac
23 abnormalities meant that we did less palliative work in
24 young children to tide them over. So for those two
25 reasons amongst others, the actual number of closed
0119
1 procedures declined following this time.
2 So that is what happened at the Children's
3 Hospital.
4 In the Infirmary, the total capacity of the
5 Infirmary did continue to increase, as I think you have
6 pointed out, but I would have to say that the increase
7 in throughput was predominantly in the adult area at
8 that time. We had, by 1989 or 1990, achieved this level
9 of 150 operations per year. It is not my recollection
10 that there was a significant increase beyond that.
11 Q. So essentially the adults' work continued to expand and
12 the paediatric work did not?
13 A. Yes. There was no increase in demand for paediatric
14 work in the early 1990s that I can recall.
15 Q. The ultimate decision to move the paediatric surgical
16 workload to the Children's Hospital was, was it not,
17 eventually decided upon as a means of further increasing
18 the adult throughput at the BRI?
19 A. I would not put it that way.
20 Q. The reason I put it that way to you arises from
21 documents which Mr Maclean explored with Mr Nix. You
22 will have read the transcript. Because you put
23 a different reflection on it in your statement, let me
24 ask you about them.
25 Can we look at JDW 3/303? It is the first
0120
1 paragraph:
2 "At a recent meeting of the cardiac surgery
3 planning group, the possibility of transferring the
4 paediatric workload currently being undertaken at the
5 BRI to the Children's Hospital as a means of increasing
6 throughput in adult surgery was discussed. It was
7 agreed that a preliminary look should be taken at
8 whether this transfer was physically possible, given the
9 space constraints at BCH."
10 The motive there in the first paragraph is purely
11 to satisfy adult demand as opposed to a response to any
12 perceived weakness in paediatric provision, is it not?
13 A. That statement does not refer to a perceived weakness in
14 paediatric provision, but I believe -- I have no
15 doubt -- that it would be correct to say that the desire
16 in principle to move the paediatric work to the
17 Children's Hospital had been established and accepted
18 for very many years. I would say that this was seen,
19 certainly as one option of increasing the adult work,
20 but it was also a means of implementing the principle
21 that had been accepted for so long and which we had not
22 been able to implement for financial reasons. This was
23 the opportunity.
24 Q. If we look again at the Surgery Management Board,
25 UBHT 81/52, the date is 8th February 1994. The
0121
1 page I want to ask you about is page 54(UBHT 81/54):
2 "Cardiac:
3 "Increased contracts will lead to an expansion of
4 cardiac services on this site. The implication in
5 1994/95 will be the need to 'borrow' theatre sessions
6 temporarily. An option for paediatric surgery to move
7 to the Children's Hospital was being considered", and
8 again the motive, "which would release beds and
9 operating sessions but could not be implemented until
10 April 1995. Until then, agreement needs to be reached
11 as to how to manage the expansion."
12 We do not seek to dispute with you at all the fact
13 that it had been recognised for some time that it was
14 far from ideal that children's work should be done at
15 the BRI and not at the BCH; that the split site required
16 to be remedied. What I am putting to you is that what
17 actually motivated the eventual move was nothing to do
18 with that but it had everything to do with the
19 expansion, the further expansion, of adult cardiac
20 surgery?
21 A. I would say it created the opportunity. The
22 "motivation" to move the children's work to the
23 Children's Hospital, because that is the word you used,
24 the motivation to make that change came from the desire
25 to integrate the children's work. This was the
0122
1 opportunity.
2 Q. JDW 3/195, I next take you to, which is 12th May 1994.
3 It begins:
4 "This paper contains proposals for the next stage
5 of the development of cardiac surgery in the UBHT and
6 recommends that all paediatric cardiac surgery should be
7 undertaken at the [Children's Hospital] where it would
8 be closely integrated with paediatric cardiology."
9 At page 196 in that document, "the feasibility of
10 transferring the paediatric cardiac surgical service has
11 been reviewed on a number of occasions in the past", and
12 that was so, was it not?
13 A. That was definitely so.
14 Q. "On the last occasion in 1990, this suggestion foundered
15 partly due to the lack of space and the expense of such
16 provision, and partly because it was overtaken by the
17 proposal for a new Children's Hospital". That was so,
18 was it?
19 A. I believe that to be correct.
20 Q. "In the intervening period there have been a number of
21 changes at the Children's Hospital which now offer
22 another opportunity for the transfer of paediatric
23 cardiac surgery to be reconsidered. Such a transfer
24 would also facilitate the development of day case work
25 and the paediatric intensive care in the Children's
0123
1 Hospital."
2 Then it goes on to deal with possible
3 developments.
4 One sees the way it puts it first: "We could take
5 no action thereby placing at risk the existing adult and
6 paediatric services. Secondly, the cardiac surgery ...
7 could expand in the Bristol Royal Infirmary; and finally
8 the children could move to the Children's Hospital,
9 vacating both beds and operating theatre space for the
10 expanded adult service."
11 That puts the options as they appeared in 1994?
12 A. That is correct.
13 Q. If we go to UBHT 8/261, 12th August 1994, the Executive
14 Committee. That identifies the document. Page 262(UBHT 8/262) is
15 the page I am going to ask you about, under "Chief
16 Executive's report", at (e) one sees the way it is put
17 in the Executive:
18 "Future funded demands to increase adult cardiac
19 surgery will be accommodated in the BRI by the transfer
20 of paediatric open cardiac surgery to the Children's
21 Hospital. This will be achieved by the provision there
22 of a day case operating theatre and additional intensive
23 care beds."
24 Again, the emphasis is all on releasing space for
25 adults, is it not?
0124
1 A. The new development in the work as an increase in the
2 number of adults, and that has been achieved by vacating
3 space in the Infirmary. The other way it could have
4 been achieved would be to keep the children in the
5 Infirmary and spend the capital increasing the facility
6 there, but instead of doing that, the capital was
7 devoted to the Children's Hospital and moving the
8 Children's Hospital there.
9 It is absolutely right to say the increase in
10 adult work was the occasion or opportunity which
11 permitted the children's work to be moved, but there was
12 a clear and independent motivation and desire to do
13 that.
14 Q. Would you go this far: that it was the proposed
15 expansion in adult surgery which was the impetus for the
16 move to the Children's Hospital?
17 A. I think I would still stick to "occasion".
18 Q. Because if it was "occasion", why did it not happen
19 earlier?
20 A. The impetus to try to make it happen earlier had
21 existed, but it had foundered for the reasons you refer
22 to in one of the earlier documents we looked at. An
23 enormous effort was mounted in around 1990.
24 Q. And that foundered?
25 A. And that foundered, not due to lack of impetus but due
0125
1 to lack of finance or prioritisation, or whatever, but
2 I mean, the impetus, the lead was there, the impetus was
3 there, but the means of achieving it did not seem to be
4 to hand.
5 Q. It was suggested, I think, in 1990 -- let us look at
6 JDW 5/26. This is 10th July 1992. This is the letter
7 to you, "Development of cardiac services ...". It is
8 the next page, at JDW 5/27, the "PS":
9 "Lesley and I met Ian Barrington to talk about
10 paediatric open heart surgery. He raised the issue
11 about how a joint contract mechanism would work for
12 paediatric cardiac services and also the usual issue
13 [the way he puts it] about whether or not paediatric
14 open heart surgery will move to the Children's
15 Hospital. On the latter point, we all agreed that we
16 were committed in principle to this, but in practice it
17 looked very difficult to achieve."
18 So everyone agreed, by 1992, as they had earlier,
19 that the principle was that there should be a move.
20 What makes it happen is the development in adult cardiac
21 demand, is it not?
22 A. Yes. I would accept that.
23 Q. The effect, since I am dealing in this part of my
24 questioning with the split site, of having a separation
25 of adults and children was, was it, potentially harmful
0126
1 to the children concerned?
2 A. Potentially, in as much as it was not an ideal
3 arrangement. It is much more difficult to say whether
4 there was any actual harm, but potentially harmful in as
5 much as it was not ideal, I think one would have to
6 accept.
7 Q. As far back, I think, as 1984 -- JDW 1/175, the third
8 report of the open Cardiac Surgery Working Party. We
9 will find the reference I want at page 186. It is 5.2,
10 "Risks of ferrying paediatric cases". This is talking
11 admittedly I think in catheter terms:
12 "The present investigational facilities at the
13 Bristol Royal Infirmary consist of two adjacent
14 catheterisation rooms ... The newest equipment was
15 installed some eight years ago and the equipment is
16 nearing the end of its useful predicted life ... There
17 is no accommodation at the Bristol Children's Hospital.
18 "Therefore, at the present time, patients' lives
19 are frequently being put at risk by the need to transfer
20 very young children between the Bristol Children's
21 Hospital and Bristol Royal Infirmary every time
22 a catheter investigation is needed."
23 That is obviously talking about catheter
24 operations?
25 A. Yes.
0127
1 Q. But until the catheter suite at the Children's Hospital
2 was developed in 1986 -- it opened I think later that
3 year or 1987 -- it remained a problem?
4 A. Yes.
5 Q. "50 per cent of these patients are critically ill
6 neonates and infants, many of whom require urgent
7 surgery. This type of emergency surgery is
8 predominantly of the closed heart type which is
9 currently performed at the Bristol Children's Hospital,
10 50 closed heart cases. The open heart cases ... are
11 usually admitted electively for surgery in the Bristol
12 Royal Infirmary."
13 So in 1984 it was well recognised there was
14 a potential risk. I appreciate from your answer you
15 accept it as real, although one could not necessarily
16 say in any given case that it produced a different
17 result?
18 A. I think the shape of the problem is a little different
19 for catheterisation of children and open heart surgery,
20 and I think that they are really talking of the problems
21 associated with the transport of very sick children
22 backwards and forwards on the same day before and after
23 the investigation.
24 The issue of transport occurred or persisted, if
25 you like, with a relatively small number of children who
0128
1 needed to be transferred for urgent surgery to the
2 Infirmary, but of course the other problems were that
3 the children were being cared for at a site which was
4 some distance from the Children's Hospital.
5 So a slightly different shape.
6 Q. It had a number of knock-on problems that you have told
7 us about, the difficulty of recruiting and retaining
8 paediatric nurses, because the intensive care nursing in
9 the Bristol Royal Infirmary would be amongst adults and
10 that is not what they were trained for?
11 A. Yes.
12 Q. It was one of the reasons why Martin Elliott decided not
13 to seek appointment to the Chair of Surgery and
14 therefore an earlier opportunity to obtain a dedicated
15 paediatric surgeon that turned out to be the case?
16 A. That is correct.
17 Q. If that had happened, you would have given up paediatric
18 surgery and concentrated on adults?
19 A. That was the plan.
20 Q. It gave you problems, I think, in 1992 when the Joint
21 Committee on Higher Medical Training visitor rejected
22 a Senior Registrar post in paediatric cardiology?
23 A. That is correct.
24 Q. On the basis that there were two separate sites and that
25 was unacceptable. So all these problems must have had
0129
1 some effect, taken collectively, upon the quality of
2 care for the children at the Bristol hospitals?
3 A. Yes, in principle, that is correct, and that is what
4 I meant when I said "in principle".
5 Q. A problem identifiable in 1984 took until, what, 1996
6 to resolve?
7 A. Decisions were made in 1994.
8 Q. Yes, from decision to implementation would take
9 18 months to 2 years?
10 A. They were fully implemented in October 1995.
11 Q. Thus far I have asked you about the way in which you
12 were able to cope personally and managerially with the
13 demands of the hospital on the one side and the clinical
14 services you provided on the other, against the
15 background of the various staffing potential problems
16 that you and I have been asking and answering about and
17 the waiting lists which never went away in the
18 background.
19 Was there also a problem so far as cardiac surgery
20 was concerned with the hours that junior doctors were
21 required to put in? You told us earlier that one of
22 your early roles as Medical Director was to achieve the
23 reduction to 72 hours that had been trumpeted. Am
24 I right in thinking that for doctors, junior doctors in
25 cardiac surgery, that reduction came rather later?
0130
1 A. Yes. The reduction in junior doctors' hours took place
2 at a number of stages, and it is certainly right, as you
3 say, that at one of the early stages we were given
4 permission by the Region for our Senior Registrars to
5 continue to work longer hours, so at that stage, we were
6 slow, if you like, in achieving the desired goal.
7 But in fact, at subsequent stages we were ahead of
8 other departments in achieving a reduction, certainly on
9 paper, although in reality, from time to time, we may
10 not always have achieved what we had hoped to achieve on
11 paper. One would have to add that. But we were far
12 from the last in the Trust to achieve the requirements
13 for junior doctors' hours.
14 Q. Let me turn a little -- it is related -- from the
15 questions I have been asking you to the questions that
16 arise in respect of the organisation and in particular,
17 your own role first as Associate Clinical Director and
18 in relation to the clinical directorates generally that
19 were established after 1990.
20 First of all, would you look at UBHT 29/9? This
21 is a letter dated 10th June 1994. It is addressed to
22 a clinical research fellow.
23 THE CHAIRMAN: I have taken the address out. Should it
24 be ...
25 MR LANGSTAFF: It is all right. If we can go down to the
0131
1 bottom of the page and over(UBHT 29/10), you will see it is from
2 Trevor Thomas. Back to the first page. It relates to
3 audit. I am going to ask you about audit separately,
4 but if you scroll down a bit, please, it gives
5 a description of you in the last two sentences of the
6 second paragraph which I just want to ask you for your
7 comment about:
8 "I fear that he [you] has become part of the
9 rather introspective organisation of UBHT management and
10 you may find that he will not wish to take you up on
11 that particular offer [an offer to come to particular
12 audit meetings]. We shall see."
13 It is the description of you having become part of
14 the "rather introspective organisation" of UBHT
15 management. Is that a description of yourself in which
16 you would recognise yourself at all?
17 A. No. I think that is a reflection of someone who takes
18 a slightly different view of the management than was
19 being taken, and I would also point out to you that the
20 prediction which he is making, although I had never seen
21 this letter until the papers for this Inquiry came, if
22 you look at the subsequent Audit Committee meetings, you
23 will see that his prediction did not come to pass and
24 that Charles Shaw was invited to continue with the Audit
25 Committee.
0132
1 Q. His description might suggest that he welcomed outside
2 input and you did not?
3 A. I would find that an unacceptable statement.
4 Q. As the Associate Clinical Director, did you see any
5 potential conflict between that role and your role as
6 Medical Director?
7 A. Well, they overlapped for a period of 8 months or so.
8 I think it was certainly undesirable that I should have
9 continued as the Associate Clinical Director when I was
10 the Medical Director, and that is why I handed it over
11 to Mr Dhasmana.
12 Q. Why would that be undesirable?
13 A. Well, there are issues of workload and there are issues
14 as to whether, as Medical Director, I had to make
15 choices or decisions which might have involved cardiac
16 surgery in relation to other directorates. I think it
17 would have been then an invidious position to be in. It
18 is better that cardiac surgery should have a lead and
19 a spokesperson who can speak independently on behalf of
20 cardiac surgery, not fettered by the wider
21 responsibilities.
22 Q. So someone who did not have to have, as it were, the
23 broader picture?
24 A. Yes.
25 Q. For that 8 months that the two roles overlapped, did you
0133
1 sense any conflict then? From what you are saying, you
2 may have done?
3 A. I certainly do not recall now that there was any
4 particular problem during that time. It may be that
5 there was some, but I cannot remember it, but I think
6 that in principle the possibility was there, and
7 therefore it was undesirable to continue that
8 arrangement longer than necessary.
9 Q. A potential conflict of interest in the same way
10 arises, does it, between chairmanship of the Hospital
11 Medical Committee and the post of Medical Director?
12 A. That is a view that some people took at the time, and
13 have taken since, and I can certainly understand that
14 view, but there was a very positive reason for having
15 the two jobs integrated at the beginning, and the reason
16 was the desire to enable the medical community to feel
17 that they were identified with and were part of the
18 management. So it was a desire to integrate this rather
19 than to polarise it by having, if you like, a "shop
20 steward" on the one hand, to use a phrase that has been
21 used here, and a representative of management on the
22 other hand. The desire was to integrate the two and
23 feel that everybody was playing on the same side.
24 Q. Did you feel, to use same analogy, that you were the
25 worker representative on the Board?
0134
1 A. Not in that sense, no. I actually felt that in the
2 Trust, to a great extent we did achieve that feeling of
3 all playing on the one side. There are many who would
4 disagree with me, and I suppose I speak from
5 a particular position and of course people always
6 complain when they do not get what they think they need
7 to have, but I had many occasions to speak with
8 colleagues from other institutions who were at absolute
9 loggerheads with the management, and I felt that was
10 something we did not have in our Trust, and I felt that
11 this policy and this desire was quite effective in
12 achieving that level of co-operation.
13 Q. Did you accept the split of Medical Director and
14 chairmanship of the Hospital Medical Committee when it
15 happened?
16 A. I am sorry; did I accept it?
17 Q. Yes.
18 A. I apologise. In practical terms there was no
19 alternative. I mean, it was inescapable. The duties
20 had simply mushroomed. I suppose, if the Medical
21 Director had had a group of Associate Medical Directors
22 with him at that time, that might have been an
23 alternative, but I do not think that was envisaged at
24 that point.
25 Q. So it was workload rather than conflict?
0135
1 A. It was a pragmatic decision and response to workload.
2 At least, that is what I understood it to be, and still
3 believe it to be.
4 Q. Looking at the Directorate structure as such, when it
5 began, as we know, cardiac surgery dealt with cardiac
6 surgery; the Directorate of Medicine dealt with
7 cardiology; and the Directorate of Children's Services
8 with much of the paediatric side. So we had three
9 separate directorates dealing with an individual case or
10 a number of individual cases of children with congenital
11 heart defects.
12 Did that, in your view, cause problems?
13 A. In terms of the delivery of surgery, I do not think it
14 caused problems. In a sense, it was even worse than you
15 say, because there was also the Directorate of
16 Anaesthesia, and one could think of one or two others.
17 So limiting my answer to delivery of surgery, I do not
18 think it did because the people, as individuals, all
19 played together as members of the surgical team.
20 I think that the issues that arose from that
21 division arose more in the context of the total care of
22 the patient. I mean, if we take an adult who comes to
23 a cardiologist and goes on a waiting list to be
24 catheterised, is investigated and referred to a surgeon
25 and there is a meeting and a discussion and so forth,
0136
1 and then the patient goes on a surgeon's waiting list
2 and eventually is operated on: we felt that by
3 integrating first the adult work and then subsequently
4 the paediatric work, we hoped that some of those delays
5 in the system could be removed and that by concentrating
6 on the care of that individual patient throughout their
7 progress through the hospital, it could be made more
8 effective and quicker and generally better.
9 That was the real reason for the introduction of
10 the patient-focused directorate.
11 Q. One of the effects, before the patient-focused
12 directorate came into operation, was that a number of
13 different directorates, as we have discussed, would deal
14 with the case of the paediatric surgical child. In
15 terms of the delivery of overall service to the child,
16 you have reservations, does it follow, about that way of
17 doing things?
18 A. In terms of the overall service? Yes, that is what
19 I have expressed, yes.
20 Q. Was one of the effects that it became something more
21 difficult to co-ordinate the activities of
22 anaesthetists, paediatric cardiologists, and those who
23 were conducting the paediatric cardiac surgery?
24 A. I am sorry, I apologise. You asked me if it was more
25 difficult to co-ordinate all their activity when the
0137
1 different directorates were involved?
2 Q. Yes.
3 A. I had never known anything else, so it is quite
4 difficult to answer the question, but I think that the
5 converse is probably true, namely, when it became
6 integrated, it became easier to integrate all the
7 different activities.
8 Q. You describe for us, in July 1992, in a letter
9 JDW 2/315, a document detailing services for patients --
10 can we go to page 317 in this document? These are your
11 handwritten notes, I think?
12 A. That is correct.
13 Q. Suggesting an alteration to the document, or an
14 improvement on the document?
15 A. Well, certain sections have been completely blank, like
16 teaching and research, so I have suggested something,
17 and in addition to the next section.
18 Q. At the end of the section on quality, you say this, in
19 handwriting:
20 "A positive and happy atmosphere is maintained
21 throughout the department and to this end counselling of
22 patients and their relatives before and after surgery is
23 a priority."
24 You are nodding. I have read your words
25 correctly?
0138
1 A. Yes. Despite the handwriting, yes.
2 Q. It is better than most doctors' handwriting.
3 "A positive and happy atmosphere in the department", is
4 that referring to staff?
5 A. It is referring to what we hoped to achieve, and did
6 achieve a great deal at the time. I could not say we
7 achieved it all the time.
8 Q. That is 1992. I wonder if you can help me with
9 UBHT 154/81. It is a letter to Mr Dhasmana, a copy to
10 you, from Mr Bryan. He is writing to Mr Dhasmana as the
11 Clinical Director of Surgery:
12 "I am sorry to keep writing you irritating
13 letters, but after yet another fiasco involving the
14 post-operative management of one of my patients during
15 which, by the morning after the operation, he had
16 accumulated a positive colloid balance of 6 and a half
17 litres. I want to reiterate my view that in line with
18 many other centres in the UK, in view of our increasing
19 clinical workload including complex paediatric
20 operations, a member of the Registrar or Senior
21 Registrar staff should be resident in the hospital and
22 should be the primary person managing intensive care
23 problems."
24 It is from Mr Bryan and he is an adult surgeon, so
25 this is plainly an adult problem, but he puts it in
0139
1 general terms, in terms of the delivery of cardiac
2 services, both adult and paediatric. The complaint
3 appears to be "Who is looking after the post-operative
4 management of my case?"
5 Have I understood it correctly?
6 A. His complaint -- at least, his proposal -- his complaint
7 is that something happened he would have wished had not
8 happened and his proposal is that the Registrar who
9 should be supervising should be resident instead of
10 non-resident.
11 Q. And should be the primary person managing intensive care
12 problems?
13 A. Yes. That would mean -- I think it really means that
14 the register should play a more active role than, in his
15 view, he had been playing.
16 Q. Is he looking for a surgical Registrar or Senior
17 Registrar to be managing the intensive care?
18 A. Yes.
19 Q. It is not quite one case on its own, because his
20 complaint, really, is the repeated nature of it, is it
21 not: "yet another fiasco"?
22 A. That is what he says. I did not have this experience.
23 Q. Was there, in your view, a difficulty between surgeons,
24 intensivists, anaesthetists, as to who actually had care
25 of intensive care?
0140
1 A. No, I do not believe that that is what this letter is
2 about. I am sorry, was your question, is that what Alan
3 Bryan is saying?
4 Q. I am asking you if that arises from this letter?
5 A. No, I do not think so. I think what arises from this
6 letter is a debate as to whether the cardiac surgical
7 Registrar/Senior Registrar should be resident at night
8 and at weekends, and whether he should take a more
9 active minute-to-minute role in the care of the
10 patients.
11 Q. In a report which was produced in 1995 by Messrs Hunter
12 and de Leval, can I ask you to look at GMC 6/54, under
13 the heading of "Current paediatric cardiac services".
14 If you scroll down to the bottom, please, of the page,
15 it deals with post-operative care in the Children's
16 Hospital in the middle of the paragraph. It is the very
17 last sentence and overleaf(GMC 6/55). This is going to be,
18 I think, the last area which I want to explore with you
19 before the overnight break, because I am sure you could
20 do with a longer break.
21 "The overall post-operative management at the
22 Royal Infirmary appears to be highly disorganised with
23 conflicting decisions between the surgical Senior
24 Registrar and the SHO who do rounds at 8.00 am, the
25 anaesthetists who see the patients at 9.00 am and the
0141
1 intensivists who work three days a week."
2 That is two persons' view following various
3 interviews, but was there difficulty in knowing who was
4 actually, at any one time, taking decisions in respect
5 of patients in intensive care?
6 A. I thought that there was not a particular difficulty.
7 The people involved in the intensive care of children
8 following surgery came from a number of disciplines, and
9 of course, in order to provide that care, they had to
10 work together. Sometimes their views would coincide and
11 at other times their initial views would be different,
12 as indeed might the views be between two surgeons, how
13 they stood together and addressed the same issue.
14 So frequently there were discussions, and some of
15 those would have been quite vigorous discussions. Often
16 those discussions were extremely beneficial because they
17 represented a real dialogue and a real exchange of views
18 and a real meeting of minds.
19 Usually an agreed way forward would emerge from
20 that discussion. That was my experience.
21 Occasionally, however, a difficulty might arise if
22 one party instituted a course of action, for whatever
23 reason, without discussing it with the other party and
24 the second party then comes along and may not agree with
25 what has been done. That is the circumstance which
0142
1 I was aware of that occasionally created difficulty, but
2 it was usually resolved if the two people simply talked
3 to each other, talked through the issue, when, as I say,
4 usually an agreed way forward would emerge.
5 Whether there were issues that arose within the
6 context of this timetable set out -- and incidentally,
7 the anaesthetists did their ward round at 10.30 or 11
8 rather than 9 -- when we were mainly in the operating
9 theatre, but whether there were issues that emerged then
10 that the nurses on the ground were more conscious of
11 than I was when I came back at midday or lunchtime or
12 whatever to see how things had progressed, I cannot say,
13 but I was quite surprised when I saw this description.
14 But I think that it is correct to say that there
15 were constructive dialogues which usually resulted in an
16 agreed way forward. There were occasionally hiccups of
17 the type that I have described, and that is how I would
18 have described it had I been asked.
19 Q. Can I, to explore this, establish some facts upon which
20 no-one could disagree: the Surgical Senior Registrar and
21 the SHO would do their rounds at 8 o'clock, before
22 theatre?
23 A. Yes.
24 Q. They would not be present once theatre began, because
25 they would be in theatre?
0143
1 A. There would always be a Senior House Officer who was
2 present 24 hours a day, and there would normally be
3 a Surgical Registrar who is not in theatre and who would
4 be available for discussion. And of course, all the
5 consultants are not in theatre at the same time, so some
6 of those would also be available for discussion.
7 Q. Those who were concerned in particular with the patient,
8 perhaps because they had been the Registrar present with
9 the consultant when the operation was performed, may not
10 always be available, then?
11 A. I am sorry, when?
12 Q. Throughout the day, because they might be --
13 A. Throughout the day they might not be, but they would
14 normally see the patient at 8 o'clock, so if it were my
15 case and my Registrar, just as an example, he would see
16 the case at 8 o'clock; I would normally see the case
17 when I came in and that might be 8, 8.30 or 9, depending
18 on whether I had a meeting, so I would normally pick up
19 anything that they had left for me or endorse what they
20 had done or whatever somewhere between 8 and 9 o'clock.
21 So that would be the situation at 9.
22 Q. At 10.30 or 11, the anaesthetist would do his or her
23 ward round?
24 A. Yes.
25 Q. And that would be in the presence or the absence of any
0144
1 surgical member of staff?
2 A. Well, he would be present on the ward but he might or
3 might not be physically with the anaesthetist doing
4 their ward round; he might well have other things that
5 he felt he had to do.
6 By the same token, the Anaesthetic Registrar was
7 present in intensive care at 8 o'clock when the surgical
8 team were doing their ward round and would be available
9 for discussion with the surgeons, so that the
10 opportunity to liaise was certainly present.
11 Q. But the ward round was not, as it were, a common ward
12 round; it took place at a different time?
13 A. Between the surgeons and the anaesthetists?
14 Q. Yes.
15 A. Unfortunately, that is correct.
16 Q. Was there any formal mechanism for briefing, handover,
17 the swapping of information, along those lines?
18 A. The formal mechanism was that there was a Surgical SHO
19 and Registrar and there was an Anaesthetic Registrar who
20 at any time was either on call or present and available
21 and I would have expected them to discuss any issues
22 that would appear to occur between them, and I would not
23 have expected there to be a continuing unresolved
24 issue. That was their duty.
25 Q. Was it sadly the case that, because that was expectation
0145
1 rather than any formalised structure, on occasions that
2 did not happen?
3 A. I think it is probably correct -- in the light of this,
4 and I think in any case, it must be correct to say that
5 there were occasions when it did not happen, but it had
6 been my understanding that they were relatively rare.
7 This report would seem to suggest that they were
8 more common than I had understood to be the case.
9 Q. Does much depend upon the particular personalities of
10 the Registrars concerned?
11 A. I think it would vary for a number of reasons between
12 the Registrars concerned.
13 Q. And in the absence of any formalised structure, one
14 remains then entirely dependent upon the way in which
15 the one Registrar may or may not talk to the other?
16 A. I would expect any Registrar to talk with his
17 colleague. It is simply, if you like, a matter of
18 observation that the ease and completeness with which
19 this would be done would vary, but I would regard it as
20 their duty to carry that out.
21 Q. What about the intensivists, once they began -- because
22 I appreciate that they were not present during the
23 earlier part of the period with which we are
24 concerned -- how did they relate to, on the one hand,
25 anaesthetists and on the other, surgeons?
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1 A. Well, they were anaesthetists, so they related
2 relatively easily, but not totally with the
3 anaesthetists, because again different people have
4 different views.
5 The intensivists began in 1993 with two sessions
6 a week, that is, two mornings a week devoted to
7 intensive care, so on those mornings they played, if you
8 like, a role in relation to the detailed care of the
9 patients, but that was only on two mornings a week.
10 I would have taken the view that what was more important
11 was the contribution that I would hope they would have
12 made to the leadership in intensive care.
13 MR LANGSTAFF: Mr Wisheart, thank you for your answers thus
14 far. Sir, would this be a convenient moment to break
15 for the evening?
16 THE CHAIRMAN: Yes. Thank you, Mr Wisheart. Thank you,
17 Mr Langstaff. We adjourn now until 9.30 tomorrow
18 morning. So I say good afternoon to everyone, good
19 afternoon, Mr Langstaff.
20 (4.50 pm)
21 (Adjourned until 9.30 am on Tuesday, 20th July 1999)
22
23
24
25
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1 I N D E X
2
3 MR JAMES WISHEART (Sworn)
4
5 Examined by MR LANGSTAFF..................... 2
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Published by the Bristol Royal Infirmary Inquiry, July 2001
© Crown Copyright 2001