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Daily transcripts
Hearing summary
7th October 1999
The Inquiry today heard from Mrs Kay Armstrong, staff nurse and later sister in cardiac
theatres at the Bristol Royal Infirmary (BRI). Mrs Armstrong described the management of
the cardiac theatres and the management style of the surgeons. She commented on her
reaction to being shown Dr Steven Bolsin’s audit work. Mrs Armstrong stated that the
surgeon’s findings during operations sometimes differed from the cardiologist’s
original diagnosis. The hours of work of staff, including surgeons, was discussed and she
commented on the precautions taken to prevent under-performance of nurses. Mrs Armstrong
also drew attention to the issue of the punctuality of the surgeons. Mrs Armstrong
concluded by indicating that some nurses had anxieties about assisting with certain
operative procedures and decided to restrict themselves to certain cases.
Mr William Booth, Clinical Nurse Manager, Paediatric Intensive Care Unit (PICU),
Bristol Children’s Hospital, UBHT, was the next witness to give evidence today. He
discussed recent changes in the management of the Trust and the consequent heightening of
the profile and value placed on nurses. He focussed on the importance of having paediatric
trained nurses looking after babies and children and the added benefit of intensive care
training for staff working in the PICU. He added that it was difficult to recruit nurses
with both qualifications. Mr Booth told the Inquiry that when Mr Ash Pawade, Consultant
Paediatric Cardiothoracic Surgeon, started work at the Bristol Children’s Hospital in
1995, he introduced protocols for open and closed paediatric cardiothoracic surgery. Mr
Booth described the transfer of patients between the BRI and BCH and concluded by
discussing staffing levels in the Bristol PICU, comparing them against national averages.
The week’s hearing concluded with evidence from Professor John Vann-Jones,
Consultant Cardiologist, UBHT. He was Clinical Director for General Medicine from
1989– 1993 and Clinical Director for Cardiac Services from 1993–1996. He
described the evolution of the Cardiac Services Directorate. He explained that the Cardiac
Services Directorate did not include paediatric cardiac surgery. He told the Inquiry that
in November 1993, Dr Steve Bolsin, Consultant Anaesthetist at the BRI, showed him data,
which indicated that mortality rates for four paediatric cardiothoracic procedures were
above the national average. He said that he had been aware that the surgical outcome in
Bristol were average, but countered this by saying that as the surgeons were not solely
dedicated to paediatric work, the outcomes would be expected to be worse than at other
centres. He explained the steps he took to check the validity of the data and outlined the
course of events which led to his writing in April 1994, together with Professor Gianni
Angellini, Professor of Cardiac Surgery, University of Bristol, to Peter Drurie, Chairman,
UBHT, suggesting that a new consultant in paediatric cardiothoracic surgery should be
appointed. He commented on his professional relationship with Dr Roylance, Chief
Executive, UBHT and his management style. Professor Vann-Jones also described his role in
liasing with non-medical and surgical staff during 1994 and 1995 about concerns in
paediatric cardiac surgery and commented on difficulties he observed in communications
within the cardiac surgical department. He concluded by commenting on the difficulties of
providing a unified cardiac service from split sites.
|
FULL TRANSCRIPT
1 Day 59, 7th October 1999
2 (9.30 am)
3 THE CHAIRMAN: Good morning, everyone; good morning
4 Mr Maclean.
5 MR MACLEAN: Good morning, sir. Today's first witness is
6 Kay Armstrong. I should say, sir, Mrs Armstrong is
7 represented by Mr Chambers and those who instruct him
8 sit behind me.
9 Could you stand to take the oath?
10 MRS KAY ARMSTRONG (SWORN)
11 Examined by MR MACLEAN:
12 Q. Your full name is Kay Armstrong?
13 A. Kay Frances Armstrong, that is true.
14 Q. Mrs Armstrong, I am going to have to ask you to speak up
15 a little. The acoustics yesterday in this room proved
16 not to be all they might be, so please keep your voice
17 up. The stenographer to your right is taking down
18 everything that you say, and it is more important that
19 she hears what you say than anybody else, with the
20 possible exception of the Panel!
21 Could I ask you to have a look at the screen in
22 front of you? Could I have WIT 132/1.
23 That, I think, is the first page of the first
24 statement that you made to the Inquiry?
25 A. That is correct.
0001
1 Q. If we go to page 16, that is your signature at the end
2 of that first statement?
3 A. That is correct.
4 Q. There have been a couple of comments on that statement
5 which I hope you have had a chance to see. You may not
6 have seen the second of them. The first one is from
7 Mr Dhasmana, WIT 132/24. There is a second page,
8 page 25. Have you had a chance to see that?
9 A. I have.
10 Q. There is a comment from Mr Wisheart as well. Have you
11 seen that?
12 A. I have.
13 Q. That is at WIT 132/67 and 68. We will come back to
14 those in due course.
15 You have supplied two other statements as well to
16 the Inquiry dealing with different topics. The second
17 is at WIT 132/26. That is the first page, is it not, of
18 your so-called Block 4 statement?
19 A. Yes, it is.
20 Q. That statement concludes at page 53?
21 A. Yes, that is my signature.
22 Q. And the most recent statement that you supplied,
23 I think, in the course of this week, begins at page 54
24 and ends at page 66. So those are your three
25 statements?
0002
1 A. That is right.
2 Q. There is a fourth relevant statement which we ought to
3 deal with in opening, which was your statement to the
4 General Medical Council. That is at GMC 14/22. If we
5 go on, please, to page 24, that is respectively the
6 beginning and end of your statement to the GMC?
7 A. That is right.
8 THE CHAIRMAN: Could we redact the one part of that
9 statement if it is going to come up again, please?
10 I apologise, I missed it. It was complicated by me.
11 What I mean is that statement had your address on and
12 unless you are anxious for it to be on, I would prefer
13 it be taken off for everybody's benefit.
14 MR MACLEAN: I think we need not go back to that page.
15 I think in the end you were not called to give evidence
16 at the GMC orally?
17 A. I was excused giving evidence because my husband was
18 very ill at the time.
19 Q. Let us go back then to the beginning. Your first
20 statement, WIT 132/1, paragraph 2. You became a Staff
21 Nurse in the cardiac theatre at the Bristol Royal
22 Infirmary in 1984?
23 A. Yes.
24 Q. And you were made Sister in 1986?
25 A. Yes.
0003
1 Q. And you are still a Sister, although you also work as
2 a surgical assistant at the Children's Hospital?
3 A. I am still a G grade, yes.
4 Q. Paragraph 9 of that first statement on page 3, at the
5 very foot of the page you say there:
6 "In the following years leading up to 1995 the
7 management structure had changed frequently and often
8 with little warning. The cardiac theatre had six
9 different managers over this period ...", and then you
10 name them?
11 A. Yes.
12 Q. Of those managers, of the people you name, some of them
13 are nurses and some of them are involved in the general
14 management side of the hospital. For example, we have
15 heard already from Lesley Salmon, the manager of the
16 Cardiac Directorate, who was replaced by Rachel Ferris,
17 so they were both managers?
18 A. They were managers.
19 Q. Whereas Julia Thomas, who was succeeded by Fiona Thomas,
20 was a Clinical Nurse Manager?
21 A. That is correct.
22 Q. So when you refer in paragraph 9 to "managers", you are
23 referring both to professional, as it were white collar
24 managers and also to professional nurses?
25 A. I am referring to the people that I was answerable to at
0004
1 that point.
2 Q. So you were answerable both to the Julia Thomas or Fiona
3 Thomas nurse figure, and also to the General Manager of
4 the directorate, or subdirectorate?
5 A. Yes, I was. When Julia Thomas first took over the
6 cardiac unit as Nurse Manager, she actually did not have
7 theatre under her at that point, so for some time, we
8 had Lesley Salmon. First we had Gill Kelly and then
9 Lesley Salmon, then Julia was made responsible for us as
10 well. So in that time I had to answer to all of those
11 people.
12 Q. For what aspects of your job would you be answerable to
13 the Nurse Manager and for what aspect would you be
14 answerable to the General Manager?
15 A. On a daily basis, we would be answerable to the Nurse
16 Manager. If there were any issues which we were not
17 happy with or she was not happy with, that would be
18 dealt with by the General Manager.
19 Q. Before you went to work in Bristol, you had worked in
20 the Frenchay Hospital. You had worked at King's College
21 Hospital in London, and you had also had a spell in
22 Holland?
23 A. That is correct.
24 Q. And also, I think, in Gloucester for a period?
25 A. Yes. I trained in Gloucester.
0005
1 Q. Can we look at page 13, please, of this first statement,
2 paragraph 34? In the 1980s and prior to that, you say:
3 "Consultant medical staff have always behaved and
4 been treated in a manner which would assume superiority
5 over the other health workers. This situation has
6 improved but not totally disappeared."
7 Is that something that you experienced in all the
8 hospitals you have worked in?
9 A. Yes, it was.
10 Q. What do you think has brought about what you
11 characterise as an "improvement"?
12 A. I think possibly -- I do not know. Most of the posts
13 that I originally came into, all the senior consultants
14 there had been there for many years. As younger
15 consultants seemed to come along, they seemed to have
16 a more easygoing approach; there is not so much of the
17 "old school" about them, really. I think that is
18 probably why, eventually, things have become easier to
19 deal with.
20 Q. When you went to the Bristol Royal Infirmary in 1984, of
21 the surgeons that this Inquiry is most concerned with in
22 terms of their work in paediatric cardiac surgery, one
23 of the surgeons had been there as a consultant for
24 getting on for a decade: Mr Wisheart?
25 A. Yes.
0006
1 Q. And the other one was on the point of being appointed
2 consultant when you began in 1984; is that right,
3 Mr Dhasmana? He was appointed shortly afterwards?
4 A. I cannot remember when he was appointed. He was
5 a senior registrar when I started in the unit.
6 Q. To what extent would you characterise each of those,
7 taking them in turn, as being of the "old school" as you
8 put it?
9 A. I would have said that I found it more difficult to
10 approach Mr Wisheart. Mr Dhasmana, I was used to
11 working with as a senior registrar, and therefore the
12 relationship very rarely changes once they become
13 a consultant.
14 Q. You mention your relationship with Mr Wisheart at
15 paragraph 40, page 15. You say an interesting sentence:
16 "We felt quite intimidated by him, although he is
17 very charming."
18 If he was not aggressive or overtly hostile,
19 indeed was charming, why did you feel intimidated by
20 him?
21 A. Because he was a charming person when he introduced
22 himself to you, or that would be the side that parents
23 et cetera would see of him, but he was someone that, if
24 you had a problem and you wished to discuss it with him,
25 he would go into periods of silence, be very
0007
1 disapproving. I myself find that sort of behaviour more
2 intimidating than someone who will confront me.
3 Q. So there would be no overt confrontation?
4 A. Not confrontation, no. I do not have a problem with
5 people who confront you with a problem; it is people
6 that can, as I say, give off a very intimidating air, as
7 if you should not have spoken, and they are not willing
8 to discuss the matter with you.
9 Q. Did you get the impression that you were seen as
10 speaking out of turn to Mr Wisheart?
11 A. Yes, I would.
12 Q. Why was that?
13 A. Because he would seem to disapprove of what was being
14 said to him, but he would not answer you or give you
15 a satisfactory answer; he would be more likely to walk
16 away.
17 Q. Was the disapproval because of what was being said
18 generally, or because of the fact that it was you that
19 was saying it, or both?
20 A. I guess a little of both.
21 Q. Mr Wisheart has responded to that paragraph. It is
22 WIT 132/68: he says simply, if we scan down a little:
23 "I am very disappointed at this comment as
24 I sought to create the opposite impression."
25 What you said at paragraph 40 about feeling
0008
1 intimidated, that obviously was your feeling?
2 A. Yes.
3 Q. To what extent were you aware that that feeling of
4 intimidation was felt by colleagues in similar positions
5 to your own?
6 A. I know that it was, because other members of staff would
7 comment as well, that they did not feel comfortable
8 questioning Mr Wisheart's decisions.
9 Q. How many G grade Sisters were there in the theatre at
10 the BRI?
11 A. Over which period?
12 Q. Over the period the Inquiry is concerned with, from the
13 mid-1980s through to 1995.
14 A. There was Angela Constance, Julie Lowe, Penny Waterson,
15 Penny James, myself, Mona Herborn, Carol Fairweather.
16 There was another girl, Patricia Carolan.
17 Q. And you would have known each other well?
18 A. I knew all of them well because I was there for the
19 whole period of that time.
20 Q. How many of them shared the impression you give at
21 paragraph 40, as far as you are aware?
22 A. Mona Herborn, certainly. Julie Lowe. I have to
23 confess, the other time is going back to 1984, and
24 I cannot remember, really.
25 Q. Do you remember any who took a different view?
0009
1 A. No.
2 Q. If we go back to page 13, where we started,
3 paragraph 34 --
4 THE CHAIRMAN: May I just ask one question of you, before
5 you leave that paragraph, which is whether anyone made
6 Mr Wisheart aware of the fact that others found him
7 intimidating?
8 A. I certainly did not. I do not know if anyone else did.
9 MR MACLEAN: Paragraph 34, the assumption of superiority
10 over other health workers that you refer to: would that
11 apply to medical and surgical staff, for example
12 cardiologists and surgeons?
13 A. I think it applies to any member of the medical
14 profession that was in a senior consultant job at that
15 time.
16 Q. If we go over the page to paragraph 36 on page 14, you
17 say the nature of theatre work makes it essential to
18 work well as a team.
19 It may be obvious, but why is that?
20 A. Because we need good communication skills in theatre.
21 We are all doing different jobs, but aiming towards the
22 same end, which is to get the operation done in a safe
23 manner, so therefore we do need to work well as a team.
24 Q. I think you do set out at some stage who is involved,
25 who was present at an operation.
0010
1 A. Yes.
2 Q. An open-heart operation. Would you briefly talk through
3 who those people are and what their jobs are during the
4 operation?
5 A. There would normally be the senior surgeon who was
6 operating with two assistants. There would be
7 a consultant anaesthetist plus registrar or senior
8 registrar anaesthetist. There would be two
9 perfusionists and then there would be an assistant nurse
10 or ODP to the anaesthetist, an assistant scrub nurse or
11 ODP to the surgeon, and a circulating person.
12 Q. Who would be available to give --
13 A. To give whatever was required to the scrub nurse.
14 Q. Just so that we have the nomenclature right, ODP stands
15 for --
16 A. Operating department practitioner.
17 Q. Through most of this period when you worked at the BRI,
18 these theatres would be doing cardiac operations on both
19 adults and children?
20 A. That is correct.
21 Q. To what extent did the line-up differ if it was
22 a paediatric operation?
23 A. It did not differ at all.
24 Q. To what extent did the job of the nurses involved in the
25 operation change when it was a child as opposed to an
0011
1 adult on the operating table?
2 A. Our job did not differ at all; the only thing would be
3 that we would normally not have relatives in the
4 anaesthetic room if it was an adult being operated on.
5 If it was a child, the parents were always present, but
6 there was usually either Helen Stratton or a ward nurse
7 present with those parents to take care of them.
8 Q. Once inside the operating theatre, as far as the nurses
9 on duty were concerned, it made no difference to the
10 actual job they were doing --
11 A. No.
12 Q. -- how old the patient was?
13 A. No.
14 Q. So there is no question of specific paediatric skills
15 for a theatre nurse in the same way there might be in
16 intensive care, for example?
17 A. No. I do not think there is.
18 Q. You talk in paragraph 36 about poor communication
19 skills, particularly from some of the members of the
20 surgical staff.
21 Two questions: first of all, how did those poor
22 communication skills manifest themselves?
23 A. It was usually in cases where the lists would get
24 altered around during the day and possibly the
25 anaesthetist had been informed but the theatre staff had
0012
1 not, so we would find out right at the very last minute
2 that we were doing the wrong case, or we were doing
3 a different case. So that can mean, for us, a different
4 setup, it could be a woman rather than a man, or
5 whatever, so that would alter our setup. So it is
6 important for us to know exactly which order the
7 patients are coming down in.
8 Q. You attribute these skills secondly to some members of
9 the surgical staff. Which members?
10 A. I am sorry, I do not ...
11 Q. You say there were poor communication skills,
12 particularly from some members of the surgical staff.
13 Which members of the surgical staff?
14 A. Both at consultant level, I think, and at senior
15 registrar level.
16 Q. So this was a general problem among surgical staff --
17 A. It was a general problem.
18 Q. -- so far as the nurses were concerned?
19 A. That is true.
20 Q. You say that it was a regular occurrence to be told at
21 the start of the day you would be cancelling a case
22 because of the lack of intensive care bed, and yet in
23 the event, carry out the operation later in the day.
24 Is that not explained by the point that
25 Mr Dhasmana makes at WIT 132/24? At the bottom of the
0013
1 page, Mr Dhasmana says:
2 "I would like to explain that members of medical
3 and nursing staff in the cardiac unit take postponement
4 and cancellation of operation very seriously and would
5 try their best to avoid it."
6 Was that your impression of the surgeons'
7 approach?
8 A. I think everybody would want to avoid a patient being
9 cancelled, yes.
10 Q. "So as a result, on many occasions, these decisions used
11 to be delayed to the last moment."
12 A. That is true.
13 Q. "Usually the cancellation would occur because of lack of
14 ITU beds and/or shortage of trained nurses in ITU or
15 operating theatres."
16 A. That is true.
17 Q. Your statement at paragraph 30 on page 35 -- this is
18 WIT 132/35 -- your second statement, you say there:
19 "Cases would sometimes have to be cancelled owing
20 to a shortage of ICU beds or alternatively the child not
21 being fit for surgery rather than unavailability of
22 theatre staff."
23 A. I think that is true.
24 Q. So that differs slightly, does it not, from the point
25 that Mr Dhasmana makes?
0014
1 A. I think Mr Dhasmana is using probably two examples that
2 I can think of in several years when we were cancelling
3 on a weekly basis. I do not really consider that to be
4 as relevant as the fact that it was more often due to
5 a lack of an ITU bed.
6 Q. So as far as you recall, the most common reason for
7 last-minute cancellation of an operation was a lack of
8 intensive care bed?
9 A. That is true. The other circumstance I can think of is
10 when the theatre staff would have been in during the
11 night and therefore we are required to have a period of
12 rest before we can come on duty again. In those
13 situations, what usually happened was the cases would be
14 staggered through the day and the second theatre would
15 start once those staff were able to come on duty. That
16 may be what he is referring to there.
17 Q. Let us have a look at your second statement, please, at
18 WIT 132/26, paragraph 3 on page 27.
19 You say in the second line that you first became
20 aware of differences in outcomes between the outcomes of
21 paediatric cardiac surgery at the BRI and other units in
22 1992 when Dr Bolsin showed you some data in respect of
23 the switch and AV canal operations.
24 Why did Dr Bolsin choose you to show the data to
25 you?
0015
1 A. He did not just choose me, he showed it to many people.
2 I am merely answering the question there that that is
3 when I became aware.
4 Q. Who else, to your knowledge, did he share the data with?
5 A. He would regularly share his work in the coffee room in
6 front of whoever may have been sat there at the time,
7 whoever was in theatre at the time. I would think there
8 were very few people working within the theatre
9 environment that had not seen those papers.
10 Q. So generally, the nurses who worked in theatre would
11 have been aware --
12 A. Would have known about his work, yes.
13 Q. What was your impression of what Dr Bolsin expected or
14 wanted you to do with this information he was giving
15 you?
16 A. I do not actually think Dr Bolsin expected us to do
17 anything with the information. I think he himself was
18 already going down that channel himself.
19 Q. Which channel?
20 A. Of actually trying to get something done about our
21 results. So by showing it to us, I do not think he
22 actually was asking us to do anything about it; I think
23 it was just a way of saying "Look at this: this is what
24 is happening. Do you realise this?" It was really
25 looking for approval rather than actually expecting us
0016
1 to do something about it. We were not in a position,
2 I do not feel, that we would have been listened to or
3 that there was anything we could do about it, but he
4 was, and he was doing that.
5 Q. Did he ever ask you to do anything? Did he ever say
6 "Look, Kay, I want you to go to X and say Y"?
7 A. No, he did not.
8 Q. You referred to the channel he was going down in terms
9 of trying to draw his data to the attention of with
10 whoever's attention it ought to be drawn to. Who
11 specifically did you understand Dr Bolsin to be
12 approaching with this data?
13 A. I am afraid I cannot really answer that question,
14 because I do not really know whom he was showing it to
15 at the time.
16 Q. Did you know Dr Black at all?
17 A. I know of Dr Black. I do not know him.
18 Q. Did he ever speak to you about the --
19 A. No, he did not.
20 Q. -- audit he and Dr Bolsin were carrying out?
21 A. He did not work within my department.
22 Q. Did any of the other anaesthetists either separately
23 raise these matters with you or, as far as you were
24 aware, ally themselves with Dr Bolsin?
25 A. The anaesthetists did not speak to me about this matter,
0017
1 the other anaesthetists. I am only aware from, again,
2 listening to conversations in coffee rooms that
3 I believe Dr Ian Davies supported Dr Bolsin. I do not
4 know who else did.
5 Q. And Dr Davies was one of the other anaesthetists?
6 A. Consultant anaesthetists.
7 Q. When you say it was your impression that Dr Bolsin was
8 really looking for approval from you and people like you
9 by giving this data, did you think he needed or wanted
10 approval, and if so, why did he need the approval of
11 theatre sisters?
12 A. "Approval" might be the wrong word to use, but he liked
13 to show his work to people whatever he was doing. It
14 did not have to be involved with these issues. Whatever
15 he was looking at at the time. He liked to show us what
16 he was doing.
17 Q. Was that being a bit of a show-off?
18 A. I guess he was. Yes, he was a bit of a show-off.
19 Q. Did that rub some people up the wrong way?
20 A. Yes.
21 Q. His was an uncommon attitude among the consultants in
22 that he would discuss what he was doing with nurses and
23 with whoever happened to be in the coffee room at the
24 time?
25 A. That is true.
0018
1 Q. Was there any other consultant, the anaesthetist or
2 otherwise, who took a similar approach?
3 A. No. I do not think there was.
4 Q. You refer over the page, at page 28, paragraph 6, to an
5 article which you think was in the BMJ --
6 A. I am not sure of that.
7 Q. -- referring to somebody called Marc de Leval, which
8 Dr Bolsin showed you?
9 A. Yes.
10 Q. Had you ever heard of Marc de Leval when he showed you
11 the article?
12 A. No, I had not.
13 Q. Can we look at PAR(1) 8/136.
14 If we just see the top of the page, the whole
15 page, do you remember, is that the article, "Analysis of
16 a cluster of surgical failures"? Perhaps if we blow up
17 the top paragraph, you will see that Mr de Leval reports
18 one death in the first 52 patients; then a series of
19 deaths; he then visited a low risk institution, and then
20 returned after patient number 68 died?
21 A. That was the content of the paper I looked at. I would
22 not recognise that that is definitely the same paper,
23 but certainly those were the facts that I was aware of.
24 That is the same story.
25 Q. If we go to WIT 132/30, paragraph 15, you say there that
0019
1 you now realise from your current experience that
2 children were being referred late for the switch
3 operation at 3 to 6 months rather than 2 to 4 weeks; the
4 same is true for many of the procedures coming out.
5 You now work with Mr Pawade at the Children's
6 Hospital?
7 A. That is correct.
8 Q. What is the typical age of switch patients for
9 Mr Pawade?
10 A. I would say approximately 10 days.
11 Q. Why should it have been, do you think, that patients
12 were referred late for switch operations? Was it
13 because, for example, that was the done thing at the
14 time, or is it your impression that patients were
15 referred later at Bristol than they were elsewhere?
16 A. I am not aware of at what point they would be referred
17 elsewhere and I can only assume that that was the time
18 that cardiologists thought it appropriate to refer them
19 to us at the BRI.
20 Q. The referral to the BRI would generally be from one or
21 other of the paediatric cardiologists at the Children's
22 Hospital; is that right?
23 A. Yes.
24 Q. They in turn might have referrals, if a baby was born in
25 the Maternity Hospital, from there, or was born
0020
1 elsewhere, from a centre more remote from Bristol?
2 A. That is true.
3 Q. So are you able to form a view as to where the delay in
4 the system was, whether it was with the cardiologists in
5 the Children's Hospital or whether it was further back
6 in the chain?
7 A. No, I am not, because as I said, at the time, I was not
8 aware that we would normally have been operating on them
9 earlier.
10 Q. How well did you know the paediatric cardiologists?
11 A. I did not really know them at all.
12 Q. Before you moved to the Children's Hospital, how many of
13 them had you worked with?
14 A. I had met Alison Hayes.
15 Q. In what circumstances?
16 A. She would occasionally come down when we had done
17 a repair, such as a VSD repair, and do an echo to check
18 the repair for the surgeon.
19 Q. At whose behest would she come to do that?
20 A. The surgeon's.
21 Q. And did both surgeons sometimes ask her to do so?
22 A. Yes, they did.
23 Q. What about the other paediatric cardiologists:
24 Dr Jordan, who retired, I think, in 1993; Dr Joffe;
25 Dr Martin?
0021
1 A. I had never met them before I went to the Children's
2 Hospital. However, occasionally Dr Peter Wilde, who is
3 one of the adult -- I do not think he is a cardiologist,
4 he is a radiologist -- he would come and do the echos
5 for us.
6 Q. You still do essentially the same job at the Children's
7 Hospital as you did at the BRI?
8 A. Yes.
9 Q. Do you see the cardiologists more often now? I do not
10 mean meet them in the coffee room: do you actually work
11 with them more often than you did at the BRI?
12 A. They still come to theatre to do the echos. I actually
13 have access now to the cardiology meeting, if I wish to
14 go on a Tuesday, which I did not previously, so I would
15 meet them there, but apart from that, only on the
16 occasions which they may be required to come to theatre
17 again to check a repair.
18 The other thing, we put in many more pacing boxes,
19 things in theatre now.
20 Q. What is discussed at the cardiology meetings on the
21 Tuesday that you got access to?
22 A. They discuss the forthcoming cases, so it gives an idea
23 to either the theatre staff or the perfusionist what
24 will be taking place in the next two or three weeks.
25 Q. Some of the same cardiologists are still working today
0022
1 as were working previously when surgery was carried out
2 at the BRI. Dr Joffe, I think, has fairly recently
3 retired?
4 A. Yes.
5 Q. And yet Mr Pawade's operations, for example, on the
6 switch, you have told us now take place at about 10 days
7 or thereabouts?
8 A. That is true.
9 Q. How has it come about that the referrals have now got to
10 the stage where the operations can take place so much
11 earlier?
12 A. I do not know. You would have to ask a cardiologist
13 that.
14 Q. But it is the same cardiologists?
15 A. Yes, it is.
16 Q. Tell me if you do not know the answer to this: to what
17 extent does the surgeon have the ability to influence
18 the time when the operation ought to take place for
19 a particular condition?
20 A. I am sorry, I do not really know.
21 Q. At paragraph 17, the bottom of the page there, you say
22 you were made aware in approximately 1992 of the fact
23 that they should be operating sooner, by a Registrar who
24 had experience in other centres.
25 Do you remember who this person was?
0023
1 A. Yes. I have remembered now. His name was Kevin
2 Waterson.
3 Q. And where did he work? Which other centres?
4 A. He had worked in Melbourne with someone called Roger
5 Mee, I think his name was, who was the same person
6 Mr Pawade worked with.
7 Q. And Mr Waterson was a Surgical Registrar?
8 A. Yes. In fact he had an overseas post. I do not know
9 what his exact title was.
10 Q. Did he only make you aware of this fact, or was it
11 something that he, rather like Dr Bolsin, was telling
12 you?
13 A. He was very outspoken, like Dr Bolsin. He would talk to
14 us in the coffee rooms.
15 Q. So again, his view that the operation was taking place
16 too late: the general run of staff in the BRI Cardiac
17 Unit would have known that was Mr Waterson's view, would
18 they not?
19 A. That is true.
20 Q. Do you know if he ever broached this view to the
21 surgeons?
22 A. No, I do not.
23 Q. Did you ever say to perhaps one of the consultant
24 anaesthetists at the end of an operation, "I hear we are
25 doing these operations much later than they do in some
0024
1 other centres"?
2 A. No, I did not.
3 Q. At page 37, paragraph 37 in the middle of the page, when
4 answering the question which I think is E11(c) in our
5 Issues List about complications that might be
6 encountered by the surgeon, you say that the paediatric
7 cardiac surgery team would know what operation was going
8 to be performed but when a child arrived in theatre, the
9 surgeon would quite frequently find an abnormality
10 present in the heart that had not been identified
11 previously in the cath' lab?
12 A. That is true.
13 Q. How frequent an occurrence was that?
14 A. It was quite frequent. I would not like to say
15 numbers. It would happen -- it happens on quite
16 a regular basis. It still does.
17 Q. Did the surgeons ever express surprise or annoyance --
18 A. They get very annoyed.
19 Q. Why? It may be obvious, but why?
20 A. Because, for example in the example I have given there,
21 it would change their technique for having to put that
22 child on to the bypass machine. If they had known about
23 there being an extra superior vena cava present, they
24 would be prepared for a totally different set up. So,
25 yes, they can change it, but it is just something that
0025
1 is annoying for them.
2 Q. How did the annoyance manifest itself? Did the surgeon
3 look at the patient and curse and swear, or --
4 A. Usually.
5 Q. Obviously they had to react to the situation as they
6 found it and get on with it and try to effect a repair?
7 A. Yes.
8 Q. Was the cardiologist ever called into the theatre during
9 the operation or subsequently on these occasions?
10 A. Sometimes they are called if we find something like an
11 extra ventricular septal defect present or something
12 like that which we were not expecting. They may well be
13 called to just check there is nothing else. So, yes,
14 they do occasionally get called to theatre.
15 Q. Was it your impression that when these unexpected
16 problems were discovered on the operating table for the
17 first time, that generally speaking the surgeons thought
18 these problems ought to be picked up sooner, or did they
19 accept that it was one of those things that can easily
20 have been missed?
21 A. No. Mostly they felt that it should have been picked
22 up.
23 Q. By ...
24 A. By the cardiologists.
25 Q. During either ...
0026
1 A. During their catheterisation, or echos, yes.
2 Q. If we go to -- it sits with this, perhaps -- page 38,
3 paragraph 39:
4 "All patients undergoing paediatric cardiac
5 surgery underwent cardiac catheterisation to assist
6 diagnosis."
7 That would be carried out during the split site
8 days at the Children's Hospital?
9 A. Yes.
10 Q. After 1987, I think when the new cath' lab opened?
11 A. I do not know where they were carried out. I have never
12 worked in the Cardiology Department.
13 Q. That whole paragraph, I take it, is dealing with
14 paediatric cardiac surgery, is it?
15 A. Yes -- I am sorry?
16 Q. The whole paragraph is dealing with paediatric cardiac
17 surgery?
18 A. Yes.
19 Q. At paragraph 54, page 42, you refer to the perfusionist,
20 Mr Caddy, who was replaced subsequently by Mr Downes
21 when Mr Caddy retired. You say that after Mr Downes'
22 appointment, the theatre staff and perfusionists worked
23 much better together as a team, which I assume you
24 considered to be a good thing?
25 A. That is correct.
0027
1 Q. What was the problem with Mr Caddy, then?
2 A. I do not think it was a problem with Mr Caddy; it was
3 purely that he and Richard had different ways of running
4 their department.
5 Q. In what ways were they different?
6 A. Mr Caddy would not ask for my advice on anything. There
7 was no reason why he should do. I know nothing about
8 perfusion. But Mr Downes will often come to me and we
9 will discuss cases together, so it just makes for
10 a better working relationship when you are in the same
11 environment all the time.
12 Q. So is it just that Mr Downes is a bit more sociable than
13 Mr Caddy was?
14 A. Well, sociable, but, yes, he is just more -- I just feel
15 I know what is going on more with the Perfusion
16 Department at the moment, whereas I did not before. But
17 that is not criticising Mr Caddy; it is just easier for
18 me.
19 Q. Let us look at paragraph 56, down the same page:
20 "Regarding the hours of work, these were and are
21 excessive ..."
22 Pausing there, is that a comment that you would
23 apply to the theatre nurses, first of all?
24 A. Yes, and to other members of staff working in the
25 theatre.
0028
1 Q. Then you say:
2 "I do not think that people under performed at
3 work because of the hours they were working."
4 If I was overtired or overstressed and unable to
5 cope, all of which are common ailments for me, I would
6 be under-performing at work.
7 Would one not expect under-performance if people
8 were working, regularly, hours that were excessive?
9 A. I think when you are regularly working long hours, yes,
10 you get tired, but in the job that we do, I do not think
11 you can be allowed to make mistakes. Therefore part of
12 my job is to monitor the theatre staff, that they are
13 not making mistakes and that they are performing well in
14 the case. If they are not, then I should pull them out.
15 Q. So it is not that working long hours does not lead to
16 under-performance; it is that there is a safety net to
17 prevent under-performance. Is that the point?
18 A. That is right. That is the point.
19 Q. How does that safety net operate?
20 A. There would always be someone like myself as a senior
21 member there, who is watching what is going on during
22 the case, monitoring people's performances.
23 Q. You would be monitoring whose performance? The nurses'
24 performance?
25 A. The nurses' performance, nobody else's.
0029
1 Q. You would not be monitoring the anaesthetists, the
2 perfusionists or the surgeons?
3 A. No, I would not have time to do that.
4 Q. I am not suggesting you should be, but you would not
5 be.
6 A. No.
7 Q. When I asked you whether this comment about
8 excessive hours of work applied to the nurses, you said
9 yes, it did, and to all the other staff in the operating
10 theatre?
11 A. If the nursing staff are there working, then, yes, it
12 stands to reason that the rest of the departments are
13 there as well, the perfusionists, the anaesthetists and
14 the surgical team.
15 Q. It may be implicit in what you have already said, but
16 there was no safety net in the theatre in place for the
17 anaesthetists or the surgeons in the same way that there
18 was for the nurses; is that right?
19 A. Well, the perfusionists have their own boss. Regarding
20 the medical staff, I do not know.
21 Q. What was your impression of the hours of work undertaken
22 by the paediatric cardiac surgeons that you worked with
23 at the BRI?
24 A. I think they were excessive.
25 Q. What is your evidence for that?
0030
1 A. They were regularly still in the hospital 10 o'clock,
2 12 o'clock at night.
3 Q. What time did they start in the morning?
4 A. 8 o'clock.
5 Q. Did that apply to Mr Wisheart?
6 A. Yes.
7 Q. Mr Dhasmana?
8 A. Mr Dhasmana worked very long hours as well, but I do not
9 think quite -- he was not late in the department quite
10 as much as Mr Wisheart was.
11 Q. Why was it, as far as you are aware, that Mr Wisheart
12 was there particularly lengthy hours?
13 A. I believe he did very lengthy ward rounds, or ITU
14 rounds, but I heard that from the ITU nurses.
15 Q. He was particularly thorough, was he?
16 A. Yes, that is another way of putting it.
17 Q. Another way of putting it might be that he was slow?
18 A. I cannot comment on that. I was not there.
19 Q. Did you ever have the impression that excessive work was
20 taking its toll on the surgeons?
21 A. I think occasionally, particularly with Mr Dhasmana,
22 I would know when he was tired because his temper would
23 deteriorate.
24 Q. I recognise that phenomenon!
25 A. But Mr Wisheart would often catnap in the coffee room
0031
1 between cases. He would often just have a small sleep
2 then, which I presume meant he was tired.
3 MR MACLEAN: Sir, I have dealt with the first two statements
4 from Mrs Armstrong. I have not yet dealt with the
5 third. I do not think I will be more than half an hour,
6 but it may be wise to have a break. The reason for that
7 is that whilst I have been on my feet I have been handed
8 a response by Mr Wisheart to the third statement of
9 Mrs Armstrong. No criticism of Mr Wisheart that it is
10 delivered at this stage because the statement itself is
11 only dated 6th October, yesterday. I do not suppose
12 Mrs Armstrong has had a chance to see these responses.
13 A. I have seen it.
14 Q. I am told you have not; it is a second set of responses
15 from Mr Wisheart. It may be wise for everyone else,
16 apart from Mrs Armstrong and I, to have a cup of tea and
17 for us to look at these comments from Mr Wisheart.
18 THE CHAIRMAN: For all of those reasons, we will take 15
19 minutes and reconvene at 10.45.
20 (10.30 am)
21 (A short break)
22 (10.45 am)
23 MR MACLEAN: Mrs Armstrong, we have dealt I think with your
24 first and second statements. I want to turn now,
25 please, to the third. That is WIT 132/54. It is your
0032
1 statement specifically concerned with Issue N in the
2 Inquiry's Issues List.
3 Can I take you to paragraph 8, page 56? You say
4 there that Dr Bolsin was concerned that too many
5 children had died and that was related to the length of
6 time the surgery was taking, the time on bypass and the
7 difficulties that caused with getting the child off
8 bypass?
9 A. Yes.
10 Q. In your second statement at page 43, paragraph 58, you
11 say that you were not aware of how Bristol compared
12 regarding the length of surgery with other units?
13 A. No. I was not. I was not aware whether other units
14 were taking the same length of time. What Dr Bolsin
15 said to me was that we were taking -- the cases were
16 taking too long and this was why the children were
17 dying, but I still did not know what the results were
18 like in other centres.
19 Q. But implicit in a suggestion that Bristol was taking too
20 long would be a suggestion that other places would do
21 them rather quicker, would it not?
22 A. Well -- yes, I guess you are right.
23 Q. You yourself did not have any knowledge of the length of
24 time that operations took elsewhere?
25 A. No. Only what Mr Waterston had told me regarding Mr Mee
0033
1 in Australia, that he was much quicker a surgeon, but
2 that was one surgeon being given as an example.
3 Q. You have been working for, what is it now, 4 and a bit
4 years with Mr Pawade, who I think started in May 1995?
5 A. I started in January 1996.
6 Q. You were off, I think, for a period in 1995 on maternity
7 leave?
8 A. That is correct.
9 Q. So you have been working with Mr Pawade for getting on
10 for four years now; is that right?
11 A. That is correct.
12 Q. Have you noticed any difference in the length of time
13 either of the operation as a whole or the time on bypass
14 since he has been surgeon?
15 A. Yes. He is much quicker.
16 Q. Does that shorter time on bypass make it easier, as far
17 as you are aware, to get the child off bypass?
18 A. It does seem to.
19 Q. Do you know why that is?
20 A. I am not really clinically trained to comment on that.
21 Q. We have mentioned the Surgical Registrar who had worked
22 in Melbourne, and we have mentioned Dr Bolsin's concerns
23 as expressed to you, showing you the data, and so on.
24 What other sources of information did you have
25 about alleged poor outcomes at Bristol other than
0034
1 Dr Bolsin and the people we have already discussed?
2 A. I do not think I did, at that time.
3 Q. Can I just show you page 62, please, paragraph 29? This
4 is your third statement. You mention there Helen
5 Stratton.
6 A. Yes, I do.
7 Q. She left the BRI before the children's surgery was
8 transferred to the Children's Hospital?
9 A. Yes, she did.
10 Q. Are you able to date these expressions or comments of
11 Helen Stratton to you?
12 A. No, I am not, because what she would say to us was done
13 when she was coming down to enquire for the parents how
14 an operation was going, and obviously when I said that
15 she expressed concern, what I was meaning there was that
16 it is obviously very distressful if the operation is not
17 going well. I do not recall her expressing any concern
18 regarding the surgeons themselves.
19 Q. So what was the specific nature of her comment?
20 A. A human response, that it is very sad to know that
21 something is not going as well as you would want it to.
22 That is very distressing.
23 Q. In your third statement at paragraph 10, page 57, you
24 say that between 1992 and 1994, Dr Bolsin's concerns
25 were "gathering momentum", as you put it.
0035
1 What do you mean by that? Do you mean he was
2 gathering more support to his cause, or that he was
3 expressing his concerns more loudly, or what?
4 A. We all felt that he did seem to be getting somewhere
5 with his efforts to stop us operating on children, which
6 was what his end aim was, I know that, because he did
7 tell me that.
8 Q. What was the evidence for that, that he was "getting
9 somewhere"?
10 A. He seemed to be meeting with various people and it
11 seemed to be under discussion, which it had not been
12 previously, and he did not seem to be willing to let
13 that drop, so we all felt that he was doing his best to
14 do something about it.
15 Q. Do you know who he was talking to, discussing it with?
16 A. I certainly know he discussed it with Professor
17 Angelini, who supported him. I believe he had spoken to
18 Dr Roylance. Several people he told me he had sent
19 letters to, but I am afraid I do not remember names
20 because I do not come into daily contact with these
21 people, so I do not remember their names.
22 Q. Professor Vann Jones?
23 A. I believe he did send a letter to Professor Vann Jones,
24 yes. But I may remember that from the inquest, I am
25 sorry.
0036
1 Q. You mean the GMC Inquiry?
2 A. Yes.
3 Q. You say in paragraph 10 that you dreaded seeing complex
4 paediatric cardiac surgery scheduled when you were due
5 to be the scrub nurse?
6 A. That is true.
7 Q. When did that feeling of dread set in?
8 A. I think it was for particular cases such as the switch
9 and cases like AV canals, which did appear to be the
10 ones that did not do very well in theatre. It was very
11 hard to have to scrub for those cases when you realised
12 that it may well end with the child dying at the end of
13 the case.
14 Q. In your statement to the GMC, which we need not go back
15 to, can I just read to you a sentence from it? You said
16 you had been concerned from around 1991 about the high
17 mortality and morbidity for switch operations carried
18 out on children in the Cardiac Unit at the BRI --
19 A. I am not sure that date is correct, actually. That was
20 the date that was given to me by the gentleman that was
21 taking my statement.
22 Q. I see. Taking your statement for the GMC?
23 A. Yes.
24 Q. As opposed to the statements for this Inquiry?
25 A. That is right, which I think I have explained, that
0037
1 I believe it was around 1992, but I am not absolutely
2 sure.
3 Q. So your best recollection is, notwithstanding what is in
4 the GMC statement which was suggested to you by somebody
5 else, that the beginning of your concerns was 1992,
6 which is when Dr Bolsin showed you his data; is that
7 right?
8 A. That is correct.
9 Q. Before Dr Bolsin showed you his data, did you have any
10 concerns of your own, gnawing away at the back of your
11 mind?
12 A. I did not realise at that time that the children could
13 possibly have done better in another centre. We always
14 have concerns. If a child does not do well, it is
15 a very distressing situation to be in, so, again, your
16 concern is a very human response to a child's death, but
17 that was what my job was at the time and that is what
18 I had to do, to scrub for those cases.
19 Q. You say again in that GMC statement that nursing staff
20 talked frequently amongst themselves about the concerns
21 they had. You touched on that earlier.
22 A. Regarding the children dying, yes.
23 Q. Would that nursing staff embrace theatre and intensive
24 care nursing staff?
25 A. We did not have a great deal of contact with the
0038
1 intensive care girls, really. We would take patients up
2 at the end of the case, hand over, but the nurses
3 themselves were then obviously very busy receiving that
4 patient into their care, so we would then have to go
5 back to theatre to prepare for either the next case or
6 to put the theatre ready for the next day.
7 So I did not have the opportunity to talk to the
8 intensive care nurses about this.
9 Q. So you do not remember discussing the concerns that you
10 had with Julia Thomas, for example, or her successor,
11 Fiona Thomas?
12 A. No, I am sure I never discussed it with Julia Thomas.
13 Q. Let us look further down this page, at the bottom of the
14 screen, paragraph 12. You say in the middle of that
15 paragraph that in the middle of 1994, you and other
16 theatre nurse colleagues stopped scrubbing for complex
17 paediatric cardiac surgery cases?
18 A. We took that choice ourselves; that we did not wish to
19 scrub for the complex cases any more.
20 Q. And with two exceptions: Alison Reed and Onyx Berwin?
21 A. Brewin. That is spelt wrong; her name is Brewin.
22 Q. What was the reaction of first of all the surgeons and
23 secondly the management of the hospital when 7 out of 9
24 members of staff said they were not doing it any more?
25 A. I think what I put in my statement is that we stopped
0039
1 scrubbing. We did not actually approach the surgeons or
2 take a stand against the surgeons and tell them we were
3 not willing to scrub. Those two people were willing to
4 do those cases, so it did not affect the throughput of
5 the children at that time.
6 Q. So the operations carried on as before?
7 A. They carried on and the surgeons and the management were
8 not aware of the fact of who was scrubbing for the
9 cases.
10 Q. So this was a kind of unnoticed protest, almost, in that
11 because there were two who were still willing to do the
12 job, life carried on as before as far as the surgeons
13 were concerned?
14 A. I cannot speak for the other girls who were not
15 scrubbing for the cases. I can only say for myself that
16 I could no longer bring myself to go and scrub for those
17 cases.
18 Q. Did you make this, if I use the word "protest",
19 "stand", if you like, known to the Nurse Adviser to the
20 Trust, or any of the more senior nurses in the Trust?
21 A. No.
22 Q. Margaret Maisey, I think, was ultimately the Nurse
23 Adviser to the Trust, was she not, and later the
24 Director of Nursing?
25 A. Was she?
0040
1 Q. Did you know that?
2 A. I know Margaret Maisey. I cannot recall what her titles
3 were. My only involvement with her was during the
4 grading, which was several years before.
5 Q. That was before the days of the Trust, in the late
6 1980s. I think she was Director of Operations and later
7 Director of Nursing. While she was Director of
8 Operations, I think I am right in saying she retained
9 a post as Nurse Adviser to the Trust.
10 A. Did she?
11 Q. Leaving her aside, you did not bring this stand that you
12 and your colleagues were taking to the attention of
13 anyone else in the managerial side of nursing in the
14 Trust?
15 A. No. I still say, I do not believe we were taking
16 a stand, because we did not do that. What we were doing
17 was saying that "We do not find it tolerable to scrub
18 for these cases", so any nurse in the department who
19 would tell me that she did not wish to scrub, then
20 I would certainly not make her scrub for one of those
21 cases.
22 Q. But why did not you bring it to the attention of some of
23 the management? After all, if all 9 members of staff
24 took the same view, then the system would have ground to
25 a halt, would it not?
0041
1 A. Because the other two members of staff were not willing
2 to do that. They were content to carry on scrubbing for
3 these cases.
4 Q. Happy or content?
5 A. I do not know. I cannot speak for them, really. They
6 did not want to stop doing them.
7 Q. Was this a state of affairs that had ever happened in
8 respect of any other operations, any other surgery you
9 had ever been involved with in your career, that scrub
10 nurses took it upon themselves no longer to scrub for
11 certain operations?
12 A. Not for operations. There are some scrub nurses that
13 perhaps would not want to scrub for certain surgeons,
14 but that is usually a personality clash and can be
15 avoided.
16 Q. You say in this paragraph, in the sentence we have been
17 looking at, that you and other theatre nurse colleagues
18 stopped scrubbing for complex paediatric cardiac cases.
19 A. That is correct.
20 Q. Did you still scrub for non-complex cases?
21 A. Some of the girls did, yes.
22 Q. Did you?
23 A. I was actually working as a surgeon's assistant at that
24 time, plus anaesthetic sister, so I was not really in
25 a position to have done it then.
0042
1 Q. How would you have decided whether a case was complex or
2 not complex?
3 A. This is just my opinion: my opinion of a non-complex
4 case is either an ASD or possibly some VSDs. Most other
5 congenital heart surgery is complex.
6 Q. You say at the end of that paragraph -- just bear with
7 me a second. I asked you whether you still scrubbed for
8 non-complex cases and you said some of the girls did?
9 A. That is true.
10 Q. I asked if you did, and you said you were working as
11 a surgeon's assistant at the time, as well as being the
12 anaesthetic sister. You said "So I was not really in
13 a position to have done it then". You mean --
14 A. I have probably not worded that very well. What I mean
15 is that the majority of my workload at that point would
16 have been in the anaesthetic room and working as
17 a surgeon's assistant. On my surgeon's assistant days
18 I would always be in with an adult because it was to
19 take veins out. Unless they were short of a scrub
20 nurse, at the time, being an anaesthetic sister, I would
21 be in the anaesthetic room.
22 Q. So your work had just taken you out of the potential
23 loop generally for being a scrub nurse?
24 A. I was still capable of scrubbing for the cases should
25 they be short of a scrub nurse, but at that point in
0043
1 time, it was not my usual routine.
2 Q. And you were not anxious to do so?
3 A. No.
4 Q. Can we go back to paragraph 12? Towards the bottom of
5 the paragraph you say:
6 "At some point during 1994, both Mr Wisheart and
7 Mr Dhasmana had been stopped from performing complex
8 heart surgery."
9 A. That is true.
10 Q. Who did you understand had stopped them?
11 A. We understood they had been stopped by the Department of
12 Health. I have seen Mr Wisheart's comment now.
13 Q. From where did you get that impression?
14 A. From Dr Bolsin.
15 Q. Let us look at what Mr Wisheart says. It is
16 WIT 132/69. You have seen this over the break, I think?
17 A. I have.
18 Q. This is the first page of three: Mr Wisheart's comments
19 on your third statement.
20 If we go to the next page, page 70, let us look at
21 the second comment on that page first, paragraph 3:
22 "Mrs Armstrong is mistaken in saying that such
23 a decision was made", in other words, a decision to stop
24 him and Mr Dhasmana performing complex heart surgery.
25 "The surgeons were not stopped from operating on
0044
1 complex neonatal cases in 1994, or stopped from
2 operating on any other type of case. In October 1993,
3 Mr Dhasmana himself stopped doing neonatal switch
4 operations. I did no correction of complete
5 atrioventricular septal defects after August 1994."
6 So the suggestion there is that the surgeons
7 themselves decided to desist respectively from neonatal
8 switches and complete AVSDs, rather than being stopped
9 from on high.
10 A. That was not the information I was given, but I wish
11 Mr Dhasmana and Mr Wisheart had informed us as the
12 theatre sisters of that decision themselves.
13 Q. So just to be clear, your impression was that the
14 Department of Health had stopped these two surgeons
15 operating on, what, all complex --
16 A. On complex cases.
17 Q. Paediatric cardiac cases?
18 A. Yes.
19 Q. Not just neonates?
20 A. I did not believe it to be neonates. We believed it was
21 to be all complex surgery, and certainly, the caseload
22 of complex surgery decreased dramatically after that.
23 Q. And you got that impression directly from Dr Bolsin?
24 A. Yes.
25 Q. From anyone else?
0045
1 A. I honestly cannot remember.
2 Q. When did you first become aware of the fact that the
3 children's surgery was going to move up the hill to the
4 Children's Hospital?
5 A. The first time I was made aware of it, I think was when
6 Dr Martin Elliott came down from London to look around
7 our facilities regarding taking up a professorial chair,
8 and the idea then was that he would be based at the
9 Children's Hospital, not at the BRI.
10 Q. Mr Wisheart says at the top of that page that at the
11 time, in 1994, when you said you and some of your
12 colleagues were refusing to scrub for the complex
13 paediatric cases, the decisions to appoint a new
14 surgeon, Mr Pawade as it comes out, and to move the work
15 to the Children's Hospital were being taken?
16 A. That is correct.
17 Q. You knew that?
18 A. I knew that. I think I have commented on that in my
19 statement, that we always thought this: that there was
20 a new surgeon being appointed and the work was being
21 moved to the Children's Hospital, but staff started to
22 get despondent when this all took such a long time.
23 Q. When I was touching on who you could have spoken to in
24 the nurse management side of the Trust about the
25 concerns which you had and the information you had been
0046
1 given by Dr Bolsin, I should perhaps have taken you back
2 to your first statement, page 12, paragraph 32.
3 You say at the end of that paragraph:
4 "The majority of staff", and I think that is
5 a reference to nursing staff, is it?
6 A. Yes.
7 Q. " -- were unwilling to make formal complaints because of
8 concern about job security. In this situation, all that
9 could be done was to accommodate that complaint and act
10 upon it as far as possible."
11 Where would the threat to job security come from
12 for a nurse making a complaint about clinical outcomes?
13 A. I think the problem is that nurses probably undervalue
14 themselves and you always feel that you will maybe not
15 be listened to should you make a complaint about
16 something, so it very rarely gets any further than
17 possibly the Sister or your first line manager level.
18 I think there is always the fear, as well as, that you
19 could end up being suspended or --
20 Q. Was anyone ever suspended for raising concern, so far as
21 you are aware?
22 A. No, I do not think so.
23 Q. So what was the basis for this concern that a nurse
24 might lose his or her job?
25 A. I think it is based on the fact that nurses have always
0047
1 felt in awe of the senior management and hospital
2 consultants. That is changing slowly now, but that has
3 been the case for many years.
4 Q. Was there a feeling that nurses concerned would not be
5 taken seriously by management?
6 A. Yes.
7 Q. And what was done in order, if anything, to encourage
8 nurses that that impression was false?
9 A. I think I can only talk from my own point of view.
10 I would certainly encourage anybody that wished to make
11 a statement or a complaint about anything to go to
12 a higher authority if necessary, but I do not feel that
13 I was in a position to force them to do so if they did
14 not feel they wanted to do that.
15 Q. Just going back to this business of stopping the
16 surgeons doing surgery, if Dr Bolsin had said to you
17 something like "The Department of Health have stopped
18 Mr Wisheart and Mr Dhasmana from doing complex
19 paediatric surgery", if that had been the case, there
20 would have been no more complex surgery at all, because
21 they were the only two paediatric cardiac surgeons?
22 A. That is true.
23 Q. But there was, throughout 1994, some complex paediatric
24 surgery being carried out?
25 A. Towards the end of the year, was there?
0048
1 Q. Was there, or was it your impression?
2 A. My impression was that the majority of my work -- my
3 memory may be failing me here, but I remember it that we
4 were doing quite a view VSDs and ASDs and we did some
5 total caval pulmonary connections which our results were
6 very good for, but I do not remember doing any AV canals
7 or -- I cannot remember doing any, actually. We may
8 have done, but I do not remember doing them.
9 Q. Because you were one of the seven or so who was not
10 scrubbing for complex paediatric cases?
11 A. That is true, but I was working in the department.
12 Q. If what Dr Bolsin said had been right, there would have
13 been no need for the seven or so nurses to refuse to
14 scrub for complex paediatric cases, because there would
15 have been none at all?
16 A. That decision came before the decision to stop us doing
17 complex surgery.
18 Q. So does that help us to date the information that the
19 Department of Health had, as you understood it, stopped
20 Mr Wisheart and Mr Dhasmana? Would that have been about
21 June or July of 1994?
22 A. I would be guessing. I really do not know.
23 Q. The decision which you and your colleagues took to stop
24 scrubbing for complex paediatric work you said was 1994?
25 A. I think it was -- yes, it was some time before that
0049
1 decision was made to do no more complex surgery.
2 Q. The operation on Joshua Loveday, which we are going to
3 come to, took place in January 1995?
4 A. That is true.
5 Q. So is this right: that the information you were given
6 about the Department of Health having stopped
7 Mr Wisheart and Mr Dhasmana from doing these operations
8 was some time between the decision to stop scrubbing and
9 the Loveday operation?
10 A. Yes, it was.
11 Q. Do you think you might be able, by looking back at
12 records, to more precisely date the decision to stop
13 scrubbing for the complex cases, if you were given some
14 more time to think about it?
15 A. I think the only way of finding that out would be to go
16 through the registers for that year and the names of the
17 scrub nurses will be beside the cases.
18 Q. So when we start seeing Reed and Brewin for the complex
19 paediatric cases, we will know that --
20 A. That was around the time. If it is their names that are
21 coming up consistently for those cases, then that would
22 be about the time, yes.
23 Q. Let us go to page 58 of your evidence. This is your
24 third statement. Paragraph 14. We turn now to the
25 Joshua Loveday operation.
0050
1 You at this time were training to be a surgeon's
2 assistant, which was an extended role from your usual
3 grade. Mona Herborn was another Sister in the
4 department. She came to see you a few weeks before the
5 operation was due to take place, confirming that the
6 operation was listed. You say, paraphrasing the
7 paragraph, that you spoke to Dr Bolsin, who seemed
8 surprised that the case was on the list?
9 A. That is correct.
10 Q. Was it your impression that Dr Bolsin knew nothing about
11 this planned operation until you had told him?
12 A. Yes, it was.
13 Q. What did he do? How did he react?
14 A. At the time he seemed to think that it would not be
15 a problem and that the child would definitely be
16 cancelled.
17 Q. If it was right that Mr Wisheart and Mr Dhasmana had
18 been stopped from carrying out complex paediatric
19 surgery already, then the operation should never have
20 been listed?
21 A. That is correct. That is why we were complaining.
22 Q. So Dr Bolsin might have realised at this stage that in
23 fact there had not been a complete cessation of these
24 operations ordered by the Department of Health?
25 A. I am sorry, what, prior to us talking to him, you mean?
0051
1 Q. Here is one listed, so it could not have been right
2 there was a cessation, because there was one planned?
3 A. My memory of that is that our main concern at that point
4 was to get that child taken off the list.
5 Q. In your statement to the GMC, when you dealt with this
6 point, you said you were very surprised and so were your
7 colleagues to see that this operation was planned?
8 A. Yes.
9 Q. Which colleagues shared your surprise at the planning of
10 this operation for January 1995?
11 A. Everybody I was working with: the perfusionists, as
12 I said Dr Bolsin, who was an anaesthetist.
13 Q. Why did you understand the operation had been listed?
14 Was it urgent? Did the patient need the operation in
15 a hurry?
16 A. I was not told why. Myself and Sister Herborn did speak
17 to Mr Dhasmana, but again, I cannot remember the exact
18 timing of that so it could have been the day, it could
19 have been the day before, to ask him why we were
20 operating on this switch. He said it was because it was
21 not a neonatal one; it was because of the child's age.
22 Q. Because, as Mr Wisheart has said in his comments on your
23 third statement, Mr Dhasmana had stopped doing neonatal
24 switches in October 1993?
25 A. I cannot remember the date he stopped doing them.
0052
1 Q. That is what Mr Wisheart says.
2 A. Yes.
3 Q. You have no reason to doubt that?
4 A. No.
5 Q. And neonates are essentially birth to 1 month of age,
6 and this patient for January 1995 was older than that?
7 A. Yes. I believe he was 13 months.
8 Q. So that is why it did not fall within Mr Dhasmana's
9 self-imposed moratorium on switches; but did he advance
10 a positive reason why the patient needed the operation
11 in January 1995 as opposed to February/March, or
12 May/June 1995, when there would be a new surgeon?
13 A. No.
14 Q. Did you know at the time this operation was planned that
15 Mr Pawade had been appointed?
16 A. Yes, I did.
17 Q. And you knew when he was going to take up his post?
18 A. Yes.
19 Q. And so, presumably, did Mr Dhasmana?
20 A. Yes.
21 Q. Did you say, "Well, why is this being listed now? Why
22 can it not wait for Mr Pawade?"
23 A. I did not say that to Mr Dhasmana. I did make that
24 comment to Dr Underwood, who was the anaesthetist.
25 Q. That is Sue Underwood, is it?
0053
1 A. Yes.
2 Q. She, as it turned out, was the anaesthetist for that
3 operation?
4 A. That is because she was the anaesthetist for that
5 operation.
6 Q. Can we look at the second page of your statement to the
7 GMC, GMC 14/23, the second paragraph on that page. You
8 say that on the Monday before the operation which was
9 scheduled for a Thursday, your colleague Sister Herborn
10 told you in the presence of Dr Masey -- she was an
11 anaesthetist as well -- "that I was the only scrub nurse
12 available to do that particular operation. Nurse
13 Herborn said that she would prefer if I didn't do it".
14 You said you would decline to act as a scrub nurse for
15 the operation?
16 A. That is correct.
17 Q. If we look at the next paragraph, Dr Masey went and got
18 the book showing he was off duty on the day of the
19 operation?
20 A. That statement is incorrect. I did say several times
21 that was incorrect. Dr Masey did not go and get the off
22 duty book. Mona Herborn already had the off duty book
23 in her hands.
24 Q. So would you take me through that part of the story?
25 A. At the time, Mona was asking me if I would be willing to
0054
1 scrub for the case because I was the only scrub nurse on
2 duty that could do a paediatric case. We were looking
3 down the people rota'd for that day at that time and
4 Dr Masey was stood with us. She pointed out the fact
5 that Alison Reed was on a day off that day, but may well
6 be willing to change her day off.
7 Q. She was one of the ones who had not taken part in the
8 self-imposed exile from complex paediatric cardiac
9 surgery that we discussed?
10 A. Yes.
11 Q. She and Onyx Brewin?
12 A. Yes.
13 Q. So did it turn out that Alison's shift was changed?
14 A. It was changed.
15 Q. So she was the scrub nurse?
16 A. She was the scrub nurse. I do not know who changed her
17 shift.
18 Q. Let us scroll down a little bit and tell me if anything
19 in this paragraph is inaccurate. There was no
20 anaesthetic nurse for the operation?
21 A. That is true.
22 Q. You were asked to do that job and you agreed. Why
23 should you agree to be the anaesthetic nurse and refuse
24 to be the scrub nurse?
25 A. I agreed to do anaesthetics that day, that is correct.
0055
1 I did not think, at the time, that that child was going
2 to come to theatre. That was how much we believed in
3 what Steve Bolsin was telling us, that that child would
4 not be coming to theatre. I really did not think he
5 would.
6 Q. Was there any pressure put on you to be the anaesthetic
7 nurse?
8 A. A comment was made, but I cannot remember exactly by
9 whom, therefore ... it was insinuated, I do not think
10 seriously, that with two anaesthetists present, did they
11 actually need an anaesthetic assistant? But I do not
12 know if it was a serious comment and I cannot remember
13 who made it, but the thought that they might carry on
14 without an anaesthetic assistant, in my view, the child
15 was better off with me acting as anaesthetic nurse on
16 that day.
17 Q. That type of suggestion would be likely to have come
18 from an anaesthetist, would it not?
19 A. Yes.
20 Q. A consultant anaesthetist?
21 A. I really do not remember who made that comment.
22 Q. So you agreed in those circumstances to be the
23 anaesthetic nurse, still not expecting the operation
24 actually to take place?
25 A. That is true.
0056
1 Q. Let us go, then, to your statement, WIT 132/59,
2 paragraph 17. The day of the operation came and the
3 case was still listed. The operation took place and, as
4 is well known and has been mentioned in various
5 broadcasts, media, about the events this Inquiry is
6 concerned with, the child died?
7 A. Yes.
8 Q. You say there that after the operation, Dr Underwood
9 told you that there would be no more, which you
10 understood to mean she would be no longer willing to
11 anaesthetise another child in these circumstances.
12 I asked you about the attitude of the other
13 consultant anaesthetists to Dr Bolsin's data and the
14 concerns that he had been expressing in 1992. You
15 suggested I think that Dr Davies was known at least to
16 you to be an ally, if you like, of Dr Bolsin.
17 By this time, was the attitude of all the
18 consultant anaesthetists that which Dr Bolsin had had
19 three years before?
20 A. At that point, I believe there were still two
21 anaesthetists who felt they would like to carry on with
22 paediatric work.
23 Q. With the same setup and the same surgeons and the same
24 cardiologists?
25 A. I think they themselves would have desired to have been
0057
1 transferred to the Children's Hospital to still carry on
2 doing the paediatric work when it went there.
3 Q. If we look down the page a little, please, to
4 paragraph 18, you say Dr Bolsin showed his work openly
5 to other people in the department, but you do not know
6 who saw it or when they might have seen it.
7 Mr Wisheart has made the comment at page 71, at
8 the top of the page, that Dr Bolsin may have shown his
9 work openly to some people, but he did not show it
10 openly to him, to Mr Dhasmana or to the paediatric
11 cardiologists.
12 Have you anything to gainsay that remark from
13 Mr Wisheart?
14 A. I certainly would not know about the cardiologists.
15 I would not be present if Dr Bolsin showing his work to
16 Mr Dhasmana, so that may well be a true statement. I am
17 sure it is.
18 Q. Dr Bolsin has made a comment as well on your statement,
19 page 72, by e-mail from Australia. He says, do you see
20 under N2, he was prepared to share his concerns about
21 the service with colleagues from medical and nursing
22 professions. He was aware that "there were doubts among
23 the theatre staff as to whether they should provide
24 nursing assistance to the paediatric cardiac surgeons."
25 I should say, he says some nice things about you
0058
1 above that.
2 Was there any express or implied suggestion from
3 Dr Bolsin that your reaction and that of your colleagues
4 to his showing you the data ought to be that you would
5 withdraw assistance at these operations; that that is
6 what he was expecting you to do?
7 A. If that was what he was expecting us to do, he certainly
8 did not voice that opinion.
9 Q. We are nearly through this statement, Mrs Armstrong.
10 Let us have a look at page 60, please. The very foot of
11 the page, paragraph 23. Mr Dhasmana's retraining. Just
12 before I come to that, I should deal with one point from
13 paragraph 21 which Mr Wisheart comments on. You refer
14 in paragraph 21 to having been told by Dr Bolsin that
15 there was a confrontation between himself and
16 Mr Wisheart and that Dr Bolsin was subdued for a while
17 after this.
18 Do you remember when that alleged confrontation
19 was?
20 A. I believe it was around about the time that there would
21 have been the discussions made for Martin Elliott coming
22 down.
23 Q. You have seen what Mr Wisheart says, I think. This is
24 page 71. There was only ever one heated discussion
25 between himself and Dr Bolsin when Dr Bolsin was not in
0059
1 the operating theatre when he should have been.
2 You were not present at the conversation
3 Mr Wisheart refers to, nor were you present at the one
4 Dr Bolsin reported to you?
5 A. No.
6 Q. So can you take this any further?
7 A. No. I can only believe both of their statements,
8 really.
9 Q. Let us go to page 60, paragraph 23. Mr Dhasmana went to
10 Birmingham for two days retraining. Did anyone go with
11 him?
12 A. Yes.
13 Q. Who?
14 A. I believe Sue Underwood went. There was certainly an
15 anaesthetist. I think it was Sue Underwood. I believe
16 Eamonn Nicholson went from the Perfusion Department and
17 nursing staff: Onyx Brewin and Alison Reed were the two
18 that went.
19 Q. Why did they go to Birmingham as opposed to London or
20 Newcastle?
21 A. I do not know. That was arranged by Mr Dhasmana,
22 perhaps because Birmingham was the closer centre to us
23 that was operating on the same sort of surgery.
24 Q. Just a couple of points to draw matters to
25 a conclusion. In your first statement at page 9,
0060
1 paragraph 24, and also at paragraph 37 on page 14, you
2 refer to the surgeons being late for surgery, for
3 theatre?
4 A. That is correct.
5 Q. You say that Mr Wisheart was the main offender?
6 A. That is correct.
7 Q. Mr Dhasmana would usually come when he was asked. You
8 say in this paragraph we are looking at now, four lines
9 from the bottom:
10 "They [the patient] would then be prepared for
11 surgery by the registrar ready for the consultant
12 surgeon to put them on bypass."
13 A. That is correct.
14 Q. So the drill was that the surgeon would be present
15 before the patient was put on bypass?
16 A. Yes.
17 Q. Is that right?
18 A. Yes.
19 Q. Was that always the position: the surgeon would be there
20 before the patient went on bypass?
21 A. Yes. I think so.
22 Q. You have seen Mr Wisheart's comment on this at page 67.
23 He deals quite rightly compendiously with paragraphs 24
24 and 37, which make the same point. He says:
25 "There is a practical problem in that the time
0061
1 taken to anaesthetise and place the patient on bypass
2 was extremely variable".
3 A. That is true.
4 Q. "And could range from a little over 1 hour up to
5 three hours."
6 If I have understood your evidence correctly, the
7 surgeon would be there before the patient was put on
8 bypass?
9 A. I am sorry, can I read that through again?
10 Q. Yes, do.
11 A. "There was a practical problem in that the time taken to
12 anaesthetise and place the patient on bypass was ...
13 variable."
14 Yes, well, the surgeon would be there before the
15 patient went on bypass, but the surgeon would not be
16 there, the consultant would not be there, when the
17 patient was brought into theatre.
18 Q. So what was the degree of variability in time?
19 A. The variability in time should have nothing to do with
20 it. The point is that we would never send for the
21 surgeons until we were ready for them to come. When we
22 sent, it was how quickly they responded to us sending
23 for them.
24 Q. But the variability, the length of time it took to put
25 the patient on bypass is completely irrelevant because
0062
1 the surgeon would always be there before the patient
2 began to go on bypass?
3 A. Yes, but not before -- when I say "put the patient on
4 bypass", there is a good half an hour's surgery that
5 takes place before that.
6 Q. I do not think we are at odds.
7 THE WITNESS (To the Panel): You understand, yes? So
8 someone else opens the patient up. Someone else may
9 well put the "purse strings" in. When we are at the
10 point when the heparin is being given and we are putting
11 the "purse strings" into the patient, then we would call
12 for Mr Wisheart or Mr Dhasmana to come to theatre to put
13 the patient on bypass.
14 Mr Dhasmana would always come straightaway, but
15 Mr Wisheart would take some time to come and we would
16 often need to call him two, maybe three times.
17 Q. Who would call the surgeon?
18 A. Whoever was the circulating nurse on that day.
19 Q. How much warning would a surgeon reasonably need, do you
20 think, to be told and able to get to the theatre and
21 change and get himself ready?
22 A. I would think they would need 10 to 15 minutes.
23 Q. So do you understand Mr Wisheart's comment there in the
24 first bullet point?
25 A. No. I do not feel that the time taken in the
0063
1 anaesthetic room is relevant because we would not send
2 for him until we were ready for him.
3 Q. He does say, over the page, page 68, that if this was
4 perceived to be a major issue, nobody told him that it
5 was a major issue?
6 A. It was brought up frequently at the meetings. We used
7 to have meetings where there was myself or Sister
8 Herborn, the theatre manager. There would be the chief
9 perfusionist and Mr Wisheart and punctuality was often
10 on the agenda.
11 Q. So he is wrong about that?
12 A. I believe him to be wrong about that.
13 Q. You have seen what Mr Dhasmana says about this point,
14 page 24?
15 A. I have.
16 Q. Have a look at paragraph 3 and tell me, once you have
17 read it, whether you accept what he says there.
18 (Pause).
19 A. He was always present in theatre if we had an emergency
20 such as a dissection or something like a TAVPD regarding
21 pulmonary. Our instructions were to bleep him when the
22 patient was brought into theatre. Those were always our
23 instructions. We would bleep him. He would respond to
24 his bleep, and then he would come to theatre. That
25 process would probably taken between 15 and 20 minutes.
0064
1 Q. Just a little longer than the time-frame you mentioned
2 a moment ago?
3 A. That is correct. I did say that Mr Dhasmana would
4 usually come when asked.
5 Q. You say Mr Wisheart was the chief offender?
6 A. That is correct.
7 Q. At page 8, paragraph 22 of your first statement, you say
8 that working with Mr Pawade is far less stressful.
9 Why is it far less stressful?
10 A. It is far less stressful because the cases go well. So
11 there is not that dread every time we go to the table
12 that the patient may not survive. Also, he is very
13 even-tempered -- that helps.
14 Q. I think you said in your statement to the GMC that you
15 never discussed your concerns with Mr Wisheart or
16 Mr Dhasmana?
17 A. No.
18 Q. Why not?
19 A. Probably because I was not brave enough.
20 Q. I think this is finally, unless somebody tells me
21 quickly otherwise: we were discussing a little earlier
22 the confrontation as you described it that Dr Bolsin
23 said he had with Mr Wisheart?
24 A. Yes.
25 Q. As you understood it, that confrontation had taken place
0065
1 about the time of Mr Elliott's visit when Mr Elliott was
2 contemplating taking the job of Professor of Paediatric
3 Cardiac Surgery?
4 A. That is true. I believe Mr Wisheart had taken exception
5 to a letter Dr Bolsin had written. That is what
6 Dr Bolsin told me.
7 Q. Is it that letter that helps you to date the
8 confrontation to Mr Elliott's visit?
9 A. No, it is not, actually.
10 Q. So why do you think that it was about that time the
11 confrontation took place?
12 A. Because there were some circumstances that happened at
13 that time that I just remember, being sat in the coffee
14 room, Dr Bolsin discussed that with me. Then I had
15 a conversation with Mr Dhasmana straight afterwards
16 regarding Martin Elliott. That is why I feel it was at
17 that time.
18 Q. Did Dr Bolsin enlighten you in any detail as to what the
19 subject matter of the confrontation was?
20 A. His letter had been about poor results. I do not know
21 what was said.
22 Q. So there was a letter, as you understood it from
23 Dr Bolsin to Mr Wisheart about --
24 A. I do not know if the letter went to Mr Wisheart. I do
25 not know who he sent the letter to, but I believe
0066
1 Mr Wisheart had taken exception to that letter. I do
2 not think it was to Mr Wisheart.
3 Q. Did you follow the course of the GMC proceedings against
4 Dr Roylance and Mr Wisheart, and Mr Dhasmana?
5 A. At the time when that was going on, my husband was
6 actually on intensive care, he was very ill, so I am
7 afraid at that point I was not really aware of what was
8 going on.
9 Q. So you were not following the detail of the evidence at
10 the GMC?
11 A. No.
12 MR MACLEAN: Mrs Armstrong, thank you very much for your
13 evidence. Those are all the questions I want to ask
14 you. The Panel may have some questions in a moment.
15 Before we come to the Panel, is there anything else you
16 want to say at this stage, anything I have not dealt
17 with properly or dealt with at all?
18 MRS ARMSTRONG: There was just one point. When we were
19 talking about communication skills and you were talking
20 about no staff wanting patients to be cancelled,
21 I thought you were wanting to question me about that but
22 you moved on. I would like to say I agree with
23 Mr Dhasmana that nobody wants to see patients being
24 cancelled but communicating any changes in the list is
25 very important for all who are concerned with looking
0067
1 after that patient that day, to make sure that no
2 mistakes are made.
3 MR MACLEAN: Thank you very much, Mrs Armstrong. Does the
4 Panel have any questions for this witness?
5 THE CHAIRMAN: Mrs Armstrong, first from Mrs Maclean
6 Examined by THE PANEL:
7 MRS MACLEAN: You were describing earlier on, page 29 in the
8 transcript, how it was your responsibility to look out
9 for under-performance amongst your nursing staff and
10 that you were able to pull people out if you felt that
11 they were overtired and not able to do their job?
12 A. That is correct.
13 Q. Did you ever actually have to do that, or was it just
14 something that was in reserve and a possibility?
15 A. No, we have regularly, particularly if a case had gone
16 on for a particularly long period of time, we have
17 certainly changed the scrub nurse, because I think there
18 is a limit as to how long you can expect somebody to
19 stand up, concentrate and perform to a high standard.
20 MRS MACLEAN: Thank you.
21 THE CHAIRMAN: Mrs Howard?
22 MRS HOWARD: Mrs Armstrong, you talked about the personal
23 choice you and your colleagues made about withdrawing
24 from scrubbing, and you also talked about professional
25 concerns in a very general way.
0068
1 Did you in any way consider approaching
2 professional organisations such as the Royal College of
3 Nursing to discuss your particular personal issues or
4 dilemmas?
5 A. No, we did not.
6 Q. May I enquire why?
7 A. I think the reason was that we also had such faith in
8 Dr Bolsin, we felt that he had taken this on as his
9 crusade and he was very determined to achieve a result
10 and we all had great hopes he would be successful. He
11 felt that he would be. We just felt that he could do so
12 much more than it would be possible for us to do.
13 MRS HOWARD: Thank you.
14 THE CHAIRMAN: Mrs Armstrong, thank you. Those are the
15 questions from the Panel. Mr Chambers?
16 MR CHAMBERS: Just one small point.
17 RE-EXAMINED BY MR CHAMBERS:
18 Q. It arises out of the question you have just been asked,
19 not going to the Royal College of Nursing. Did you in
20 fact, or would you in fact have had any facts and
21 figures that you could have presented to the Royal
22 College of Nursing, if, for example, you had spoken with
23 them?
24 A. Nothing in writing, no.
25 Q. Any other source of information, apart from what you had
0069
1 seen or heard from Dr Bolsin?
2 A. No. I had no facts about other centres, so, no.
3 MR CHAMBERS: Thank you very much.
4 THE CHAIRMAN: Thank you, Mr Chambers, that is helpful.
5 Mrs Armstrong, we have no further questions. May
6 I first of all thank you very much for coming this
7 morning. We found it very helpful to listen to you and
8 your evidence. Mr Maclean did raise one matter on which
9 you might be able to help us further, and if you are
10 able to do so, we would be very, very grateful.
11 Equally, if there is anything else that comes to your
12 mind that you would like to let us know, we would be
13 grateful to receive that. But for the moment, thank you
14 very much indeed.
15 MRS ARMSTRONG: Thank you.
16 (The witness withdrew)
17 MR MACLEAN: Sir, before we go any further, that took
18 slightly longer than I anticipated. I was shocked to
19 discover that it is 10 to 12. The next witness,
20 Mr Booth, will be relatively short and the one after
21 that, Professor Vann Jones, will be considerably
22 longer. It is really a matter for the Panel, whether
23 they want to have a lunchtime break now and then run
24 Mr Booth and Professor Vann Jones together in the
25 afternoon, or whether we start now with Mr Booth, or
0070
1 whether we have a very short break now, before we start
2 Mr Booth.
3 THE CHAIRMAN: Thank you for helping us, Mr Maclean.
4 I think, if we can, we perhaps should go on for another
5 half an hour and at that point have a half an hour break
6 for lunch, so let us proceed with Mr Booth until 12.30,
7 shall we?
8 MR MACLEAN: Yes. The next witness then is Mr William
9 Booth.
10 Mr Booth, could you stand up, please, to take the
11 oath?
12 MR WILLIAM BOOTH (SWORN):
13 Examined by MR MACLEAN:
14 Q. Your full name is William Booth?
15 A. That is right.
16 Q. Can we have a look, please, at WIT 309/1? We see from
17 that you are the Clinical Nurse Manager of the
18 paediatric Intensive Care Unit at the Bristol Children's
19 Hospital?
20 A. That is correct.
21 Q. And that is the first page of your formal written
22 statement to the Inquiry?
23 A. Yes.
24 Q. Page 27 is the final page of that same statement,
25 I think. That is your signature?
0071
1 A. It is.
2 Q. Have you read that statement through recently?
3 A. Yes, I have.
4 Q. And is there anything in it that you want to change
5 before we adopt that as part of your evidence to the
6 Inquiry?
7 A. No, there is not.
8 Q. I am not going to take you through that statement
9 paragraph by paragraph, or even page by page, because
10 the Panel have it and we have all read it. I simply
11 want to draw out one or two matters that arise from it.
12 You have also submitted some other materials by
13 way of annex to the statement, have you not?
14 A. Yes.
15 Q. I think your own curriculum vitae?
16 A. Yes.
17 Q. And a table showing nurse ratios and so on in different
18 hospitals?
19 A. Yes.
20 Q. And also the booklet -- this is 309/34 -- produced by
21 the Trust called "Remembering your Child, Parent's
22 Booklet", of which you were the main author?
23 A. That is right.
24 Q. I think you know that the Inquiry spent some time
25 recently dealing specifically with the issues of
0072
1 counselling and bereavement and how bad news was broken
2 and handled, and so on, and I hope you will forgive me
3 in those circumstances if I do not dwell today on that
4 booklet. As I say, the panel are fully aware of it and
5 will have read through it.
6 You began work in Bristol as a charge nurse in the
7 paediatric intensive care unit in the BCH in 1990?
8 A. That is correct.
9 Q. You worked in that post until 1995 with a very short
10 break in 1993 in the fair city of Glasgow?
11 A. That is right.
12 Q. And I will not ask you why you left there so quickly,
13 because it might upset me!
14 You became the Clinical Nurse Manager in April
15 1995?
16 A. That is correct.
17 Q. Back at the Children's Hospital?
18 A. Yes.
19 Q. At paragraph 11 of your statement, page 3, you refer to
20 a medically orientated model of management at the UBHT
21 which you believe was not dissimilar to other hospitals
22 at the time?
23 A. Yes.
24 Q. How did that manifest itself?
25 A. I came to Bristol after a short-term commission in the
0073
1 Royal Air Force and when I left the Radcliffe Infirmary
2 in Oxford, Trust status was not evident at that time.
3 After leaving the Air Force and returning to the
4 National Health Service, the UBHT was being created and
5 it was my impression that medical staff held all key
6 managerial posts within the Trust. I believe that was
7 not dissimilar to Trusts elsewhere.
8 Q. So UBHT was not out of the mainstream at that time?
9 A. I do not believe so, no.
10 Q. You say that this has changed over the last three to
11 four years?
12 A. Yes.
13 Q. And nursing is a heightened profile?
14 A. Yes.
15 Q. Is that again, that change, something that, as far as
16 you were aware, has been manifested throughout the NHS
17 generally?
18 A. Yes. I think so. The changes occurred three to four
19 years ago, which coincided with several new key
20 appointments, and particularly with a Director of
21 Nursing.
22 Q. And that would be Mrs Scott?
23 A. Yes, that is right.
24 Q. And she was appointed and also, about four years ago --
25 A. A new Chief Executive.
0074
1 Q. -- Mr Ross was appointed?
2 A. Yes.
3 Q. Were there any other key appointments?
4 A. Those were the key appointments that I think influenced
5 the profile of nursing in the UBHT.
6 Q. So how these two key appointments make their impact felt
7 at your level as being Clinical Nurse Manager in
8 intensive care?
9 A. It was my impression, and I was comparing UBHT with
10 Oxford when I left Oxford, Oxford enjoyed a very high
11 nursing profile, but I think that was quite unusual and
12 when I came to UBHT, I felt that nursing generally was
13 undervalued. With the appointment of Hugh Ross, and
14 then Lindsay Scott as the Director of Nursing, I felt
15 certainly over the last three to four years, as I have
16 stated, that nursing has enjoyed a much higher profile
17 and the contribution that nursing makes to the
18 organisation has been valued.
19 Q. You heard, I think, some of the evidence at least of
20 Mrs Armstrong this morning. I mentioned to her the fact
21 that Mrs Maisey was the Nurse Adviser to the Trust
22 whilst she held the post of Director of Operations
23 before she assumed the title of Director of Nursing
24 latterly?
25 A. Yes.
0075
1 Q. Mrs Armstrong did not seem to know about that.
2 A. I was not aware that she had assumed the title of
3 Director of Nursing.
4 Q. Were you aware that she was, before assuming that title,
5 the Nurse Adviser to the Trust?
6 A. Yes.
7 Q. I think she did have the title of Director of Nursing
8 for a relatively short time towards or perhaps just
9 after the end of the Inquiry's period of concern.
10 You have always worked at the Children's Hospital
11 in Bristol; you have never worked at the BRI?
12 A. That is correct.
13 Q. So under the Trust system, you would only ever have
14 worked within the Directorate of Children's Services?
15 A. That is right.
16 Q. And the General Managers were respectively, one after
17 the other, Marion Stoneham and Ian Barrington, who is
18 the Manager today?
19 A. Yes, that is right.
20 Q. And the Clinical Director of the Directorate was, for
21 a large part of the time, Dr Joffe?
22 A. Yes.
23 Q. He has now retired?
24 A. No, he is actually still a consultant paediatric
25 cardiologist.
0076
1 Q. And still the --
2 A. He is not the Clinical Director. That is now Dr David
3 Hughes.
4 Q. But until the period we are concerned with, it would be
5 Dr Joffe?
6 A. It would be Dr Joffe, yes.
7 Q. Paragraph 16 of your statement, Mr Booth, page 4. You
8 say that until paediatric cardiac surgery moved to the
9 Children's Hospital, the unit in the PICU was a small,
10 stable workforce, but once that work was moved to the
11 Children's Hospital, there was an increase in beds and
12 recruitment became an issue. Difficulties were
13 experienced recruiting qualified children's nurses with
14 additional intensive care qualifications.
15 The most relevant qualification would be ENB 415?
16 A. Yes, to have a qualification at ENB 415, they must be
17 children-trained as well.
18 Q. So that would be the ultimate specific qualification?
19 A. That would be the ideal, yes.
20 Q. Is there a reluctance among nurses to seek out that
21 qualification?
22 A. There is not a reluctance. Paediatric intensive care is
23 a very exacting speciality, an extremely stressful
24 environment to work in and it is not suited to all
25 children's nurses, so there are few children's nurses
0077
1 who would seek to work in a paediatric intensive care
2 unit.
3 Q. So most of those who obtain the Registered Sick
4 Children's Nurse qualification would not go on to
5 ENB 415?
6 A. No. I mean, it would be dependent upon, if they came to
7 work in the Intensive Care Unit and decided to make
8 paediatric intensive care their career, or for whatever
9 length of time, then they would undertake the ENB 415
10 course.
11 Q. Over two pages to page 6, you say at paragraph 26 that
12 from time to time there were people involved in the
13 support group for nursing staff. There were
14 professional counsellors and a psychologist?
15 A. Yes.
16 Q. And the Inquiry has heard about those previously.
17 "At the request of the staff, this no longer
18 happens. This is because by approximately a year after
19 primary nursing was introduced --", and that was in
20 1993?
21 A. Yes.
22 Q. "-- the nurses felt they had adequate support from their
23 peers within the primary nursing team."
24 You explain, if we look up the page to
25 paragraph 24, what primary nursing is. It is basically
0078
1 a group of teams, with each team being headed by a named
2 nurse, who was responsible for the co-ordination of the
3 care of a particular patient.
4 Is that the essence of it?
5 A. Yes.
6 Q. Is that too brief a summary?
7 A. Primary nursing was introduced in January 1993 as
8 a model of care delivery and to my knowledge, I think we
9 are probably one of the only paediatric intensive care
10 units in the country to have adopted that method of care
11 delivery.
12 I think previously in intensive care units nurses
13 have always been allocated on a sort of daily basis and
14 would care for a patient over the length of duty and the
15 difference between primary nursing and total patient
16 care as it is known is the continuity of care provided,
17 in that the child will be cared for by a small group of
18 nurses from their admission until discharge. Within
19 that group, one nurse would elect themselves as the
20 child's primary nurse or named nurse, and they would be
21 responsible for co-ordinating that child's care.
22 Q. Why does the institution of this system mean that the
23 nurses themselves feel they do not need the help from
24 counsellors and psychologists they needed in the past?
25 A. Previously when we practised total patient care and
0079
1 allocated nurses on a daily basis, the staff worked as
2 one team. Within primary nursing, we also introduced
3 a system where we split the nurses into several teams.
4 Usually each team composes around 12 nurses. They work
5 together all the time. They also have regular monthly
6 meetings to discuss issues within the team and about 12
7 months afterwards when they introduced primary nursing,
8 they felt they got peer support from each other, and we
9 encouraged that to the extent that each team would give
10 them a study day every year.
11 The team themselves decide on issues they wish to
12 discuss in the morning, usually clinical updates, then
13 in the afternoon, usually we spend the afternoon on team
14 building exercises, so we strengthen the team and
15 approximately, as I stated, 12 months after introducing
16 primary nursing, the nurses themselves felt they got
17 support from each other, and therefore chose themselves
18 to stop the more formal support meetings that we
19 previously had.
20 Q. If we go over the page, please, to paragraph 30, you say
21 you do not recall a key clinician who accepted overall
22 responsibility for the Intensive Care Unit?
23 A. That is right.
24 Q. What time period are you discussing there?
25 A. I think that was from my appointment in 1990, late 1990,
0080
1 up until about 1995, when several changes occurred on
2 the unit.
3 At one time Professor Peter Fleming did show
4 a particular interest in intensive care. That was quite
5 short-lived, if my memory serves me right, just a brief
6 period of time.
7 The paediatric anaesthetists in rotation, a weekly
8 rotation, accepted responsibility for the unit for that
9 period of time, but I do not recall one of them
10 accepting overall responsibility for the management of
11 the unit.
12 Q. What is the position now?
13 A. The position now has changed over the last five years
14 and we now have a Clinical Director of the Intensive
15 Care Unit.
16 Q. At whose behest was that change made?
17 A. Several changes occurred around 1995. Not only the move
18 of open-heart surgery from the Bristol Royal Infirmary
19 to the Children's Hospital, but two key reports were
20 also published at that time, one which is more commonly
21 known as the "Troop Report" which is a report to the
22 Chief Executive of the NHSE looking at the provision of
23 paediatric intensive care and making several key
24 recommendations, and at the same time there is a report
25 from the Chief Nursing Officers' Working Party looking
0081
1 at nursing standards, nurse education and workforce
2 planning in paediatric intensive care.
3 So there was a lot of activity at that time, and
4 at that time there were also other key appointments made
5 on the medical team, when cardiac surgery moved from the
6 Bristol Royal Infirmary to the Children's Hospital, in
7 that several new paediatric cardiac anaesthetists were
8 appointed and they also had a role on the Intensive Care
9 Unit.
10 Q. At paragraph 38, page 8, the bottom of the page, you
11 refer there to Mr Pawade, the paediatric cardiac surgeon
12 who is in post now, introducing protocols and guidelines
13 for open and closed procedures following his appointment
14 in May and the transfer of the work in October?
15 A. That is right.
16 Q. To what extent were those protocols and guidelines
17 a codification of past practice or a new development?
18 A. That was a new development. Previous to Mr Pawade's
19 appointment, we did not have any written protocols or
20 guidelines to care for children involving closed cardiac
21 surgery.
22 Q. What did those protocols provide for? What did they
23 say?
24 A. The protocols are very specific to the care of children
25 following both open and closed cardiac surgery. The
0082
1 children often have very complex problems
2 post-operatively, and within the protocols and
3 guidelines specific to some of those complications that
4 we often see post-operatively, they guide us through
5 certain clinical conditions that may appear. For
6 instance, when a child has had open-heart surgery,
7 particularly babies and young children, they can often
8 experience a transient phase of renal dysfunction and
9 may require peritoneal dialysis. So the protocols guide
10 us when we should start peritoneal dialysis and the
11 procedure that we should follow.
12 Q. So these are helpful or unhelpful?
13 A. Extremely helpful.
14 Q. Over the page, page 9, dealing with issue B.9 just above
15 paragraph 42, you say you are unable to comment on the
16 information available to referring clinicians and to
17 members of the public on the standards of treatment and
18 care attained at the BRI.
19 Did you, between 1990 when you started work and
20 1995, the end of the period we are concerned with, form
21 any impression of the quality of paediatric cardiac care
22 at the BRI?
23 A. The Children's Hospital functioned completely separate
24 to the Bristol Royal Infirmary and we did not have
25 access to any information that existed at that time on
0083
1 the results of surgery, so we were not aware of the
2 results of the Bristol Royal Infirmary.
3 Q. So you did not have access to any official data?
4 A. No.
5 Q. Did you have any unofficial sources of information?
6 A. Certainly I think towards the end of or during 1994, for
7 want of a better word to use, I sometimes heard sort of
8 gossip from colleagues, not from the Children's
9 Hospital, it was often some of the anaesthetists in
10 training who rotated to the Children's Hospital who
11 would sometimes talk about or express concern over
12 results of surgery at the Bristol Royal Infirmary.
13 But we were never able to substantiate those
14 comments, because we actually did not know what the
15 results were. We certainly did not know what the
16 results were compared with other centres in the country.
17 Q. Paragraph 51, page 13.
18 You refer there to the transfer of children from
19 the Children's Hospital down to the BRI.
20 A. Yes.
21 Q. And at paragraph 81, page 20, you refer to the transfer
22 of children in the other direction?
23 A. Yes.
24 Q. I do not know if you have had a chance to see the
25 transcript of Joyce Woodcraft's evidence on -- it seems
0084
1 like days ago but I think it was only Tuesday.
2 A. Yes, I have.
3 Q. You will have seen there she was asked about
4 a particular medical record. It is MR 722/63.
5 You see in the top of the sheet:
6 "Transferred from Ward 5", that is the BRI cardiac
7 ward?
8 A. Yes.
9 Q. "Arrived unannounced as usual". Joyce Woodcraft was
10 asked about that. Is that something, a state of affairs
11 that you are familiar with?
12 A. When I read this, it implies that a child just arrived
13 and we knew nothing about the child. What occasionally
14 happened is that we may know, we would obviously know
15 that a child was going to be transferred from Ward 5 to
16 the paediatric intensive care unit at the Children's
17 Hospital on a certain day. The transfer often is
18 reliant upon ambulance transport and the transfer would
19 not be an urgent transfer, it would be a routine
20 transfer. When we book transport, even now, today, we
21 are given either that the transport will be provided in
22 the morning or the afternoon and we are not given
23 a specific time.
24 So it did happen on occasion that we knew a child
25 was coming from Ward 5 in the morning or the afternoon,
0085
1 but the nursing staff on Ward 5 could not specify
2 a time.
3 What would be common practice is that the nurse on
4 Ward 5 would phone us to say that the child had left and
5 would be arriving at the Children's Hospital shortly
6 afterwards. Usually, one reason for transfer is when
7 Ward 5 was extremely busy and required another intensive
8 care bed, so on occasion they perhaps forgot to phone us
9 because they were busy preparing the bed for another
10 child, or adult case. So sometimes a child would arrive
11 and we did not know, they had left the Bristol Royal
12 Infirmary but we were expecting the transfer some time
13 that morning or after.
14 Q. It is the use of the words "as usual" that make this
15 record stand out. The usual position would be that the
16 Children's Hospital would know a child was coming rather
17 like a plumber, either morning or afternoon, but would
18 not know when specifically in the morning or afternoon?
19 A. We would know specifically it was in the morning or
20 afternoon, but not the time.
21 Q. You might then expect a phone call from the BRI saying
22 the child has just left at 10.30, and you would expect
23 them by a quarter to 11, or whatever time it took?
24 A. Yes.
25 Q. So it would not be usual for a child to show up at the
0086
1 Children's Hospital when the Children's Hospital did not
2 know that the child was coming that morning or that
3 afternoon?
4 A. I never experienced that. We always did know the child
5 was going to come in the morning or the afternoon.
6 Q. Let us look at paragraph 68 of your statement, which is
7 page 17. You refer there to an annex to your statement
8 which are the results of a summary of a survey of nurses
9 in paediatric intensive care prepared by the Department
10 of Health based on 1996 figures.
11 A. I am sorry, which paragraph?
12 Q. Paragraph 68.
13 A. Yes.
14 Q. If we look at page 52, tell me if that is the table that
15 you are referring to.
16 A. No.
17 Q. That is not my 52. Let us look at 32, then.
18 A. Yes, that is the table.
19 Q. Is that the one?
20 A. Yes.
21 Q. If we just turn that round, Bristol is at the bottom
22 entry there, at line Y, is it not?
23 A. Yes.
24 Q. If we look first of all at column 10, that shows
25 the percentage of children trained nurses in the
0087
1 Children's Hospital, the relevant paediatric intensive
2 care units?
3 A. Yes.
4 Q. And Bristol's percentage is 82 per cent?
5 A. Yes.
6 Q. Which is higher than some, and not as high as others?
7 A. That is right, although the national average at the
8 bottom being 84 per cent, so Bristol compared
9 favourably.
10 Q. Just a little under?
11 A. Just a little under at 82.
12 Q. Column 12 is the percentage of children and intensive
13 care nurses, so that is those who have both
14 qualifications?
15 A. Those are nurses who are sick children trained and also
16 in possession of an intensive care certificate.
17 Q. This shows Bristol at 48 per cent, which is bang on the
18 national average?
19 A. Yes.
20 Q. Then column 13 shows the agency or bank nurse staff who
21 were working on the particular day on which this data
22 was based?
23 A. Yes, that is right.
24 Q. Which was 22nd May 1996?
25 A. Yes.
0088
1 Q. And on that day in Bristol there were none?
2 A. That is right.
3 Q. So this table suggests, as you put it, that Bristol
4 compares pretty favourably with the national averages
5 for children with children trained nurses and paediatric
6 intensive care trained nurses in the Intensive Care
7 Unit?
8 A. Yes.
9 Q. But these figures are for 1996?
10 A. Yes.
11 Q. If we look at your statement at page 4, paragraph 15,
12 you see:
13 "Coinciding with the move of paediatric cardiac
14 surgery from the BRI to the Children's Hospital, the
15 nursing establishment was increased to accommodate three
16 additional beds, bringing the total number of open beds
17 to 8. Staff was actively recruited to fill vacancies.
18 They were required to be Registered Sick Children's
19 Nurses and it was desirable for them to have an
20 intensive care certificate."
21 A. Yes, that is right.
22 Q. In the process of recruiting additional nurses to meet
23 the demands of extra beds, did Bristol's percentage of
24 Registered Sick Children's Nurses or intensive care
25 nurses increase?
0089
1 A. We actively recruited nurses who were sick children's
2 trained, and as I state, it was desirable to have an
3 intensive care qualification. They are an extremely
4 rare commodity, and we were not always able to recruit
5 nurses with both those qualifications. More often than
6 not, we recruited nurses who were sick children trained.
7 The survey has been conducted annually since then,
8 and our percentage of sick children's trained nurses and
9 nurses with intensive care qualifications have increased
10 slightly, but generally remain static, although, having
11 said that, we have, this April, opened 10 or 12
12 intensive care beds, and although the percentage is very
13 similar, we actually have more nurses who are sick
14 children's trained and with an intensive care
15 qualification, because the percentage of the whole time
16 equivalents employed, you can sort of understand what
17 that -- so the reality is we do have more nurses, or the
18 percentage remains very similar.
19 Q. I know it is difficult to look back now so far in time,
20 but your impression is that this data that we have in
21 this table for 1996 does not show Bristol in any
22 materially different position than it would have been in
23 1995, before the paediatric cardiac surgery had moved to
24 the Children's Hospital?
25 A. I think in 1995 a percentage would have been very
0090
1 similar to 1996.
2 Q. The numbers would have been smaller but the percentages
3 would have been the same?
4 A. Yes.
5 Q. So it is not a misleading document to take as a snapshot
6 of where Bristol fits in the pecking order?
7 A. No.
8 Q. But it is based on data collected on one particular day?
9 A. Yes.
10 Q. Mr Booth, I should have shown you earlier -- I tried to
11 show you WIT 52, expecting it to be something else. Can
12 I show you WIT 52 again, WIT 309/52. Have you seen this
13 before?
14 A. Yes, I did see it.
15 Q. It is a comment I think by Joyce Woodcraft, is it not?
16 A. Yes.
17 Q. You have had a chance to read through it?
18 A. Yes.
19 Q. Do you have any comments to make on it?
20 A. Can we scroll down?
21 Q. Yes, do. Go back to the beginning and tell us when you
22 want to scroll down. The numbers on the left-hand side
23 are references to paragraph numbers in your statement.
24 (Page scrolled)
25 A. Yes, I agree with those comments.
0091
1 Q. And over the page, a short concluding comment?
2 A. I cannot comment on that. My appointment was in 1990
3 and I do not recall, since my appointment, that any
4 nurses from the BRI were rotated to the Children's
5 Hospital, or vice versa.
6 Q. Finally, I think, Mr Booth, just dealing again with that
7 booklet that we saw at page 34, "Remembering your
8 Child", I think you say in your statement that you had
9 a large part in the writing of that document but you had
10 some assistance, I think, from others?
11 A. I had assistance from other nursing colleagues, and
12 several parents who have lost children also contributed
13 to the booklet.
14 Q. Was Mr Bradley, for example, one of the --
15 A. Yes, and in fact they also paid for the booklet to be
16 printed.
17 Q. So you would obviously recognise the crucial role that
18 they played in bringing that document to fruition?
19 A. Yes.
20 MR MACLEAN: Mr Booth, my time estimate has been rather
21 better for you than for Mrs Armstrong. Those are all
22 the questions I wish to ask you. Is there anything that
23 you want to tell the Inquiry?
24 MR BOOTH: There was a general feeling at the Children's
25 Hospital that a split site service was not good for the
0092
1 child in respect of continuity of care, and certainly
2 from a nursing perspective. It was often very difficult
3 for us, when we had cared for a child on intensive care
4 at the Children's Hospital, for them then to go to the
5 Bristol Royal Infirmary to have open-heart surgery. We
6 thought it was particularly unfair on parents, after
7 they had been with their child at the Children's
8 Hospital for a period of time, to then meet a new bunch
9 of nurses at the BRI. Although it was a general feeling
10 that this was not ideal, I do not think -- there was not
11 an opinion that this affected the outcome of surgery.
12 That was all.
13 Q. Is there anything else you want to add?
14 A. No.
15 MR MACLEAN: Does the Panel have any questions for
16 Mr Booth?
17 THE CHAIRMAN: Mrs Howard?
18 Examined by THE PANEL:
19 MRS HOWARD: Mr Booth, we have heard on several occasions,
20 lastly from Miss Woodcraft, about the skills required by
21 intensive care trained nurses and paediatric intensive
22 care nurses and paediatric nurses.
23 Given that you clearly need to manage a mix of
24 these nurses, based on the outcome of the 1996 survey,
25 do you have any comment on make on the difficulties
0093
1 encountered by those nurses who, for example, do not
2 have a paediatric qualification; and whether you have,
3 in your professional view, a comment to make about the
4 impact on care for the patient?
5 A. As I stated earlier, we would ideally recruit sick
6 children's trained nurses to intensive care. I myself
7 came from an adult intensive care background, as I think
8 a lot of children's and intensive care nurses tend to
9 do. I trained in adult nursing and adult intensive care
10 and then had a particular interest in children and then
11 went off to do my children's training before going to
12 the PICU.
13 Nurses who are not children trained do often
14 experience difficulties coming to a PICU. Those
15 difficulties, because they find looking after children
16 particularly stressful, I think not only looking after
17 the child but I think the differences they find as to
18 their whole philosophy of being a children's nurse, that
19 you do not care only for the child in isolation, but you
20 have to take account of the family and the family's
21 needs, particularly working in an intensive care in
22 a tertiary centre such as Bristol is, often those
23 families have travelled from very long distances. If
24 the mother is on her own she does not have the immediate
25 support of her family. So I think children's nurses are
0094
1 more aware of the needs of parents as well as the needs
2 of the child.
3 Since I came into post, we now have a very
4 comprehensive orientation programme, which in fact lasts
5 for 9 months, that all new nurses appointed to the unit
6 go on, unless they are sick children trained, with an
7 intensive care qualification. We are very conscious
8 during the orientation that we have nurses who, for
9 a variety of reasons, some of them work on adult
10 intensive care units and want to have some experience in
11 paediatric nursing, because they want to make a career
12 in an adult intensive care unit, where children are
13 still often cared for; so they come to gain that
14 experience. During the orientation we also will teach
15 these nurses about the differences between nursing an
16 adult and a child, not just the physiological
17 differences but also the concept of family care.
18 Q. To push you a little, your answer implies that you do
19 perceive an impact on nursing care from the perspective
20 of somebody who does not have paediatric training. Am
21 I misunderstanding what you are saying?
22 A. No. I think there is an impact on nurses who are not
23 children's trained, caring for children. We are all
24 well aware that children react very differently,
25 physiologically, to adults, and children's nurses
0095
1 I think have greater observational skills, particularly
2 caring for children. A child cannot tell you when there
3 is something wrong, so children's nurses are more
4 adapted to noticing changes in their behaviour as well
5 as the physiological parameters.
6 MRS HOWARD: Thank you very much.
7 THE CHAIRMAN: Mr Booth, there are no further questions from
8 the Panel. Mr Chambers?
9 MR CHAMBERS: I have no questions.
10 THE CHAIRMAN: I am very grateful. Although we appear to
11 have, as it were, dealt rather more quickly with your
12 evidence than the previous witness, I am anxious for you
13 to understand that we have read and will take account of
14 the totality of your statement and we are much assisted
15 by it.
16 So may I thank you very much for coming and
17 talking to us this morning.
18 MR BOOTH: Thank you.
19 MR MACLEAN: Just before Mr Booth leaves the witness chair,
20 it is obviously sensible now to have a break for lunch.
21 Professor Vann Jones, the next witness, has been given
22 a not before 1 o'clock listing. I understand he is
23 meeting somebody in the building now. I am told it is
24 just after 12.30. Perhaps we should sit again shortly
25 after 1 o'clock?
0096
1 THE CHAIRMAN: Thank you. Shall we say 1.10, to reconvene?
2 Thank you.
3 (12.35 pm)
4 (Adjourned until 1.10 pm)
5 (1.10 pm)
6 MISS GREY: Good afternoon. Sir, Professor Vann Jones will
7 be giving evidence this afternoon.
8 PROFESSOR VANN JONES (SWORN):
9 Examined by MISS GREY:
10 Q. Professor Vann Jones, you have given two statements to
11 the Inquiry. If we could look at the first, please, it
12 is WIT 115/1. Your title, "Professor Vann Jones of the
13 Department of Medical Cardiology", is set out on the
14 first page there; is that right?
15 A. Yes.
16 Q. If we look at page 17 of this statement, is that your
17 signature we see at the bottom?
18 A. It is, indeed.
19 Q. Are the contents of this statement true to the best of
20 your knowledge and belief?
21 A. As far as I know, yes.
22 Q. We see there that you say that you are willing to make
23 further comments on Issue N at a later stage.
24 If we turn, please, to page 19, there is there the
25 first page of a statement on that subject.
0097
1 Again, if we could turn, please, to the last page,
2 that is page 24, is that your signature again at the
3 bottom?
4 A. It is, indeed, yes.
5 Q. Again, are the contents true to the best of your
6 knowledge and belief?
7 A. To the best of my knowledge, yes.
8 MISS GREY: The statement is dated 4th October. Sir, it is
9 right I should say for the sake of the record here that
10 the date of its receipt has meant that interested
11 parties have not had an adequate opportunity yet to
12 comment on its contents. Some have made considerable
13 efforts, including in one case with the assistance of
14 e-mail, that is Dr Bolsin, but not all others have been
15 able to comment on Professor Vann Jones' statement and
16 that of course is no reflection on them. So it may well
17 be that their commentary will have to come at a later
18 date, obviously.
19 Q. With that introduction, could I turn back, please,
20 initially to the first part of Issue N, page 19 of your
21 statement.
22 You say at the very introduction that you were not
23 involved clinically nor managerially with the management
24 of children with heart disease.
25 That is a theme to which I will return. It is
0098
1 also covered to some extent in your first statement.
2 Can you just tell the Panel briefly the background of
3 your medical experience and expertise?
4 A. You mean from immediate post-graduate stage?
5 Q. No, we will take it please, if we may, from the late
6 1980s. I would like you to comment on the medical
7 background from which you make the statement that you
8 were not involved clinically nor managerially with the
9 management of children.
10 A. When I was appointed to Bristol in the early 1980s I was
11 one of two cardiologists and we covered an area for
12 tertiary referrals which covered a population of
13 3.3 million. There were two of us covering 3 million
14 adult patients, so there was absolutely no way I was
15 involved in paediatric concerns. They had their own
16 paediatric cardiologists. Also, before I moved to
17 Bristol, I was a paediatric cardiologist in as much as
18 I happened to be working with a paediatric cardiologist
19 when he developed a fatal illness. I was the Senior
20 Registrar and I took up the mantle and did all the
21 paediatric cardiology in Oxford until I left on 30th
22 April 1992 --
23 Q. Professor Vann Jones, if I could stop you for a second,
24 it may be that you need both to speak up and also to
25 slow down a little for the sake of the record that is
0099
1 being made of your evidence.
2 A. I think every single lecture I have given, I have been
3 asked to do precisely that!
4 THE CHAIRMAN: Professor Vann Jones, it will help you and
5 perhaps also us, feel free to do as you wish, if you
6 were actually to turn a little bit to face Miss Grey,
7 because the stenographer is on your immediate right and
8 is assisted if she can also see you as well as merely
9 hear you. If you were to go a little more slowly, we
10 would be helped. Do not for a moment feel that we will
11 take any offence at all by seeing only your shoulder.
12 A. Thank you very much. That clarifies things, thank you.
13 Basically I had a background in paediatric
14 cardiology which ceased the moment I came here, although
15 I did offer Dr Bolsin assistance because he was also
16 very short-staffed. However, that was not taken up.
17 From that moment on, I had nothing further to do with
18 children with heart disease. As you can imagine, having
19 3 million adults to look after, that was more than
20 enough for two of us.
21 So I had nothing to do with children with heart
22 disease.
23 So far as my management activity was concerned,
24 that started in 1989 when I became Clinical Director for
25 Medicine. I ceased that in October, I think, 1993.
0100
1 At that point I was asked to become Clinical
2 Director for Cardiac Services, which had not been set up
3 at that point, it was a new concept in a disease-based
4 directorate, so there were no guidelines and there were
5 no ground rules.
6 But I never ever envisaged that it would encompass
7 children, because I had had nothing to do with children
8 from 1982 onwards.
9 Q. You have given us the date. It was in October 1993 the
10 suggestion was made that you should become Clinical
11 Director of Cardiac Services. At that stage, was the
12 directorate fully operational?
13 A. The directorate, as I said in my first statement earlier
14 in the year, was a concept. I think it was a fairly
15 sound concept, to try and bring cardiac services
16 together -- I really mean adult cardiac services,
17 because we do have to operate as a team -- and to bring
18 surgeons out of the Directorate of Surgery into the
19 directorate with cardiologists, seemed to me a sensible
20 idea. But that was the level of it, it was an idea, so
21 the remit was to try and turn this idea into something
22 tangible. It had no financial backup. It had no
23 management structure, other than as of October 1993
24 I was appointed and Lesley Salmon was appointed as
25 a manager. None of the infrastructure or anything else
0101
1 was in place.
2 Q. We will come back if we may to its composition later,
3 but I think it is right to note you finally obtained
4 a budget in April 1994?
5 A. That is correct.
6 Q. So when, looking at paragraph N2 of this statement,
7 page 19, Dr Bolsin came to your office on 16th November
8 1993 to talk about the results of four different types
9 of operations on children in the Bristol Royal
10 Infirmary, why do you think that he came to see you?
11 A. As I stated -- we did not discuss why he came to see me
12 because when he made the appointment I had no idea what
13 it was about, but if another consultant asked to come
14 and speak to you, you do not say "No", you say "Yes,
15 that is fine by me", and it turns out to be on
16 16th November.
17 Q. Can I stop you there then just to investigate that? You
18 say when another consultant asked to see you, and you
19 have given us a specific date. How were you able to
20 give us that date, Professor Vann Jones?
21 A. I keep my own diaries and whenever anyone, no matter who
22 it is, asks for an appointment, I write it in the diary.
23 Q. So the date of the appointment is recorded in your
24 diary?
25 A. It is indeed.
0102
1 Q. You say that when he made the appointment, he did not
2 say why he wanted to see you?
3 A. Not that I can recall.
4 Q. Can you tell us what you can recollect of the meeting?
5 How good is your recollection of the meeting, first?
6 A. Average, I would say. I can recall some of it. I can
7 remember Steve coming and saying he was concerned about
8 some of the results in paediatric cardiac surgery. He
9 had data on four different operations. Honestly,
10 I cannot remember what the four were, except that one of
11 them was ventricular septal defects. It was 11 years
12 since I last had done paediatric cardiology, but I knew
13 even then the results on the ventricular septal defects
14 could not be true. It was just not possible that was
15 true for what was a relatively simple operation.
16 However, I listened to Steve, we talked it
17 through. I have said in several places, there were no
18 concerns of urgency, "We must do something about this,
19 it is terrible. These are the figures". The only sense
20 of urgency from Steve was, if I remember rightly, that
21 Bristol below the national average was underlined for
22 the four operations.
23 We talked it through and he left. That was
24 a Thursday morning. I was going to do a list at
25 9 o'clock, so it could not have taken much longer than
0103
1 an hour.
2 Q. Can I go back to my earlier question: did he say to you
3 why he had come to see you specifically?
4 A. No, he did not.
5 Q. Do you know yourself or can you venture any guess as to
6 why you think he came to see you?
7 A. I had been in Bristol Royal Infirmary for 12 years at
8 that time. I think I was seen as a fairly active member
9 of the hospital. I have been Clinical Director for
10 Medicine. I think I have a fairly high profile. I had
11 been given a personal Chair and been made a Clinical
12 Director. I think if Steve was trawling around for
13 people to go and speak to, I would have been on his
14 list.
15 Q. First of all, can we try and identify the document that
16 Steve brought to you when he gave you the results for
17 four different types of operations.
18 If we look at UBHT 61/81, is that something that
19 you recognise? Do you want to see the whole document
20 first?
21 A. I knew it had something like "Bristol significantly
22 worse than the rest of the UK". It is not underlined;
23 I thought it was underlined.
24 Q. That is one page, tetralogy of Fallot. We can turn over
25 the page. There is a similar couple of tables, 82.
0104
1 Again, please, 83. These purport to be the results for
2 the VSD operations.
3 Again, can we turn over, please? AV canal starts
4 at the bottom of that page. Over the page, please,
5 page 85: further results for AV canal.
6 Then, if we look over the page, we will see the
7 results for single ventricle.
8 Does that correspond to your memory of what
9 Dr Bolsin brought to you?
10 A. I remember there were four operations and I guess that
11 is four we have run through, so I think that must have
12 been the document.
13 Q. Were they presented in that sort of form, tabular form
14 with conclusions?
15 A. Absolutely. As I recall, the arrangement was, I do not
16 know if it was a desk as big or high as this, but he sat
17 on that side with sheets of A4 and turned them round and
18 said "John, there seems to be a problem here with one or
19 two of these operations".
20 As I say, the VSD figures just did not square up.
21 If you were just dealing with four operations in
22 paediatric cardiac surgery there are actually dozens of
23 operations, so I would expect any surgeon to be worse
24 than average in some operations and better than average
25 in some others, and some not significantly different,
0105
1 but the VSD figures just stood out to me. That is now
2 a low risk operation where an average paediatric cardiac
3 surgeon would expect to go 100 operations without losing
4 a patient. So it just did not square up.
5 Q. If we can turn back to page 84, please, is this what you
6 say did not square up to you, the results of the VSD,
7 all ages, said to be Bristol significantly worse than
8 the rest of the UK?
9 A. Yes.
10 Q. If we turn back a page, we will see there the bottom
11 tabulation, age less than 1 year, again, Bristol is said
12 to be significantly worse than the rest of the UK?
13 A. Yes. That is the figure that I saw, and the mortality
14 rate of 4 out of 21 for ventricular septal defect, that
15 is a mortality rate of about 16 per cent, almost 20 per
16 cent. I just could not believe that.
17 Q. Just remaining for a moment on what you saw, can we go
18 on, please, to page 87? This is mortality for AV canal
19 broken down by consultant. Do you recollect being given
20 any consultant-specific figures at this meeting?
21 A. I do not, no.
22 Q. You have spoken of your scepticism or negative reaction
23 to the data for one reason, that is to do with the VSD
24 results. Were there any other elements in your reaction
25 to the data at this stage?
0106
1 A. We have to envisage the situation in which I found
2 myself. At that stage I had 12 years of very good
3 service from Mr Wisheart, and from Mr Dhasmana, although
4 not so many years. For many years these chaps operated
5 on some extremely sick patients of mine, and the
6 patients survived, the patients did well and were very
7 grateful, and so was I. In front of me was a set of
8 figures which said three operations were worse than the
9 national average, one was not significantly different,
10 and one I could see was blatantly flawed, so I actually
11 wanted some further clarification of this information,
12 and where were the data on all the other operations that
13 were going on.
14 Q. Can I just distill that into this: I asked you what
15 other elements there were in your reaction. You have
16 repeated I think, as part of your answer, the fact that
17 the results for VSD in particular did not square with
18 your knowledge of that difficulty posed by that form of
19 operation.
20 You also started by referring to your personal
21 knowledge or experience of working with Mr Wisheart as
22 a colleague.
23 A. Yes.
24 Q. Can you just expand on what you meant by that, please?
25 What was your judgment of Mr Wisheart's competence and
0107
1 also his integrity?
2 A. For many of these years when we were looking after the
3 whole of the South West, 3.3 million people, we were the
4 sole cardiac surgical unit, but we could not cope, so
5 a number of patients went off to London and some were
6 done in Bristol. By and large, the sort of patients we
7 would keep in Bristol would be the acute admissions who
8 could not travel, the more serious cases. So we had
9 many discussions about very serious cases and James
10 Wisheart and Janardan Dhasmana -- there were only two of
11 them -- Mr Keen who was a third surgeon did valvular
12 surgery pretty well exclusively -- so the acute ones,
13 the coronaries and post-infarct disasters and so on --
14 both Mr Dhasmana and Mr Wisheart operated on many many
15 sick patients very successfully.
16 What I had in front of me when Steve came was data
17 on two operations which seemed to do worse than the
18 national average. Against that, I think the total has
19 been calculated; the whole GMC Inquiry was based on
20 4 per cent of the paediatric workload, and not only
21 that, but these surgeons were also doing a lot of adult
22 work as well. So I really wanted a bit more information
23 before alarm bells were going to ring in my head and we
24 started a major inquiry.
25 I asked Steve, as I recall, to go at least away
0108
1 and check his VSD figures.
2 Q. You had known Mr Wisheart for a number of years.
3 Dr Bolsin, by contrast, had been appointed and taken up
4 his job in 1988. How well did you know him?
5 A. I did not know Steve at all well, but I say now, I knew
6 the anaesthetist not at all well. The meetings are with
7 surgeons and the toing and froing and discussion about
8 patient management is with the surgeon, not with the
9 anaesthetist. Occasionally an anaesthetist will of
10 course say "I am not happy with anaesthetising this
11 patient" and he will become involved in the discussion,
12 but Steve Bolsin had been a consultant for two years, so
13 my involvement with him had been minimal up to that
14 point.
15 Q. You have spoken to Mr Wisheart on a professional level.
16 Was he also a friend?
17 A. He was, as I said in my GMC statement, a friend. James
18 and I were friends on the basis that in the 12 years
19 I had been in Bristol up to that point, perhaps I had
20 been in his house twice and he had been in my house
21 twice, enjoying a party every now and again or
22 a welcoming event for some new consultant. It was that
23 sort of level. But never did we socialise out of that
24 sort of narrow context. But I would have regarded him
25 as a friend.
0109
1 Q. Do you think that the length of time for which you had
2 known and dealt with Mr Wisheart as opposed to the very
3 limited contact which you had with Dr Bolsin made any
4 difference to your reaction to figures when presented
5 with them?
6 A. I think you would be less than human if you did not
7 react in a slightly different way. He was a young
8 consultant presenting very limited data which appeared
9 to be condemning -- there were only two of them so
10 Mr Wisheart had to be one of them, and also I had the
11 same sort of relationship with Janardan Dhasmana. So
12 these were chaps who had worked extremely hard for us
13 over the years, and these were very limited data. Yes,
14 I think undoubtedly I was swayed by my 12 years of
15 dealing with two men of the highest integrity.
16 Q. You have talked about being presented with data. Is it
17 possible that another thread in your reaction to this
18 was your general experience of the creation of audit
19 programmes and data at that time within the UBHT?
20 A. Well, audit was very much in its infancy. Steve Bolsin
21 happens to be a particular expert in audit, although
22 I must say, I did not know that on that particular
23 morning in November 1993, but it turns out that is his
24 major interest. But audit was in its infancy and the
25 sort of information technology that was required to be
0110
1 available to make audit much more comprehensive was not
2 available in those days. It is now, and as you know,
3 audit is very well established, especially in the UBHT,
4 but it was not in those days.
5 I actually set up the audit process for the
6 Director of Medicine in 1988, and it was very basic:
7 just getting out hard copies of notes, going through
8 with the collected physician body and deciding how we
9 would have done things differently, and then getting
10 feedback some months later as to whether the practice
11 had changed, but it was very, very basic. Audit is
12 entirely different nowadays.
13 Q. I ask you that because I think to the GMC you spoke
14 about scepticism when presented with figures at a time
15 when you said that information technology and audit were
16 breaking out all over the place. A slightly colourful
17 phrase. Is that evidence -- I am summarising it -- that
18 you would stand by?
19 A. For that time period I would certainly stand by that.
20 The audit -- I mean in the 1990s, there has been
21 a complete sea change in the practice of medicine. As
22 you know, there was no information about how people were
23 performing, even numbers, you could not get, and
24 certainly could not get financially reliable statistics
25 in the early days. Every now and again you get a set of
0111
1 data that is completely meaningless. You were seeing
2 500 patients in an outpatients clinic, and things like
3 that made you distrust the data. It has improved out of
4 all recognition.
5 Audit, on the other hand, everyone was setting it
6 up. There were no clear guidelines -- they were with
7 the Royal College of Physicians and I used their
8 guidelines to set up audit. I was not Clinical Director
9 then. These were only published in the late 1980s, and
10 then people had to take that forward and set up audit,
11 and it all takes time. As I say, my own particular job
12 involved looking after half of 3.3 million people, so
13 you have to prioritise your things on a day-to-day
14 basis.
15 But a lot of progress has been made.
16 Q. You have said repeatedly that the VSD figures struck you
17 as being flawed. What is your recollection of whether
18 you discussed that matter and queried it with Dr Bolsin
19 at the time?
20 A. I think, as has even been shown on television
21 programmes, I questioned the validity of the data. It
22 was just so far out of what I knew was the state of play
23 12 years earlier. That was 12 years earlier, when
24 cardiac surgery on children was a very risky business.
25 It was worse than the figures from 12 years earlier, and
0112
1 I just knew that these were not the sort of figures that
2 were occurring anywhere.
3 Q. So to be clear, is your evidence to the Inquiry that
4 this was something that you raised with Dr Bolsin?
5 A. Absolutely.
6 Q. Can I again go back to the evidence before the GMC,
7 then, and read you out this paragraph, where, again, you
8 said that you would be talking of the VSD data:
9 "I was surprised if that had really been the
10 Bristol mortality for VSDs, because I had not heard
11 there was any problem" and the question was put to you:
12 "In the light of your answer there, do you think
13 it is likely you would have queried VSDs in particular
14 with Dr Bolsin? Your answer was:
15 "I cannot recall that, but I know that was just
16 about the soul discussion I had with James when James
17 came to see me, because I am sure I said to him that
18 I was surprised to find six deaths, I think it is --
19 I cannot remember the number -- in ventricular septal
20 defects. I have to say that surprised me from what
21 I knew of the operative risks for this procedure".
22 Then the questioner came back:
23 "I appreciate that point, but what I am asking is
24 in relation to Dr Bolsin. With your knowledge of
25 paediatric cardiology and your suspicion about the
0113
1 success of ventricular septal defects, do you think it
2 is something you would raise with Dr Bolsin?"
3 Your answer was:
4 "I think it is highly likely. I can say no more
5 than that."
6 Then you went on in response to another question
7 to say that you would not have been as specific as the
8 questioner had suggested.
9 "I think I would have said that is a very
10 surprising result and I had not actually heard there was
11 a problem with VSDs. With all due respect to Steve,
12 I would have had reservations about that figure."
13 I read that passage back to you because it appears
14 apparent from that that at the time of giving evidence
15 two years ago, you were doing your best to recall, but
16 you could put it in terms of a matter being highly
17 likely, at most?
18 A. Maybe I am being too positive today. As you can
19 imagine, over the past few years this has gone through
20 my head a million times and I am just absolutely not
21 certain what is fact and what is fiction with some of
22 these meetings that took place. The VSDs certainly
23 stood out. Whether we spent a long time discussing them
24 or not, certainly the four sets of operations were put
25 in front of me and one of them looked to me as if they
0114
1 were way offline, so way offline that I could not
2 believe the data. Whichever way I phrased it to the GMC
3 and I am phrasing it to this Inquiry, I think the
4 message is still the same: that there was something
5 wrong with the VSD data.
6 Q. Because Dr Bolsin, for his part, will say that he did
7 not take away that message from his meeting with you,
8 and that the proof of that is that the VSD data was not
9 checked and corrected and an error acknowledged in them
10 until 1995.
11 Is it not likely that if you had raised a query
12 with him about the VSD data, that indeed he would have
13 gone away and checked it?
14 A. I had no control over Steve's actions after that
15 meeting. Lots of us have been accused of inertia;
16 why should we not reciprocate and perhaps accuse Steve
17 of inertia in not going and checking the data? So
18 I would suggest that the problem was highlighted to him.
19 Q. For your part, from your recollection, what message or
20 impression do you think that Dr Bolsin would have gained
21 from you after leaving that meeting?
22 A. It was a totally amicable meeting. It is absolutely
23 right that people should express concerns about the
24 management of cases. That is what they are all there
25 for. Our job is to look after patients in the best
0115
1 possible way. So it was a perfectly amicable meeting.
2 I was somewhat worried about the tetralogy of Fallot
3 figures. I was hoping he was a bit worried about the
4 VSD figures, but I have to say, it was only four
5 operations, one was not significantly different. Three
6 were and one set of results was obviously quite wrong.
7 I most definitely mentioned that to him, but just how
8 strongly or what message he got from it, I do not know.
9 I think if you are taking sets of figures around and
10 someone actually questions the validity, and it is
11 a very, very important issue you are raising -- I mean,
12 we all know how important it is now -- I think the least
13 you should do is go and make sure you have your facts
14 right. And I did expect him to come back and he did
15 not.
16 Q. What did Dr Bolsin ask you to do, if anything?
17 A. He asked me to do absolutely nothing. He purely and
18 simply said "Look at these tables, John. I think this
19 is worrying". That was it.
20 Q. Did he suggest that any particular action needed to be
21 taken on those figures?
22 A. No.
23 Q. Because again, his account is that he explained to you
24 that this was as thorough and as complete an audit as he
25 could carry out, and that he believed that there needed
0116
1 to be a full investigation into the paediatric cardiac
2 surgery service on the basis of the figures that you
3 were given?
4 A. Well, I have no recall of him being anything like as
5 positive as that.
6 Q. What was his manner to you, as you recollect it?
7 A. As I have already indicated, it was a very bland, no
8 sense of urgency type meeting that we had that morning.
9 He presented those very sheets of A4, we talked around
10 them for an hour, but there was no question of "This is
11 a national tragedy brewing, John", absolutely nothing of
12 that. There was a concern about some of these
13 operations and it was expressed at that sort of level,
14 no emotions involved, no tears, such as has happened
15 subsequently.
16 Q. Does it need emotions or tears to translate the sort of
17 figures that you are being given into the proposition
18 that children's lives were being unnecessarily
19 endangered?
20 A. No, it does not, but you have to remember that if you
21 are talking about 4 per cent of the paediatric cardiac
22 programme and we are talking about a very small
23 percentage of the cases, then I would want to have seen
24 the whole picture. If the whole picture was one of
25 uniform, you know, worse performance, then that
0117
1 obviously would have been a very, very major cause for
2 concern, but I have not the slightest doubt that had
3 people taken my angioplasty results for 1985, let us
4 say, and compared them with elsewhere, I may well have
5 looked worse than Southampton and I may well have been
6 worse for two vessel disease than for single vessel
7 disease. We all have runs of procedures where we get to
8 the stage where we think we cannot do them any more, and
9 have bad runs.
10 In paediatric cardiology in particular, the
11 investigations are very complicated. When you inject
12 dye into a little heart that has new vessels all over
13 the place, you often get incomplete information. You
14 often get surprises when you open up the chests of these
15 youngsters, so you have to have some scepticism about
16 things just being called Fallot's tetralogy, because it
17 is often Fallot's tetralogy plus something else: no
18 liver or diabetes, et cetera.
19 So I thought on two of the operations they were
20 worrying figures, but I wanted more information.
21 Q. If we go back to your statement, page 19 of WIT 115, at
22 the very last sentence you say that it was obvious from
23 your conversation with Dr Bolsin that he had shown these
24 figures to a number of other more relevant people.
25 Leaving aside for the moment the comment on
0118
1 relevance, can you tell us, did he say to you that he
2 had shown these figures to anybody else?
3 A. This is almost exactly six years ago, and I cannot
4 recall, to be honest.
5 Q. So is this right from your statement: you are left with
6 the impression of others having seen them?
7 A. I had the distinct impression that I was well down the
8 pecking order and quite honestly, I would have expected
9 to have been well down the pecking order of people that
10 Steve should have been reporting his concerns to. The
11 impression I had was that I was well down in the pecking
12 order. That may well have been erroneous. I think he
13 subsequently said it was erroneous, but why he should
14 elect to come to an adult cardiologist who had been
15 Clinical Director of a non-existent directorate for
16 three weeks and regard me as an important player in
17 this -- well, you would have to ask Steve that.
18 Q. Did Dr Bolsin leave you with a copy of the figures?
19 A. Not that I recall.
20 Q. I think it is right you say when you spoke to
21 Mr Wisheart later, you did not have them available to
22 you; is that right?
23 A. No, I did not. I am pretty sure of what happened, and
24 as I say, it is six years and a lot of things have
25 happened since then, but I am pretty sure that I almost
0119
1 certainly handed them back to him and said something
2 along the lines of, "You had better check out the
3 figures, Steve, because there is something wrong with at
4 least one of them". Anyway, I was not left with a copy,
5 of that I am certain.
6 Q. If you got the impression you were well down on the
7 pecking order of whom these figures had been shown to,
8 did you get any impression as to whether the surgeons
9 most directly concerned had been shown them?
10 A. No. If you mean Mr Dhasmana and Mr Wisheart, I had no
11 feel for that, no.
12 Q. What was your understanding of how such an audit, if one
13 may call it that, of results in surgery should have been
14 handled at the time, if, for instance, a junior
15 cardiologist had had worries -- a consultant
16 cardiologist had had worries about the outcome of
17 results in surgery? How would you expect that to have
18 been handled by him or her?
19 A. If anyone had concerns, real concerns, then there were
20 various routes to take, but the obvious one was the
21 professional route, and as I say, there were Clinical
22 Directors of Surgery; there were Professors of Surgery.
23 These were the two places I would have gone to first of
24 all, I have to say, because these were professional
25 matters.
0120
1 The directorate system was basically set up as
2 a management system for clinical input into management
3 issues. There still existed absolutely in parallel and
4 still does to this day a completely separate
5 organisation in the hospitals for professional issues,
6 for instance, if a Senior House Officer is misbehaving,
7 then there is a professional forum to deal with that.
8 I am talking about professional performance. This is
9 a question of professional performance.
10 Ultimately, if an employee is not carrying out his
11 professionalism to a level that one would expect him to
12 do so, his professional duties, then obviously
13 management has to get involved at a senior level to make
14 decisions about the career of that person, but
15 initially, matters are usually resolved by professionals
16 themselves to decide whether it is an issue that has to
17 be taken further.
18 So I would have expected Steve to at least have
19 gone to his Chairman of Division in anaesthesia -- and
20 as it happens, anaesthesia, if I remember rightly, was
21 one of the areas where in fact they decided that the
22 Chairman of Division and the Clinical Director should be
23 the same person. In general medicine, when I was there,
24 we kept the professional issues separately and we had
25 a Chairman of the Medical Division as well as the
0121
1 Clinical Director, so I was very much used to the
2 Clinical Director being a management person who gave
3 management and financial advice to my colleagues while
4 at the same time there was an absolutely parallel system
5 for the professions.
6 Cardiac services was three weeks old when Steve
7 came to see me, and absolutely none of this had been
8 thought through.
9 Q. You say there you would have expected Steve to at least
10 have gone to his Chairman of Division of Anaesthesia,
11 but that suggests his concerns might have been with his
12 own professional grouping; is that correct?
13 A. I think that is not unreasonable, yes.
14 Q. Because one of the suggestions that will no doubt be put
15 to Dr Bolsin is that what he should have done would have
16 been to raise these matters with the surgeons
17 themselves, and by that I mean in this case Mr Wisheart
18 and Mr Dhasmana.
19 What is your comment on that?
20 A. I think that is a common courtesy, I have to say.
21 I like to think that if someone thought I was not up to
22 the mark professionally, they would have the courtesy to
23 come and mention it to me. Almost certainly, with my
24 personality, that would have been an acrimonious
25 meeting, but so be it! At least I would have had the
0122
1 courtesy of being told someone was identifying
2 a problem. If Steve did not do it -- and I gather he
3 did not -- I think he owed the two surgeons a courtesy
4 to say he had concerns about their performance.
5 Q. Was that a matter of courtesy, or is that a matter of
6 professional obligation and etiquette?
7 A. I think it is both, really. I think you are obliged to
8 go and discuss with people how they were performing and
9 in this context -- I mean, I have never experienced this
10 before and I have never experienced it since, so
11 I really do not have a set view on it, but I would have
12 thought if one consultant was really concerned with the
13 performance of another two consultants, that he should
14 go and say "I have serious concerns about this and
15 I must go and raise the subject with the relevant
16 parties". I think it would have been courtesy. Then we
17 would not have people running about with different sets
18 of figures and we could perhaps have sat down and got
19 the whole thing clarified.
20 Q. Turning to the next event in these matters, you say at
21 page 20 of your statement that a day or so after this
22 meeting with Dr Bolsin, Mr Wisheart also visited you in
23 your office. Can you tell us, did Mr Wisheart say why
24 he had come to see you?
25 A. Again, this is six years ago, and I mean, I presume
0123
1 Mr Wisheart had got wind of the fact that there were now
2 adverse comments going round the hospital about his
3 surgical performance. I was not terribly surprised to
4 see him because I must say, if the same rumours had been
5 going around about myself, I would have tried to see the
6 people and put my side of the story. So I was not very
7 surprised to see him.
8 Q. Did he lead you to believe, one way or the other,
9 whether he had known that concerns were being expressed
10 by Dr Bolsin specifically?
11 A. I honestly cannot recall.
12 Q. Would it be fair to assume then, by the same token, that
13 you cannot recollect whether he indicated whether or not
14 he had seen Dr Bolsin's figures or not?
15 A. I cannot recall that either.
16 Q. You mentioned that he had quite a different set of
17 figures. Can you describe to us how those figures were
18 presented to you, what form they took?
19 A. They were handwritten. I think at the GMC I mistook
20 Steve Pryn's handwriting for James's handwriting. There
21 is a handwriting account of I think he said to me the
22 data that had been presented to the UK Cardiac Surgical
23 Register.
24 Q. I can show you one of the returns to the Cardiac
25 Surgical Register as an example. If we look at
0124
1 UBHT 55/212 to identify the concerns that would have
2 been most current at the time you saw Mr Wisheart, if we
3 turn to page 219, that is an example. Can we see the
4 full page, please, of how the data would have been
5 presented to the Register for Congenital Heart Disease.
6 There is further data over the page, page 220, in
7 similar form.
8 Is that similar to what you were given by
9 Mr Wisheart?
10 A. I do not think so. I am pretty sure it was all
11 handwritten. I cannot be certain.
12 Q. Because the data that is presented in these returns is
13 for one year only?
14 A. Yes.
15 Q. Did the figures that Mr Wisheart gave to you range over
16 a greater period of time, can you say?
17 A. Yes. They certainly did. I mean, I do not know why or
18 how James Wisheart had got wind of criticism about his
19 AV canal operations, but he certainly presented me with
20 figures for the AV canals. I can remember that he had
21 a good run and then he had a bad run. In fact he had
22 a run for a number of years when he had no mortality, as
23 I recall. For that operation, I know it was pretty
24 impressive. It is a very major piece of cardiac
25 surgery. Then, of course, there was the adverse run.
0125
1 Q. So if he was presenting results for the AV canal
2 operations, were they specific for his results or were
3 they aggregated for the unit as a whole?
4 A. I cannot recall. Having said that, I got the feeling
5 they were his results, but I cannot recall, to be
6 honest.
7 Q. You say, looking back at page 20 of your statement, that
8 Mr Wisheart informed you that a number of other people
9 had seen "the figures", and then you come on to give
10 some names. We will come back to that.
11 If a number of people had seen "the figures", to
12 what was Mr Wisheart referring: the figures he was
13 showing to you, or the figures you had seen already?
14 A. By that I meant I thought that these people had seen and
15 been spoken to, or spoke to Steve Bolsin. I thought
16 they were talking about Steve Bolsin's figures.
17 Certainly, the only one I am fairly certain about is
18 that Paul Dieppe, I think, was seen the day before
19 myself by Steve. I mean, This is all second-hand
20 because this is something that James Wisheart told me,
21 that Paul had seen the figures and Paul had contacted
22 him about the matter.
23 Q. From that, it appears that you recollect that
24 Mr Wisheart spoke about Paul Dieppe seeing the figures,
25 but you seem uncertain about the evidence in the
0126
1 statement about Dr John Roylance?
2 A. I cannot be certain. I mean, there are situations in
3 which you get an impression that things are fairly
4 widely known. I certainly could not swear that John
5 Roylance had seen the figures, that is for certain, but
6 I just had an impression that he had, for some reason or
7 another. I think that would not have been unreasonable,
8 because I think if Steve Bolsin was really wanting to go
9 down the pecking order in the figures to show the
10 figures to, he certainly should have had John Roylance
11 at the top of the list.
12 Q. That implies the reason you thought Dr Roylance might
13 have seen them was merely because you thought Dr Bolsin
14 ought to have shown them to him if he was serious about
15 his concerns?
16 A. It could be interpreted in that light, yes, certainly.
17 Q. Does it come back to a lack of certainty as to whether
18 or not Dr Roylance had seen them or not, such that in
19 truth you are not able to recollect whether or not you
20 were told that he had?
21 A. I absolutely agree. I could not swear that John
22 Roylance had seen the figures.
23 Q. You were presented with what you describe as quite
24 a different set of figures. Was that a matter of
25 concern to you, or was it something to be expected,
0127
1 given perhaps the state of information collection at the
2 time?
3 A. As I told you, information technology was in its infancy
4 and everyone, certainly throughout my tenure as Clinical
5 Director of General Medicine, we all had a healthy
6 scepticism about data we were provided with. As far as
7 someone presenting a completely different set of
8 figures, I have to say I had seen that so often in
9 financial terms, it did not surprise me too much that
10 the same thing might be happening in audit terms at that
11 time, 1993.
12 Q. In other words, that you had knowledge of situations in
13 which figures were presented to support a case, or could
14 be manipulated to support a case?
15 A. That implies that there was some sort of malice on
16 either part of the parties concerned. I do not think
17 that is true. I think we both genuinely believed that
18 the figures were correct and that presents a difficulty
19 as to whom to believe in at the end of the day.
20 Q. So you discussed, I think you said the AV canal
21 results. Did you have any further discussion about any
22 of the other results, or discrepancies in figures?
23 A. I cannot recall.
24 Q. If you thought that what had been presented to you were
25 returns or data that had been presented to the UK
0128
1 cardiac surgery register, were you at the time making
2 any assumption on what happened to such returns to this
3 central national register when they were received?
4 A. Yes, I think that is true. I think I made assumptions
5 that that must be validated data. I did not know until
6 later on, for instance, that the whole thing was
7 anonymised and lumped together. I still do not know how
8 the cardiac surgeons manage their data. I think it is
9 now much more objective, but I had no idea in those
10 days, it was just people sending forms in and the whole
11 thing was lumped together, so therefore any particular
12 centre that was not performing was just lost in the
13 overall ...
14 Q. What did you think did happen to it?
15 A. I thought, naively, I guess now, that people would make
16 comparisons between centres. There were not that many
17 of them doing paediatric cardiac surgery. I think in my
18 statement I said 14, but I think it was 9 supra-regional
19 centres, so I would have thought that someone was making
20 comparisons. I would have thought that was the purpose
21 of the register.
22 Q. From this meeting you were taking the fact that both
23 Mr Wisheart and Dr Bolsin were conducting a debate,
24 possibly not between themselves but at least with other
25 members of the community within the UBHT.
0129
1 What impression did you form as to how the matter
2 was to be further taken forward, or perhaps resolved,
3 after your discussion with Mr Wisheart?
4 A. First of all, I thought that everyone who was
5 relevant -- and I have to say, I do not include myself
6 in that, although others obviously disagree; I was not
7 making assumptions -- had been informed, including the
8 people I have listed there: the Professor of Surgery,
9 the Professor of Anaesthesia. I really did think that
10 Dr Roylance had been informed, and of course the Dean of
11 the Medical School. That seemed to me to be the
12 principal players in the decision-making, had all been
13 informed.
14 Q. Why do you say that Professor Farndon and Professor Prys
15 Roberts were more directly relevant to this matter than
16 yourself, because neither of them, I think I am right in
17 saying, had any direct involvement in paediatric cardiac
18 surgery any more than you did?
19 A. That is true, but the divisions of surgery and the
20 divisions of anaesthesia were -- this directorate, which
21 was not a division, had been a theory for three weeks,
22 not a reality; a theory for three weeks. If you are
23 expressing some concerns about something going back, as
24 we now are to 1984, and I think Steve's figures were for
25 1990 to 1995, then someone who had been given a concept
0130
1 to deal with for three weeks would not have been the
2 person that was that important, I would not have
3 thought. I think I would have wanted to speak to the
4 Professor of Surgery, or at least the Clinical Director
5 of Surgery, because cardiac surgery was surgery. It was
6 an anaesthetist who was expressing a concern. His
7 Professor was Prys Roberts and he also had a Clinical
8 Director and a Chairman of Division. He had a lot of
9 other avenues to explore.
10 Q. In any event, you thought that those who had been or
11 were more directly concerned had been informed of this
12 discussion, debate, call it what you will. What did you
13 think would happen as a result of that?
14 A. Well, I thought that the sensible thing I would have
15 expected to happen would have been that the Chief
16 Executive would have organised at least an internal
17 assessment of what was going on, and there were
18 clinicians involved with these, quite apart from the
19 surgeons and anaesthetists: the cardiologists, some
20 cardiac radiologists and a lot of other anaesthetists.
21 It would have been very easy to have had a view from
22 people who were dealing with these babies and had dealt
23 with these babies for the five-year period that -- at
24 that time it was a three or four-year period that Steve
25 was querying, people involved with these children on
0131
1 a day-to-day basis. It would have been a simple enough
2 thing to have asked them what they thought.
3 Q. Did you yourself make any suggestions to Mr Wisheart how
4 the matter ought to be taken forward?
5 A. I did not make any suggestions to James Wisheart because
6 that would have been inappropriate, because he was the
7 chap who was involved in it.
8 Q. You have mentioned that the Chief Executive might be
9 expected to call a meeting between the relevant
10 clinicians. That, of course, firstly would depend on
11 him being apprised of the situation by those working for
12 him; is that right?
13 A. I think he would have had to have been apprised of the
14 situation, yes. Of course he would have been, yes.
15 Q. You mention, I think, that there were perhaps two
16 relevant ways in which matters might be dealt with.
17 One, a possibility, you say there the route for you to
18 have expressed concern would have been to Mr Wisheart as
19 the Hospital Medical Director, and to Dr Roylance as the
20 Chief Executive, and both of them seem to have been
21 informed already. I think we have already established
22 that the evidence, and your recollection of whether
23 Dr Roylance had been informed already, is based upon an
24 assumption rather than any clear recollection to which
25 you could swear; is that right?
0132
1 A. That is absolutely true, but it was a very strong
2 assumption.
3 Q. But you say that there are two patterns there, and one
4 of course will depend on it being invoked. What about
5 that of Mr Wisheart as the Hospital Medical Director?
6 He in this case was not merely an independent figure who
7 might therefore chair a meeting of clinicians without
8 having a direct involvement himself, but he was one of
9 those engaged in the service which was facing potential
10 criticism.
11 Do you think under those circumstances the route
12 to the Hospital Medical Director could operate
13 effectively?
14 A. I do not think it could. I have said that in my
15 statement. I do not think either Steve Bolsin could
16 express his concerns through that route and neither
17 could I.
18 Q. Was there not, therefore, a case for suggesting the
19 involvement of either the former Medical Director or the
20 Medical Director elect?
21 A. I think if I had been -- there was not a Medical
22 Director elect. There was no such position. There was
23 a medical graduate, an indefinite appointment. The
24 Chairman of the Hospital Medical Committee, which James
25 Wisheart was, the clinical forum, there is certainly
0133
1 a deputy appointed two years in advance.
2 Q. You are quite right to pick up my mistake there, yes.
3 Do you think that such a person could not perhaps have
4 been called upon, given Mr Wisheart's own position in
5 the Department of Surgery?
6 A. The timing of this, I cannot recall whether James
7 Wisheart was still Chairman of the Hospital Medical
8 Committee at that time, or not. I know that very soon
9 afterwards he was not because Dr Laszlo became Chairman
10 of the Hospital Medical Committee, but if James Wisheart
11 had been at that time Chairman of the Hospital Medical
12 Committee, and he may well have been, it would also have
13 been inappropriate to have him do that. But he would
14 have had Dr Laszlo waiting in the wings to take over
15 from him.
16 So, yes, I think to have asked Dr Laszlo to run
17 some sort of independent inquiry, particularly as he was
18 not cardiac orientated, would have been a reasonable
19 thing.
20 Q. I think it is implicit from your evidence that you did
21 not feel the need, indeed it is explicit that you did
22 not feel the need to call upon any further people to get
23 involved in this matter. Why was that, given
24 Mr Wisheart's position as Medical Director?
25 A. I do not think that is true. I obviously discussed this
0134
1 with Lesley Salmon, who was my manager. I asked her if
2 she had seen the figures and we did ask a considerable
3 number of people, by that time talking about people on
4 the ground looking after these children. I did not go
5 and ask people like John Roylance to organise an
6 external enquiry, you are absolutely right, but I did
7 ask a considerable number of people. I think the
8 evidence of that is that just five months later I wrote
9 a letter suggesting that we should appoint a full-time
10 paediatric cardiac surgeon if humanly possible. That
11 was not based on an interview with John Roylance, it was
12 not based on an inquiry set up by Dr Laszlo, but it was
13 based on canvassing a lot of people in corridors and
14 various other places during the course of the next few
15 months.
16 Q. Why do you say that Dr Roylance would have been
17 a suitable person to chair a meeting on this matter,
18 because Dr Roylance was obviously the Chief Executive of
19 the hospital; he was the Chief Manager, therefore, of
20 the Trust affairs? He would say, I am sure, that he was
21 responsible for budgetary organisational and planning
22 matters, and would therefore perhaps make some of the
23 same points about the limitations of his role as you
24 have done already in discussing your role as Chairman of
25 the division of cardiac services.
0135
1 A. If you got the impression I was suggesting that John
2 Roylance should chair that committee or investigation,
3 I am sorry, that is not what I meant to say. I am
4 saying as a Chief Executive he should have set it up.
5 I think that is different. He could have appointed
6 someone and the sensible thing absolutely would have
7 been somebody totally removed from it, such as an adult
8 cardiac surgeon. Jill Bullimore was asked to do that
9 from the Oncology Centre, 400 yards away. I think it
10 would have been easier to find a senior figure in the
11 hospital who could have conducted an inquiry. John
12 Roylance was seeing James Wisheart on a day-to-day
13 basis. As Medical Director and Chief Executive they
14 were seeing each other every single day, so John could
15 not have been objective, either, really. But he could
16 have set up some form of inquiry.
17 Q. Do you think it was his responsibility to do that, to
18 initiate such an inquiry, notwithstanding the fact that
19 his role was primarily one of a managerial function, not
20 one directly concerned with matters of professional
21 competence?
22 A. The Chief Executive at the end of the day is the chap
23 who makes all the decisions in a Trust. He is the peak
24 of the pyramid, and at the end of the day, something as
25 important as this should have been a matter that the
0136
1 Chief Executive should have attended to. I do not mean
2 personally, but certainly he should have set in place
3 some form of investigation.
4 Q. If we go over the page to page 21, we see over the
5 ensuing few months there was much debate about
6 Dr Bolsin's concerns and Professor Angelini approached
7 you about them.
8 You do not date that, but it must have been
9 obviously some time after you had had an initial
10 discussion with Mr Wisheart?
11 A. Professor Angelini is someone of course I was seeing on
12 a regular basis, because he is one of the surgeons to
13 whom I refer cases. There is no way that this sort of
14 information was not going to be discussed informally,
15 frequently, between myself and just about everyone else
16 in cardiac services. Gianni Angelini, if you have not
17 interviewed him yet, you will see Gianni sees things in
18 very black and white terms. So you have to be a little
19 bit circumspect when Gianni is jumping up and down
20 asking for inquiries and giving his view.
21 He is a very able surgeon and has done commendable
22 things, but there is no doubt that he and James Wisheart
23 had a personality clash. I listened to Professor
24 Angelini's concerns, but I wanted my own information.
25 Q. So is it right to say there were a number of discussions
0137
1 with Professor Angelini before the letter written
2 jointly with him in April 1994, to which we will come in
3 a moment, was written?
4 A. There is absolutely no way I would have written that
5 letter. It was dictated in his presence into my
6 dictaphone. If I had not by that time had some
7 background information on which to base that letter,
8 I would never in a million years write a letter like
9 that just because Gianni came into my office one day and
10 said "I would like you to dictate this letter, please".
11 Q. You paint a picture of general debate between November
12 1993 when you first were seen by Dr Bolsin and then
13 April 1994 when you wrote the letter we will come to.
14 Can you tell us, how widely spread was this debate
15 amongst those involved in cardiac surgery and paediatric
16 cardiac surgery specifically?
17 A. This debate was everywhere by that stage. By April
18 1994, in the course of the ensuing year or two it was
19 a major topic of conversation by everybody in cardiac
20 circles.
21 Q. So if I mention specific names, did you have any
22 conversations firstly with Mr Dhasmana about the
23 subject?
24 A. I am absolutely certain we must have talked about it,
25 but no formal interview.
0138
1 Q. And what about Dr Hyam Joffe? Can you recollect any
2 discussion with him?
3 A. I saw Hyam quite regularly because he was Clinical
4 Director for children's services. I am equally certain
5 that I must have expressed my concerns to him. It was
6 almost impossible not to discuss it, rather than
7 specifically going to find people. Whenever you bumped
8 into someone, it was the topic of conversation, "What is
9 happening?" et cetera, so it was not a question of
10 having to go and see people, it was quite the reverse.
11 It was sometimes a question of not discussing it when
12 you met somebody.
13 Q. Nevertheless you say "I must have spoken to him about
14 it", which is the language of assumption rather than
15 definite recollection?
16 A. This is six years down the line, and as I say, just
17 about everyone you spoke to had a discussion on the
18 subject. It would have been remarkable -- let us put it
19 this way. I had seen Hyam Joffe at the Clinical
20 Directors' meetings monthly for four years -- well, it
21 was not four years, it was towards the end then, but
22 certainly the Clinical Directors' meetings for a year or
23 two, it would have been remarkable if we had not
24 discussed it.
25 Q. Those meetings I think were chaired by Dr Roylance.
0139
1 I have asked you about Mr Dhasmana and Dr Joffe. What
2 about Dr Roylance? Did you have any discussion with him
3 about this matter that you can recollect?
4 A. Well, he was not somebody I ran into in the corridors.
5 But certainly -- I do not have in my diary specific
6 dates when I went to speak to John Roylance, although we
7 did later on. John Roylance was not a very approachable
8 chap. He was also somewhat inflexible. I finally
9 suggested one or two things, like, for instance, I was
10 the person who finally suggested that Mr Wisheart and
11 Mr Dhasmana should give up paediatric cardiac surgery
12 altogether. That certainly was not welcome. It was
13 made clear to me it was not welcome. It was also made
14 clear to me it was none of my business. So I do not
15 find John a particularly approachable chap. He is an
16 archetypal politician, very difficult to get past the
17 facade. So I certainly did not specifically go and
18 speak to him. But again, he was present at all the
19 Clinical Directors' meetings, and I would be surprised
20 if I had not raised the subject with him, particularly
21 as we each had to give reports to this meeting.
22 Hyam Joffe had to give a report about what was happening
23 in children's services and I had to give a report on
24 what was happening in cardiac services. I would have
25 been very surprised if the subject had not been given an
0140
1 airing at some point in these meetings.
2 Q. At that point, what you are describing is formal
3 reporting to the meeting from the Clinical Directors.
4 Are you saying that the subject of debate within the
5 Paediatric Cardiac Surgery Unit was given an airing at
6 these meetings in the form of such a report?
7 A. I honestly cannot recall. This went from the November
8 16th meeting with Steve Bolsin to becoming absolutely
9 widespread to the point where James Wisheart stood up in
10 front of the Hospital Medical Committee and tried to
11 defend himself and a very serious extra meeting was
12 called. What took place in-between, it was very
13 imprecise. It was a diffuse spreading of information,
14 conversations, of people starting to think maybe there
15 was something happening that we should be worried about,
16 and it was not a sudden blinding flash of light and all
17 of a sudden things were clear.
18 Q. If the matter had been raised to the meetings of the
19 Clinical Directors in the form of a report, either from
20 yourself or from Dr Joffe, would we expect that to be
21 minuted?
22 A. Well, the way the meetings took place was that we
23 discussed much of the business and then the Chief
24 Executive went to the Clinical Directors and said "Do
25 you have anything to report?" I suspect it was probably
0141
1 aired in the terms of "In the light of the difficulties
2 that everyone is familiar with, we are now appointing
3 a new paediatric cardiac surgeon". I do not think it
4 was ever raised, well, I know it was never raised in
5 terms of the set of figures which was raised, that
6 "there may be a very major concern here". It was not
7 raised in that way.
8 Q. So if it was raised in that context, it would have been
9 in the same context perhaps as that of your letter,
10 which again we will come to, which saw the solution to
11 whatever difficulties you had been notified of as lying
12 in firstly the appointment of the new paediatric cardiac
13 surgeon, and secondly, the removal of children's
14 facilities up the hill to the Children's Hospital?
15 A. Yes.
16 MISS GREY: Sir, I am conscious of the time. It may be that
17 this is an appropriate moment and we can have a quarter
18 of an hour?
19 THE CHAIRMAN: Yes, shall we do that? We will reconvene at
20 a quarter to 3.
21 (2.30 pm)
22 (A short break)
23 (2.45 pm)
24 MISS GREY: Professor Vann Jones, before we took a break, we
25 were talking amongst other things about the monthly
0142
1 meetings with the Clinical Directors and I was asking
2 you whether you thought it had been raised -- that is
3 the problems with the paediatric cardiac surgery, or
4 allegations concerning them -- in that forum. I think
5 you gave evidence that you thought it might have been at
6 some point in the context of reporting on the move to
7 the Children's Hospital and the appointment of a new
8 surgeon.
9 Can I just put to you what was said again by you
10 at the General Medical Council on this subject matter,
11 because you were asked whether you met Dr Roylance on at
12 least a monthly basis, and you said you met in a very
13 public forum, rather like this, with John at the head of
14 the table with some of his fellow officers and then the
15 Clinical Directors, of whom there were 14, you thought.
16 Then the question was put:
17 "Each Clinical Director was given the opportunity
18 at such a meeting to raise any matter of concern, or for
19 general discussion?"
20 Your answer was:
21 "A brief opportunity."
22 The question was put:
23 "To your knowledge, the question of outcomes in
24 paediatric cardiac surgery was never raised by anyone at
25 this meeting?"
0143
1 What you said was:
2 "This was a question of professional performance
3 and that was not the sort of issue that was raised at
4 Clinical Directors' meetings. It was very much the
5 bottom line and contracts and all the rest of it. This
6 matter would have been a matter for private discussion,
7 or through the Hospital Medical Committee which dealt
8 with medical matters. The directorate system dealt with
9 management matters."
10 Does that answer help you to recollect whether or
11 not you can be sure in your evidence to the Inquiry that
12 the subject may have been raised at least in the context
13 of a discussion on the move to the Children's Hospital
14 and other changes?
15 A. As I said to you, I do not think the specific figures
16 were ever discussed at the directorate meetings, and
17 I do not think that would have been appropriate, as
18 I said there, but certainly, everyone knew about it and
19 so if someone like Hyam Joffe or myself said that a new
20 consultant was coming, everyone would know exactly why,
21 and the move to the Children's Hospital which to
22 a certain extent was a very expensive manoeuvre,
23 considering it was a brand new being, just about to be
24 built. Everyone knew why that was taking place too.
25 Q. There is a difference between assuming or thinking that
0144
1 everyone knew why something was happening and giving
2 evidence that at such a meeting there was a specific
3 reference to the reason for such changes being because
4 of problems.
5 A. I am sorry if I gave you that impression. I do not
6 think that is what I was intending. I was intending
7 to -- just everyone knew about the subject and it was
8 just, you know, you can imagine, it has been national
9 news and it was in Private Eye in 1992, so everyone
10 knew. You did not really have to spell it out, as to
11 why money was being spent on relocating paediatric
12 cardiac surgery to the Children's Hospital.
13 Q. Your earlier evidence was that there would have been
14 reference to problems as an introduction to a discussion
15 of a move to the Children's Hospital at least. Can you
16 recollect such an introduction being tagged on to any
17 discussion of the move, or the new appointment?
18 A. No, not specifically, but I must say, if I had been
19 dealing with the matter, I would have said "As everyone
20 knows, there have been problems with paediatric cardiac
21 surgery and now we are going to do A, B or C". That is
22 what I would have done. I do not recall what Hyam Joffe
23 did.
24 Q. Because it would not have been you who would have been
25 reporting on such a move or changes because as you told
0145
1 the Inquiry already, they were not within your remit?
2 A. No, but it did affect us as adult cardiologists, because
3 we were of course going to free up a number of ITU beds
4 and we also wanted Mr Dhasmana to be an adult cardiac
5 surgeon, so there were effects for us in the children
6 moving to the Children's Hospital.
7 Q. You spoke also about everybody knowing about it because
8 it was national news, there had been articles in Private
9 Eye. I think it is a matter of record that there would
10 have been no national news items on the subject until
11 after January 1995. Is that not right?
12 A. I cannot be sure about that.
13 Q. What about the Private Eye articles? Can you recollect
14 any discussion about articles in Private Eye?
15 A. Not specifically. Everyone knew that someone had
16 written something in Private Eye. No-one knew who had
17 written it. I certainly did not know why it had been
18 written. I believe it was written in 1992. I was
19 reading through piles of paper last night and I think it
20 was in 1992. That comes as a surprise to me,
21 considering that my first knowledge of any of these
22 problems was November 16th 1993.
23 So I do not actually remember a discussion about
24 articles in Private Eye before seeing Steve Bolsin. But
25 maybe it did happen. I do not know.
0146
1 Q. What would be your general attitude to articles in
2 Private Eye?
3 A. Well, I have already responded to that in the GMC
4 response. That is no way to conduct business, is it?
5 If we have problems we need to look at them
6 scientifically and objectively, and solve them. I do
7 not think scaremongering in satirical rags is the way to
8 change anything.
9 Q. So if you had either read or had drawn to your attention
10 something in Private Eye in 1992, your response would
11 have been what?
12 A. My response would have been to have ignored it.
13 Q. You speak in your statement about being approached by
14 Professor Angelini and I am looking at the top of the
15 paragraph on the page. Before that date, before you
16 wrote the letter to Mr Drurie, did you have any role in
17 reassuring any other members of your staff, those who
18 worked in your directorate, about rumours that by this
19 time on your evidence were widespread?
20 A. I was trying to allay people's fears. You have to
21 remember, a lot of these people had grown up with James
22 Wisheart and were extremely loyal to him, including
23 myself. He had operated on many, many sick patients and
24 many, many patients were extremely grateful to James
25 Wisheart for their lives. People had divided emotions.
0147
1 Rather than trying to change people's perception of what
2 was going on, I was trying to get less turbulence. We
3 still had patients going through this unit whom we had
4 to think about.
5 Q. Can you clarify what you were doing? Is it right that
6 you held or chaired a meeting of the non-medical staff
7 involved in cardiac services?
8 A. You are quite right. We have Steve Bolsin's letter
9 about it. Basically, I was asked by Lesley Salmon to
10 convene a meeting of the non-medical staff, the
11 perfusionists, the physiotherapists, the nurses and so
12 on. I told them at that meeting that I still had
13 reservations about some of the data because Steve had
14 not come back about the information on the VSDs. I was
15 not certain by any means about the statistics and that
16 the matter was being looked into. I said, "In the
17 meantime, we have to carry on business as usual".
18 Q. You said the matter was being looked into. On what was
19 that statement based?
20 A. Well, maybe I did not say the matter was being looked
21 into. This is so long ago, specifically little terms
22 like that tend to get taken out of context, but we were
23 all aware that things were progressing; there was
24 a working party to look to appointing a new cardiac
25 surgeon. There was a working party evaluating the move
0148
1 up to the Children's Hospital and quite honestly, these
2 were surgeons who one minute were operating on
3 a 17-stone adult and the next minute, a 1.7 kg baby.
4 That is not a fair thing to ask any human being to do.
5 At exactly the same time we were setting up the
6 angioplasty department. We would ring up the cardiac
7 surgeons in the middle of their list and say "We have
8 another one", and all hell would break loose.
9 I personally felt the way to remedy this situation
10 was to give the surgeons a chance, to give them their
11 own theatres, to give them their own dedicated staff,
12 to give them their own ITU. That seemed to be
13 progressing. After all, we had been talking about just
14 two or three operations, 4 per cent of the total
15 paediatric work. I honestly thought a lot of it, the
16 final tidying-up, if you like, could be taken care of by
17 such a move; and also the appointment of someone who was
18 dedicated to paediatric cardiac surgery. It is severely
19 unfair to expect someone to go from operating on someone
20 of your size to someone the size of your forearm on the
21 same day.
22 Q. You have made that point twice, Professor Vann Jones,
23 in saying it is unfair to expect a surgeon to move from
24 a large adult to a very small child in the course of an
25 afternoon. Is not the consequence of that firstly
0149
1 a recognition that there might well be a severe problem
2 with the outcomes in paediatric cardiac surgery because
3 of the technical demands that were being placed upon the
4 surgeons?
5 A. No question. I think that is true.
6 Q. The implication, though, is that there was a problem:
7 the results might well be worse if these demands were
8 being placed on the surgeons?
9 A. I think it is a matter of record that I have said that
10 the results are bound to be worse. I mean, paediatric
11 cardiac surgery is now a dedicated specialty in just the
12 way that paediatric cardiology is a dedicated specialty,
13 and has been for a number of years. Even grown-up
14 congenital heart disease has been taken away from people
15 like myself to paediatric cardiologists because it is
16 such a complicated and different business. There is not
17 the slightest doubt that our surgeons were disadvantaged
18 because they had to switch one minute from a major large
19 "plumbing" job to extremely intricate surgery on
20 a hearts this size (indicating). There is no question
21 of a disadvantage.
22 Q. If the results were bound to be worse, if the surgeons
23 were disadvantaged, why was the response that was being
24 developed, namely the appointment of a new surgeon who
25 would not be able to take up post until May 1995, and
0150
1 a move to the Children's Hospital, which would take even
2 longer, an adequate response to worse outcomes?
3 A. The worse outcomes, so far as I was aware, were on two
4 or three operations, but by the same token, I understood
5 there were better outcomes on some other operations.
6 That is going to be the nature of something which covers
7 a spectrum.
8 The point is that the public have to be served and
9 in the course of evolution, with all these units, some
10 are set up sooner than others and some later than
11 others.
12 There were extenuating circumstances in Bristol.
13 The number of patients I think was 117 in that final
14 year. The cost to relocate to the Children's Hospital
15 was in excess of #1.5 million. At the same time, they
16 were having to organise charity campaigns and so on to
17 pay for the new children's Hospital. #1.5 million would
18 certainly have paid for a fair few bricks for the new
19 children's hospital.
20 So there was an understandable dilemma, but the
21 work had to go on because these were sick children. The
22 surgeons, if they had stopped operating for a couple of
23 years, would have been deskilled.
24 Q. You have spoken about the disadvantage under which the
25 Bristol surgeons were operating. Before Dr Bolsin came
0151
1 to see you in November 1993, what was your understanding
2 of the reputation that was enjoyed by the Bristol
3 paediatric cardiac surgery service?
4 A. My knowledge of that is pure hearsay. If you are asking
5 me to comment on hearsay --
6 Q. I am asking you for knowledge of the reputation in which
7 Bristol was held amongst your professional colleagues.
8 A. It was a very distant impression that I had, but I knew
9 that it was regarded as an average unit. It was not
10 regarded as a disastrous unit. The performance, I had
11 certainly never heard anyone express the concerns that
12 Steve expressed ever before.
13 Q. So is it fair to say, then, that there was a movement in
14 your mind from regarding it as being an average movement
15 to one in which the surgeons were labouring under
16 a disadvantage and might be having worse outcomes for at
17 least some procedures?
18 A. I am sorry, I do not understand the question.
19 Q. If, before Dr Bolsin came to see you, you thought of
20 Bristol as being an average unit but at some point you
21 formed the opinion that the technical demands being
22 placed on the surgeons in moving from adult to
23 paediatric surgery, for example, were such that they
24 might well be having unfair demands being placed upon
25 them, and that the outcomes might be worse than in other
0152
1 centres, at least in some operations, how did you come
2 to move from holding one opinion to the other?
3 A. I still do not understand the question. Let me just say
4 that the evolution of units everywhere is that they
5 evolve. Some places are fortunate, they get their
6 funding first and their unit is therefore better
7 equipped than the next one. In our own unit, for
8 instance, with the adult cardiac work at the present
9 time, the equipment is not nearing the end of its
10 lifetime so it is cine films that we use. At least
11 90 per cent of the country does not use cine films any
12 more for adult coronary angiography. But, of course,
13 the technology has developed in-between but it would be
14 ludicrous to throw out this perfectly good equipment,
15 albeit running on valves rather than transistors,
16 because of the cost involved. So people have cycles of
17 development.
18 I saw exactly the same in Oxford before I left.
19 There was a strong move that cardiac work was going to
20 be closed down in Oxford because it had reached its
21 zenith, but then they decided to invest heavily and
22 build a new building on the grounds of the John
23 Radcliffe and now it is a very good unit, but at that
24 time it was a very bad unit. Trusts have to take
25 decisions at some point as to the right time for them to
0153
1 invest in cardiac services which are competing with all
2 other sorts of interests.
3 So, you know, I do not think it was unreasonable
4 for a Trust which had decided to build a brand new
5 hospital to waver a little bit about investing very
6 heavily on a building that was going to be walked away
7 from. I think that is the evolution of most businesses
8 and services.
9 Q. If I could come back to the meeting in April 1994, this
10 was a meeting called --
11 THE CHAIRMAN: Miss Grey, before you do go on to that
12 question, I think we would just like to press the
13 previous question a little bit more. There seem to
14 be -- we look to you for elaboration or elucidation --
15 two propositions: (1) you had a view that the BRI
16 cardiac services were regarded as average; (2) that
17 their outcomes were bound to be worse than other centres
18 because of the unfair demands -- your language -- put
19 upon them. Those two propositions do not, on the face
20 of things, easily sit together. We are looking,
21 perhaps, for some further elucidation.
22 A. What I am meaning is that, given an equal opportunity,
23 then these two surgeons could actually perform very
24 well. Janardan Dhasmana, for instance, in his last year
25 in adult cardio work was the best surgeon in the
0154
1 building, and yet all the other surgeons were absolutely
2 superb. So that makes him better than average, in that
3 context. If, however, we had decided that he should be
4 disadvantaged in some way, that he should not be allowed
5 the best anaesthetists or the best theatres, then he
6 could easily have become average as a result of that.
7 Basically what I am saying is that they were provided
8 with facilities which meant that they could never be the
9 Brompton or they could never be a Magdi Yacoub, given
10 the circumstances under which they were operating. But
11 neither did it so disadvantage them that the unit should
12 have been closed down.
13 Q. Thank you. Using a sporting metaphor, it is your view
14 that they were playing slightly "uphill"?
15 A. Absolutely.
16 MISS GREY: Coming back to the meeting in April 1994, you
17 told the Inquiry you were called in in order to inform
18 or to reassure the departmental staff in a situation
19 where there were many rumours flying around. You said
20 that you were asked to convene it by Lesley Salmon;
21 is that right?
22 A. So I believe.
23 Q. So you believe? How firm are you on that recollection?
24 A. Not firm at all. I am pretty certain Lesley asked me to
25 speak to the nurse members up in cardiac surgery, the
0155
1 non-medical staff, and obviously I agreed, but --
2 Q. The reason I put the question to you is that there was
3 a suggestion or discussion in the course of the conduct
4 of the General Medical Council proceedings again that it
5 might have been Dr Roylance who asked you to convene
6 that meeting. Can you remember that?
7 A. I would be absolutely certain -- I cannot be absolutely
8 certain about anything to be honest, but I would be
9 pretty confident that that was not the case.
10 Q. This was a meeting which was discussing the situation in
11 paediatric cardiac surgery. How is chairing that
12 meeting consistent with your understanding that you were
13 not responsible for that aspect of the service?
14 A. I was not responsible for that aspect of the service.
15 It was very difficult to be a senior cardiologist in
16 a building where, up until that point at which I was
17 a respected member of the medical staff in the Bristol
18 Royal Infirmary, and people asked me to do all sorts of
19 things all the time, counselling medical students,
20 absolutely nothing to do with me because I am not an
21 academic, but I do it. To be asked to do things that
22 were not strictly in one's remit, it happens all the
23 time and you just have to be flexible. If someone
24 wanted me to go and speak to the staff up in cardiac
25 surgery, I was more than happy to try and help out.
0156
1 Q. If we look at WIT 132/72, this is a comment received
2 today, in fact, from Dr Bolsin, not on your statement
3 but in fact on in that of Sister Armstrong's.
4 In the course of commenting on Sister Armstrong's
5 statement, Dr Bolsin suggests that there was a meeting
6 at which some of the theatre nursing staff and perfusion
7 staff were present. Do you see that, towards the bottom
8 of the page?
9 I think this must be a reference to the same
10 occasion. Is that a fair assumption?
11 A. I am sorry, can you just let me read it? (Pause).
12 I have read it. What would you like to ask me?
13 Q. First of all, would I be right in thinking that
14 Dr Bolsin was describing the same meeting that we have
15 been discussing already in which you addressed the
16 non-medical staff on the subject of the paediatric
17 cardiac surgery unit?
18 A. Since there only was one meeting, it has to be the same
19 meeting.
20 Q. He says that this meeting was addressed by both you and
21 Mr Wisheart. Was it addressed with Mr Wisheart, that
22 you can remember?
23 A. No. That is one thing I am 100 per cent certain about,
24 I think. It was not addressed by Mr Wisheart.
25 Q. You shook your head, I say that for the sake of the
0157
1 transcript.
2 A. As far as I can recall, and it is a meeting I can
3 remember fairly well, there is absolutely no reason why
4 Mr Wisheart should have been there, and he was not, so
5 far as I know.
6 Q. Was there some discussion by you of the data that had
7 been produced by Dr Bolsin which in fact Dr Black had
8 collaborated with?
9 A. I told the non-medical staff of the meeting on
10 November 16th and I had been presented with some data
11 that had caused some concern and I had been presented
12 with some that was basically wrong, I thought incorrect,
13 and we waited for their clarification of that.
14 Q. The reference to the data that was wrong and incorrect
15 was meant to be a reference to Dr Bolsin's figures on
16 VSD, was it?
17 A. That is right.
18 Q. Was it fair to characterise what you said to the meeting
19 as "an attempt to discredit the Bolsin/Black data"?
20 A. Absolutely not. The whole point of the meeting, as
21 I recall, was to try and keep our team figure -- inform
22 people as to what might be happening, and as I say,
23 there were moves afoot to appoint a new surgeon and move
24 to the Children's Hospital, so it was an information
25 providing meeting. There was absolutely no way I was
0158
1 attempting to discredit Steve Bolsin and Andrew Black.
2 Q. After that, Dr Bolsin goes on to say you received
3 a letter from Dr Black asking you to retract your
4 criticism of the Dr Black/Dr Bolsin data, which you did
5 by letter. Do you have any recollection of that account
6 of events?
7 A. That is also inaccurate. What actually happened was
8 that within about half an hour of the end of that
9 meeting -- and it was a very efficient grapevine.
10 Within half an hour of the end of that meeting Andy
11 Black was in my office, all fire and brimstone, and not
12 very pleasant. However, I told him to calm down and
13 tell me what the problem was. He accused me of casting
14 aspersions on his statistics, his statistical ability.
15 That is quite a bit different to the data. So we agreed
16 that we had actually not disagreed at the end of the day
17 and there was no, as far as I recall, exchange of
18 letters, but it was certainly a very entertaining
19 half-hour with Andy Black in my office.
20 Q. You talk about a very efficient grapevine. It follows
21 from that that Dr Black had not been present at the
22 meeting himself?
23 A. He was medical staff. This was non-medical staff.
24 Q. And Dr Bolsin likewise had not attended?
25 A. He was medical staff.
0159
1 Q. So when Dr Bolsin says that the meeting attempted to
2 discredit the Bolsin/Black data, that must be at least
3 a second-hand account by him; is that correct?
4 A. That is absolutely true.
5 Q. I should say again, for the sake perhaps of yourself and
6 also for the Panel, that we have searched the database
7 of letters in our possession and can find no letter from
8 Dr Black to Professor Vann Jones, or reply, so that if
9 these letters exist, we must wait for others to produce
10 them to the Inquiry.
11 As a result of that visit by Dr Black, though, did
12 you in any way change your views as to whether or not
13 there might be a difficulty or problems within the
14 paediatric cardiac surgery service that required further
15 investigation?
16 A. As I told you earlier, I was doing my homework. To
17 digress, you just cannot change the whole practise of
18 medicine on the basis of someone coming to your office
19 and presenting you with a few facts. That is just no
20 way to run any matter, no matter what Professor Angelini
21 might think. You have to do your homework, you have to
22 find out what is happening. Episodes like Andy Black
23 coming to the office and feeling very strongly about
24 something do gradually alter your opinion as to what is
25 going on. Undoubtedly, Andy was defending his
0160
1 statistics, and very vociferously so. As subsequent
2 events have proven, his data was wrong. He cannot blame
3 me for being a little bit suspicious when I can see
4 there is a blatant flaw in his data. The statistics
5 were perfectly sound, but the raw material on which it
6 was based, in at least one of the operations, was
7 inaccurate. There is a difference between statistics
8 and data.
9 Q. If it is important that you should do your homework,
10 I am sure that everybody can understand the importance
11 of ensuring that the figures are accurate and agreed.
12 What information did you have that led you to believe
13 that that homework, as it were, was being done at that
14 point in order to resolve this matter?
15 A. I had no information as to what Steve was doing to check
16 on the data that he had presented to me. That was up to
17 Steve. I had told him I did not believe it, and surely,
18 that was now his obligation, to go and check this data,
19 and I think you have told me, and I did not know, it was
20 1995 when it was finally agreed that the data on the
21 VSDs was erroneous.
22 Q. If we can go on to UBHT 61/246, this is a letter which
23 is signed -- if we scroll down, please; I am sorry, can
24 you turn to page 247 -- by both yourself and Professor
25 Angelini and it is the letter which arises I think out
0161
1 of the May 1994 visit by Professor Angelini to yourself;
2 is that right?
3 A. That is correct. He was in my office and I dictated
4 that letter into my dictaphone to make sure that it was
5 agreed in its content and it was factually correct.
6 Q. If we go back, please, to the first page, it says
7 firstly that Gianni Angelini has been to see you at
8 Peter Drurie's behest. Why do you think he had been
9 sent -- that is Professor Angelini -- to see you?
10 A. I think Peter Drurie was a chap who pressed me very hard
11 to become Clinical Director of Cardiac Services, very
12 much against my wife's best wishes, I might say, but
13 I agreed to do it. Peter, much as I have a great
14 respect for him, I think with all due respect he had
15 a similar respect for me, and I think he felt, as many
16 of us feel, that Gianni can portray things, you know, to
17 suit Gianni and it might have been better and a bit more
18 objective if he came and discussed things with me.
19 You can regard that as being a negative influence
20 on progress, or you can regard it as Peter Drurie being
21 sensible and wanting a slightly more "camera" view.
22 I was happy to see Gianni, discuss it and move
23 things forward. We were both keen to appoint
24 a paediatric cardiac surgeon but we were not alone on
25 that. James Wisheart had been trying to do that from
0162
1 the 1980s onwards. It was not new, but the whole thing
2 was gathering momentum.
3 Q. There is a reference in the second line to discussing
4 "the problems we have with paediatric cardiac
5 surgery". What did you understand by "the problems"?
6 A. I am sorry, can I read it? (Pause). Well, the point
7 had been becoming increasingly obvious, as I made my
8 enquiries. The mortality data is very hard data. There
9 is no question about that. If you have 10 bodies from
10 one surgery and no bodies from another surgery, there is
11 a big difference. But there also appeared to be
12 problems with morbidity, and that has led to stays in
13 the ITU and things like that, and these problems were
14 beginning to emerge in discussion. So it was not just
15 a question of mortality, it was a question of morbidity
16 as well.
17 So it seemed as though there was more than one
18 problem arising in the paediatric service. I am pretty
19 certain that is what I meant by that.
20 Q. So that is a reference to poor results --
21 A. No, well, it was a reference to length of stay in ITU
22 which, I do not think you can say it is poor results,
23 but I think it is fair to say that the patients after
24 the operation were a little bit sicker perhaps than
25 otherwise. The impression I was getting from the staff
0163
1 up there was that the children, after the operations,
2 were having to stay in ITU longer than perhaps may be
3 expected from a top class unit.
4 Q. Were you getting an impression as to the cause of this,
5 the factors that might lie behind it?
6 A. I must say, my own feeling was that this was the wrong
7 environment for children. As I have already said in my
8 statement, when I did paediatric cardiology, having been
9 an adult cardiologist and thrown into this unusual
10 circumstance, I felt very uncomfortable with it, because
11 these youngsters have many metabolic problems that
12 develop extremely quickly. They are tiny little
13 things. They become acidotic very easily; they have
14 their ventilation suppressed very easily. If you do not
15 actually have general paediatricians in the building and
16 you do not have paediatric cardiologists in the building
17 all the time, and you do not have dedicated paediatric
18 anaesthetists, you are going to have more morbidity.
19 That problem needed to be resolved.
20 Q. You talk about paediatric cardiologists not being in the
21 building all the time. Were you able to form an
22 impression as to the effect that the fact that they were
23 primarily located in the BCH, the impact that that fact
24 had on their ability to get to the BRI?
25 A. Obviously it must impact on the ability -- if I am in
0164
1 the clinic and someone asks me to go to the ITU two
2 storeys away, I can be there in 15 seconds. Obviously
3 you cannot do that in a building the best part of half
4 a mile away. So these sort of children can go
5 dramatically wrong dramatically quickly. Any cardiac
6 patient can. So there is no way it can have anything
7 other than a negative impact, but I do not think it is
8 quantifiable.
9 Q. Going on to the next line, you went on to say, with
10 Professor Angelini, you were sure the recipient was well
11 familiar with the history of this, "but it has run along
12 in a rather half-baked fashion, certainly for all the
13 time that I have been here."
14 What did you mean by the reference to
15 a "half-baked fashion"?
16 A. Well, it was rather strong language. When you have got
17 Gianni breathing down your neck you are rather inclined
18 to use strong language. Basically it meant that
19 I thought that we should have had a paediatric cardiac
20 surgeon and we did try. Perhaps to try and get
21 a professor in is not the way to do it; maybe the
22 sensible thing would have been to try, as we have now,
23 and get a full-time paediatric cardiac surgeon. To go
24 straight for a Professor of Paediatric Cardiac Surgery
25 was maybe a "one and a half-baked fashion" thing to do.
0165
1 We should perhaps have been trying to do something
2 realistic.
3 Q. That is a reference, is it, to the fact that in 1991 the
4 attempt was made to appoint a Professor of Paediatric
5 Cardiac Surgery, but it was not possible to find
6 a suitably qualified applicant who wanted to take up the
7 post; is that right?
8 A. That is absolutely correct, yes.
9 Q. So instead Professor Angelini was appointed as an adult
10 cardiac surgeon?
11 A. That is correct, yes.
12 Q. Is it right, I think you have mentioned it already, that
13 Mr Wisheart was very influential and involved in that
14 drive to appoint a paediatric cardiac surgeon?
15 A. Yes. He was behind it and he was very keen there should
16 be a Professor of Paediatric Cardiac Surgery.
17 Q. If we go on, then, you set out the history of the move
18 or the anticipated move up to the Children's Hospital
19 and the fact that it would be subject to some delay.
20 You go on to say that "the present problem is that
21 there are good units on our doorstep, mainly in
22 Southampton and Cardiff and if paediatric cardiac
23 surgery is to survive in Bristol, the surgical side
24 certainly needs a very major shake-up."
25 That reference to folding is echoed at the bottom
0166
1 of the paragraph, where you say that if you do not go
2 ahead with an appointment of a new surgeon, paediatric
3 cardiac surgery in Bristol is going to fold.
4 Was that your opinion on the state of the
5 pressures that were on the service?
6 A. That was my opinion. This is just -- I am sorry, this
7 is just such a separate specialty nowadays that you just
8 cannot have people doing adult cardiac surgery and
9 paediatric cardiac surgery. If you were not going to
10 separate that out, the service was going to fold. There
11 had to be a dedicated paediatric cardiac surgeon sooner
12 or later, and the sooner the better, so far as I was
13 concerned. It is like a lot of aspects of paediatric
14 and adult work. There are many other aspects. For
15 instance, the management of diabetes in children is
16 quite different to the management of diabetes in adults
17 and you have paediatric dietologists and adult
18 dietologists and the two do not cross.
19 What we were doing here was extremely complicated
20 surgery which people had realised, really since the
21 mid-1980s, had to be separated off from the adult work.
22 The chap in Cardiff was appointed long before this
23 letter was written but he made a great success of it.
24 The two surgeons in Birmingham also made a very good
25 success of it, but they had only recently been appointed
0167
1 and they were dedicated paediatric cardiac surgeons.
2 What I was trying to say here was "If we are not
3 going to do the same thing, we are not going to have
4 a paediatric cardiac setup".
5 Q. If the service was that far behind the times because
6 since the late 1980s it had been recognised that
7 a paediatric cardiac surgeon was a specialised
8 discipline, why was it acceptable to continue the
9 service in its present form?
10 A. It was not that far behind the times. As I told you,
11 the chap who was appointed to Cardiff had only just been
12 appointed. The two paediatric cardiac surgeons in
13 Birmingham I understand were not appointed much before
14 this, so this was a period of evolution. You always get
15 leaders in a field where things happen, like in the
16 Brompton and Harefield which started heart transplants
17 before anywhere else, and they come in elsewhere later.
18 Basically what we were doing, and I was hoping we would
19 do, would be part of the seeding out process. We had to
20 get on and get our act together because they were
21 starting to do that in Southampton, Cardiff and
22 Birmingham.
23 Q. If there was a danger you would begin to lag behind the
24 rest of the field because the leaders are moving
25 forward, does that not argue the need for a particularly
0168
1 sensitive and careful monitoring of performance and
2 quality of care in your own unit, that is, within the
3 Bristol service, so as to ensure that the gap has not
4 become unacceptably large?
5 A. I think anybody involved in clinical practice should be
6 monitoring their activity. There is no question about
7 that. In some areas it is easier to do than others.
8 Q. What was your understanding at the time when you wrote
9 that letter as to whether or not that was taking place
10 within the Paediatric Cardiac Surgery Unit?
11 A. I was not terribly certain of how they were monitoring
12 their results. I have to say that -- well, I would not
13 say I was not certain how they were monitoring their
14 results, but everyone was very results conscious by this
15 stage, as you can imagine.
16 Q. The main thrust of this letter was the novel idea of
17 appointing a senior lecturer under the auspices of
18 Professor Angelini for two years before NHS funding
19 would kick in.
20 Was that a new suggestion?
21 A. That was a brand new suggestion -- brand new to me at
22 any rate -- that Gianni came up with. I spoke to him.
23 He had University money, I gathered, but he wanted,
24 obviously -- this was going to be an NHS commitment --
25 us to fund it for a finite period of time. I had at
0169
1 that stage had a budget for six weeks in the adult
2 cardiac services, and quite honestly, I had no business
3 suggesting I should fund a paediatric cardiac surgeon,
4 but if he was going to be in the BRI and this was going
5 to help resolve the problem and keep the unit viable,
6 then I as a doctor felt it was a reasonable thing to
7 suggest, irrespective of whether it was within the
8 bounds of my directorate or not.
9 Q. The last sentence on that page says:
10 "We both feel very strongly that it needs to be
11 resolved and if we need to do it in-house, I shall
12 certainly take that on board."
13 What was the reference to doing this "in-house"
14 meant to mean?
15 A. I meant out of my newly acquired budget. I just meant
16 out of my newly acquired budget. I was basically asking
17 Peter Drurie if he had money to fund this appointment,
18 but experience has told me the answer is always "No" and
19 if not, then I would try and come up with the funding.
20 Q. We have received recently some comments of Mr Wisheart
21 on the statement, and they have not been scanned in as
22 a result of the time at which they were received, but
23 what Mr Wisheart says is this: that he was not aware of
24 the letter at the time and only learned of it recently.
25 He believes it was written in May 1994, as indeed it
0170
1 was. He goes on to say:
2 "In May 1994 the Working Group, considering the
3 future of paediatric cardiac surgery, was approaching
4 the decision to appoint a new surgeon and move the work
5 to the Children's Hospital. Professor Angelini was
6 a member of the group and although I cannot remember
7 Professor Vann Jones' involvement, as Clinical Director,
8 he must have been aware of it and its work. The letter
9 seems to have been written as if these developments were
10 not taking place or the writers were unaware of them."
11 Firstly, can I ask you --
12 THE CHAIRMAN: Miss Grey I have a witness number for it. It
13 may be scanned in. Therefore it may be easier for the
14 witness to see it on the screen. It is 115/28.
15 MISS GREY: First of all, is it right that you were not
16 a member of the Working Party which was organising and
17 considering the move of paediatric cardiac surgery?
18 A. That is correct. I would not have expected to be,
19 because, as I keep telling people, paediatric cardiac
20 affairs were not my affair. I was never invited to be
21 a member. It is not as if I was invited and declined.
22 I think it was right I was not a member because we never
23 envisaged cardiac services embracing paediatric work.
24 The only reason I think this changed was because
25 of all of this blowing up and then everyone got
0171
1 involved, no matter where they were.
2 Q. If we look at UBHT 84/129, this is a meeting held on
3 25th April, a meeting of the Cardiac Services Management
4 Board. You were certainly present and indeed I think
5 would have been chairing that meeting.
6 If we could look, please, at page 130,
7 paragraph 6, would this represent the state of your
8 knowledge, roughly, as to the planned move at the time?
9 Would it be before you wrote that letter?
10 A. Certainly I knew no more than that, that is for certain.
11 Q. I am sorry?
12 A. I said I certainly knew no more than that.
13 Q. If we go on to UBHT 84/145, this is a meeting now
14 shortly after the letter had been written, 24th May, and
15 again, you were present at it. If we look at page 147,
16 down to paragraph 14, we see there a report back from
17 Mr Dhasmana.
18 A. Well, part of the purpose of these meetings, of course,
19 was to feed back to people and myself too, from people
20 who were members of other groups. I remember this one
21 because I remember being really upset, concerned, that
22 this chap was going to be offered adult cardiac
23 sessions, which I had assumed to fly in the face of
24 logic, really.
25 Q. If we go back to Mr Wisheart's comments, please -- if we
0172
1 could have that reference again, Chairman?
2 THE CHAIRMAN: From memory, I think it was 115/28.
3 MISS GREY: We have it now, thank you. If we go back to
4 Mr Wisheart's comments, he was making the broad point
5 that although you might not have been a member of the
6 Working Group, you must have been aware, as Clinical
7 Director, of the fact that moves were afoot firstly to
8 approve the decision to appoint a new surgeon, and
9 secondly, to progress a move to the Children's Hospital.
10 Would it seem, having looked at those two minutes,
11 that that is a broadly accurate or inaccurate
12 description of your state of knowledge at the time?
13 A. I certainly knew very little about the Working Group,
14 other than it existed. It was to facilitate this move
15 and it was one reason why I felt things were happening.
16 From my own point of view of course it was
17 important, because there was going to be a lot of space
18 left behind -- theatre space, ITU beds, general beds --
19 and that was going to allow an expansion of adult
20 cardiac work. So obviously, nobody could really plan
21 this without letting me know there was going to be
22 a vacuum left to be filled.
23 Q. But the point that Mr Wisheart is making is that the
24 letter from yourself and Professor Angelini makes it
25 appear that the prospect of both the appointment of the
0173
1 paediatric cardiac surgeon and the move to the
2 Children's Hospital are remote, whereas in fact plans
3 were well in hand to attempt to achieve both of those
4 things?
5 A. I do not think it does any harm, a letter trying to
6 accelerate the process. The history of development in
7 cardiac services in Bristol is littered with dead plans
8 and -- you know, you could just see the scenario where
9 they were trying to play for time until the new building
10 was opened, and it is still not opened, as you know. We
11 just did not want that to happen, basically.
12 Q. So in other words, you were not ignorant of the moves
13 that were afoot, but you wanted to try and exert
14 pressure so as to ensure that they happened and they
15 happened sooner rather than later?
16 A. I think that is a reasonable interpretation, yes.
17 Q. Looking at the letter as a whole, would it be fair to
18 say -- perhaps we should go back to it; it is
19 UBHT 61/246, please -- that firstly you acknowledged
20 that there were problems with paediatric cardiac surgery
21 at the time?
22 A. Yes.
23 Q. But that those problems were ones that, in your view,
24 would be met by the appointment of a new surgeon and
25 a move up the hill to the Children's Hospital?
0174
1 A. I think that has been demonstrated. It has certainly
2 transformed the situation. It is a combination. It is
3 not just the new surgeon, it is the new surgeon who has
4 had everything thrown in his direction. He is a very
5 accomplished surgeon but he has his own ITU, he has his
6 own theatres and he has his own anaesthetists, he has
7 his own staff and he has access to paediatricians on
8 site and access to paediatric cardiologists on site.
9 The point I am trying to make there is it is not just
10 the fact that it is Ash Pawade now, it is Ash Pawade
11 plus all the facilities.
12 Q. If a new paediatric cardiac surgeon were to be
13 appointed, what was the proposal concerning
14 Mr Wisheart's involvement in paediatric cardiac surgery?
15 A. As you know, I got involved in that, and my own view was
16 that both Mr Dhasmana and Mr Wisheart should drop
17 paediatric cardiac surgery completely.
18 Q. At the time when the letter was written, was that your
19 view?
20 A. I am not sure I held a view at that particular time,
21 because we still did not have the surgeon. Quite
22 honestly, this was 117 operations and that is two
23 a week. That is just about enough to keep one skilled,
24 it is not enough to keep two or three skilled. For all
25 the reasons I have intimated before, I thought the
0175
1 paediatric cardiac surgeon who arrived should do all the
2 paediatric cardiac work, solely.
3 Q. I think Mr Wisheart's evidence would be that it was
4 always envisaged, and certainly was in May 1994, that on
5 the appointment of a dedicated paediatric cardiac
6 surgeon, he would retire from paediatric work. Was that
7 something you were aware of at that time?
8 A. I do not know the timing of my awareness of that, but
9 obviously that is something I would have strongly
10 supported.
11 Q. Turning to the letter as a whole, it follows from its
12 contents that it was not your view at the time when you
13 wrote the letter that any more radical step to improve
14 the paediatric cardiac surgery service was required that
15 was set out in that letter and in particular, that there
16 was no need to stop any particular operations or
17 specific operative procedures before those steps taken
18 were achieved?
19 A. You have to remember that my knowledge of the operating
20 statistics is exactly the same as at the end of November
21 1993. I had not been shown any further data that
22 suggested that the cardiac surgery should be stopped;
23 I just had the figures in my head that I had been shown
24 by Steve Bolsin. So that would not have justified
25 stopping a service that was quite important and
0176
1 successful in many ways. The two surgeons had had very
2 bad results with one operation each. You have to
3 remember that they did much good work apart from that.
4 Q. You are skipping ahead to justify an answer which you
5 have not yet given. What I asked you was whether or not
6 you considered that it was necessary to stop one
7 operation, or all of the paediatric service. I think it
8 follows from what you have just said that your answer
9 must be "No"?
10 A. My answer to that specific question was, it was actually
11 none of my business. I was an adult cardiac surgeon.
12 There were three paediatric cardiologists in the
13 building and if they felt an operation was not performed
14 to the standards expected by paediatric cardiologists,
15 then fine; it should have been stopped. But it would
16 have been like me telling one of the gallbladder
17 surgeons to stop taking gallbladders out. You have to
18 appreciate this is a different specialty.
19 Q. In other words, although it was none of your business,
20 you certainly never expressed the view at the time that
21 any operations, series of operations let alone the
22 entirety of the service, should be halted?
23 A. I had not seen any further -- in fact I think at that
24 time, even the switch operation was not in question, if
25 I remember rightly, so, no, I had not been provided with
0177
1 any more information, nor had my enquiries found any
2 more information.
3 Q. Again, Professor Vann Jones, I am simply trying to
4 elucidate what you said or opinions that you expressed.
5 Did you suggest that either a series of operations or
6 the entirety of operations should be halted?
7 A. This was not my specialty. It would have been highly
8 inappropriate for me to have done so, so the answer is
9 no.
10 Q. In your statement you carry on to say, at page 21 now,
11 if we go down a little, please, to N4, you say that you
12 certainly "met Dr Bolsin once again with his revised
13 figures and was gradually persuaded that there was
14 a problem in performance of some of the paediatric
15 cardiac surgery". We have covered, I think, the extent
16 of the problem that you acknowledge there.
17 Did that meeting take place in the presence of
18 anybody else?
19 A. Dr Laszlo was there. He was a new --
20 Q. He at that time was the Chairman of the Medical Council?
21 A. Yes, the new Chairman of the Hospital Medical Committee,
22 yes.
23 Q. Can you give us a date on that meeting?
24 A. I have no recall, unfortunately, in this two-year span
25 when it was.
0178
1 Q. Could we look, please, at the letter DOH 1/12, please?
2 This is a letter from Professor Angelini to Dr Doyle
3 dated August 1994. If we could skip straight ahead to
4 the next page, page 13, there is there set out,
5 "cc Professor Vann Jones". Did you receive a copy of
6 that letter?
7 A. I was asked that before and I do not have any recall of
8 this letter at all. I must say, to get copied into
9 letters to the Department of Health would have come as
10 rather a unique experience to me, so I am sure I would
11 have noticed it. The first time I saw this letter, so
12 far as I recall, was when it was faxed to me by the
13 lawyers in relation to the GMC Inquiry.
14 Q. Did you have any knowledge of any contact with the
15 Department of Health or officials within it at the time?
16 A. None at all.
17 Q. So does it follow that the first time you would have
18 been aware of that was after or in January 1995?
19 A. The first time I became aware of all of this, as far as
20 I recall, was when a meeting was held. Was that January
21 1995, 1996? I cannot remember. In 1995 there was
22 a meeting held, I think I have said in my evidence what
23 I can remember about it was that it was an incredibly
24 small room for a large number of people. That was the
25 first time I became aware of concerns from the
0179
1 Department of Health. I think that was after the Joshua
2 Loveday operation.
3 Q. You had been seen by Dr Bolsin in November 1993; this
4 exchange of letters between and you Professor Angelini
5 occurred in May 1994. What progress did you think had
6 been made to resolve this matter by mid-1994?
7 A. By mid-1994? I suppose it was round about mid-1994 that
8 I learned that the decision had been made to transfer
9 the children up to the Children's Hospital and the
10 decision had been made to appoint a paediatric cardiac
11 surgeon. That was about the middle of the year, because
12 I think the interview was in September 1994.
13 Q. I think it is right that you yourself had no involvement
14 in the appointment process for that surgeon?
15 A. None at all. Like I was saying, it was not my specialty
16 and it was not appropriate for me to do that.
17 Q. So those decisions had been taken in or around that
18 time, but it is right that Mr Pawade did not ultimately
19 take his post up until May 1995 and the transfer to the
20 Children's Hospital was not completed until October
21 1995.
22 At what point did you become aware of the
23 substantial time-lag that would follow, intervene,
24 between those decisions and the point when they were
25 implemented?
0180
1 A. I knew that Graham Nix, who was the Treasurer, a very
2 nice chap, but this was a major financial thorn in his
3 flesh and at meetings it was always mentioned how this
4 was being costed and how much it was going to cost, and
5 for 120 patients it was an enormous sum of money, but
6 nonetheless, I knew the process was going through and
7 obviously you have to find space in the building, you
8 have to take down walls, put walls up, put in
9 ventilation. So all the business of costing and drawing
10 up that and constructing the facility was obviously
11 going to take months and months. More than that,
12 I cannot say. I was not sure whether it was going to
13 take a year or 6 months or what, but obviously there was
14 going to be a substantial time-lag.
15 I think about that time the only problem I had
16 with Janardan was the switch operation and I think about
17 they time they stopped him doing switches on neonates.
18 He was perfectly competent at doing switches in older
19 children and was perfectly competent at every other
20 paediatric cardiac operation.
21 Q. Does it follow from what you were saying that you did
22 not feel any concern that the solutions being proposed
23 to the problem would take too long to be implemented?
24 A. I think that we offered to try and expedite matters did
25 indicate that we were concerned, that is Gianni and
0181
1 myself. He perhaps wanted things to go at a different
2 pace from myself, but we are different personalities and
3 have a different time-scale for things. I felt a lot
4 was being done. I felt that we had a surgeon who was,
5 as the de Leval report has indicated, as good as anybody
6 else in the country for every other operation except the
7 switch operation and provided he was not doing that, we
8 were in a reasonable position until the new regime then
9 took over.
10 Q. But that de Leval report of course was not data you had
11 access to at the time. That was produced in February
12 1995. So at the time, do you think that enough was
13 being done to resolve a dispute as to figures or
14 performance that was taking place between clinicians?
15 A. You have to remember that Steve's doubts were only
16 expressed about two operations, including Fallot's
17 tetralogy, but somehow Fallot's tetralogy seems to have
18 got lost from the picture and has been concentrated on
19 AV canals and switches. James Wisheart stopped doing
20 AV canals, he never did switches I do not think, and
21 Janardan Dhasmana stopped doing switches.
22 Concerns were not expressed about the rest of the
23 spectrum of paediatric cardiac surgery and you have to
24 remember, that was only 4 per cent of the total.
25 Q. I think as a matter of record you said earlier
0182
1 Mr Dhasmana stopped doing switches for neonates rather
2 than for the non-neonates?
3 A. Yes.
4 Q. If we look, please, taking matters through
5 chronologically, at UBHT 38/208, this is a letter from
6 you to Mr Roylance dated October 1994. Could you scroll
7 up the page, please? Could I invite you to read it,
8 please?
9 Can you explain to the Inquiry what lay behind
10 that letter?
11 A. This was the time at which GP fund-holding was becoming
12 available; in other words, general practices that held
13 their own budget could buy their own procedures. There
14 was concern in the profession certainly that this may
15 set up a two-tier system -- and did indeed eventually
16 set up a two-tier system, now abolished, but basically
17 this practice said "We have X amount of money to spend
18 on cardiac surgery for our patients; we would like to
19 spend it up in the BUPA Bristol hospital and get our
20 patients operated on quickly by the cardiac surgeons in
21 the city". The cardiac surgeons in the city are
22 employed by the UBHT.
23 To me as Clinical Director, where we needed
24 operations to happen in the Infirmary, that is where our
25 income came from. That is how we could develop the
0183
1 service. To see members of my staff going off to work
2 for one specific general practice up in the private
3 sector was not something I thought should be
4 encouraged. I also thought it could lead to conflict of
5 interest, because if there was an NHS operation to be
6 done in the Bristol Royal Infirmary and there was an NHS
7 operation to be done up the road at the BUPA Bristol
8 hospital, but we were going to be paying #500 to be up
9 the road, it is human nature to be up the road rather
10 than down, where we were doing the largest chunk of the
11 work. I think this was nipped in the bud and John
12 Roylance said "Absolutely not". Obviously I cannot
13 remember. When you showed me that letter earlier on
14 today, it just jogged memory cells that had long since
15 been dormant.
16 Q. Was there private practice taking place amongst the
17 cardiac surgery unit within the hospital?
18 A. There was a small number of private patients operated in
19 the Bristol Royal Infirmary. The vast majority were
20 operated on in the Bristol BUPA hospital.
21 Q. How did you see a difference, if any at all, between
22 private patients taken within the UBHT and those taken
23 within a BUPA hospital? Was there a difference?
24 A. There is a difference, because UBHT gets the income from
25 private patients operated on in the UBHT. Obviously
0184
1 a hospital, like the BUPA hospital, likes to make
2 a profit out of cardiac surgery, so it is a potential
3 source of income.
4 If National Health Service patients go up to the
5 private sector, that is income that is going to be taken
6 away from the UBHT.
7 Q. So you were concerned that colleagues might put
8 themselves in a situation where there was a conflict of
9 interest?
10 A. Well, absolutely. That is what I have said in the
11 letter, yes.
12 Q. Would that affect your view of their judgment?
13 A. As far as I know, none of them did it, so I did not have
14 to make that decision.
15 Q. Were any of those involved in this venture also involved
16 in delivering a paediatric cardiac service?
17 A. I am not sure where the data is on that, but at that
18 time there were four surgeons in the Bristol Royal
19 Infirmary and two of them were James Wisheart and
20 Janardan Dhasmana, so if they were to be involved --
21 well, they were adult cardiac surgeons as well, so
22 I presume they would have had a share of this work.
23 Q. So you are saying that the cardiac surgery team in
24 general was involved?
25 A. I do not think this got much further than this stage.
0185
1 I do not think specific surgeons and anaesthetists and
2 perfusionists really got involved. I was keen to stamp
3 this out. This was the start of a two-tier service and
4 financially disadvantageous to the Bristol Royal
5 Infirmary.
6 Q. And you received guidance from Dr Roylance and it was in
7 fact stamped out?
8 A. As I recall, yes.
9 Q. Can we go on, please, to JDW 5, page 180? This is
10 a letter from you to Mr Wisheart dated 15th December
11 1994. It is concerning a discussion relating to cardiac
12 surgery. Can you tell us a little bit about what was
13 behind this letter?
14 A. Exactly the same sort of criticism started to be
15 levelled at adult cardiac surgery. I must say, the very
16 first day I heard about that I went straight to John
17 Roylance and said "It is happening all over again with
18 adult cardiac surgery". At that point we asked for all
19 the figures and the whole thing was very much brought
20 out into the open.
21 I saw the figures for the various surgeons over
22 several years and while they had blips up and down, it
23 did not seem to me that there was any particular pattern
24 of one being better or worse than the other. That
25 letter was a reference to adult cardiac surgery.
0186
1 At the same time, we set up an internal inquiry.
2 These were the figures, the raw data. We then asked
3 Jill Bullimore, an oncologist, to conduct an internal
4 inquiry so we could have someone looking at it
5 objectively. I assisted her: to my mind it was
6 a Bullimore inquiry, some would say a Vann Jones
7 inquiry, but basically she needed someone giving her
8 a hand and it was adult surgery and an adult Clinical
9 Director, so obviously I had to be involved in that.
10 Jill Bullimore interviewed all the relevant parties and
11 I was present for most of it, gave a hand with the
12 language, "perfusionists", and so on. She produced her
13 report at the end of the day which actually did not say
14 there was a lot wrong with adult cardiac surgery but
15 there was a lot wrong with morale and some people needed
16 to be realistic in what they could achieve in the
17 working day. For instance, James Wisheart was
18 criticised for doing two very complicated operations.
19 James, having been around for a long time, was into the
20 business of re-doing operations. New surgeons do not
21 have the re-dos coming back for quite a number of
22 years. But James of course, having been there for the
23 best part of 20 years or whatever it was, was now having
24 re-dos coming back and he was trying to do two of these
25 on one day, and that was just exhausting the team. So
0187
1 I spoke to him and said, "You know, one perhaps on one
2 straightforward case, but not two". So there were no
3 major criticisms of the standard of adult cardiac
4 surgery. But subsequently that still rumbled on and
5 there was a further inquiry, as you probably know.
6 Q. In any event, this letter related to adult cardiac
7 surgery?
8 A. Absolutely.
9 Q. And the next event, I think, which you would have been
10 concerned with in paediatric cardiac surgery, was the
11 operation upon Joshua Loveday?
12 A. Yes.
13 Q. I think if I can summarise the position to you, would it
14 be right to say that you were told by Sheila Willis, an
15 anaesthetic colleague, of the operation and the fact
16 that there were misgivings about it, and that as
17 a result, you spoke to Dr Martin about it on the
18 telephone?
19 A. That is absolutely right.
20 Q. And he informed you that there had been a meeting, as
21 you understood it, to discuss this case?
22 A. I thought the meeting was past tense, I must say, when
23 I spoke to him, but I have subsequently found out it was
24 to be. I have also said in my statement, I am now
25 unclear whether there was one meeting or two meetings.
0188
1 At the end of the day, he assured me, the day Sheila
2 spoke to me I spoke to Rob Martin and spoke back to
3 Sheila Willis. It was a fortnight before Joshua Loveday
4 was operated on. I presume Sheila spoke to me because
5 I was Clinical Director and also happened to be in the
6 ward doing a ward round, but I was reassured it was not
7 a neonatal switch operation and Mr Dhasmana's figures
8 were as good as anyone's for switches in the
9 non-neonatal age group. In any event, there was going
10 to be a meeting where all interested parties were going
11 to meet including Dr Bolsin to discuss whether the
12 operation went ahead or not. I relayed that information
13 back to Sheila Willis.
14 Q. So you yourself were not present at the meeting in
15 question?
16 A. I would have had no business being there.
17 Q. Do you think that a meeting of the clinicians concerned
18 in the case was a normal way of resolving such disputes
19 on the management of a case?
20 A. If there was a dispute -- I think with hindsight, a lot
21 of people have been very wise over this operation, but
22 basically Dr Bolsin, I gather, was present, and I gather
23 he was the only dissenting -- I do not think in fact it
24 was a dissenting voice, he was an abstainer, from what
25 I understand subsequently. But obviously it is not
0189
1 normal practice have a committee decide when you do an
2 operation or not. It is common practice for the
3 decisions on operations to be made collectively. For
4 instance, every Tuesday morning we have a cardiac
5 meeting at which all the surgeons are present and some
6 of the cardiac radiologists and all the cardiologists
7 and we describe and discuss difficult cases. Very often
8 there are as many views about the operation as there are
9 people there, but at the end of the day we come up with
10 a consensus as to whether this patient has an operation
11 or not. I think it is a sensible way forward.
12 This particular situation with Joshua Loveday
13 seems to have been a little bit -- you do not usually
14 have anaesthetists, cardiologists and surgeons together.
15 Q. Is that what you understood had taken place when you
16 made your enquiries?
17 A. I do not think I would put it as definite as that.
18 I was told a meeting was certainly going to take place
19 in which all the aspects of the operation were going to
20 be looked at.
21 Q. If we go on, then, to UBHT 61/255, you must have learned
22 at some point after the operation took place that the
23 child had unfortunately died?
24 A. I did learn that, yes, and John Roylance asked that
25 I call that meeting. Just exactly how I learned that,
0190
1 I do not know.
2 Q. Why do you think that you were being asked to call that
3 meeting, to chair it, by Dr Roylance?
4 A. I have no idea why I was chosen, to be perfectly honest,
5 but -- I am afraid all my life I have been one of those
6 people who find it very difficult to say "No", so if he
7 asked me to call the meeting and he wanted me to be
8 there and all these other people, it was not any effort
9 to type out a letter and send it really.
10 Q. Again, it appears to imply that you might have been
11 thought of as having some sort of leadership role within
12 the cardiac services department that encompassed
13 a paediatric matter?
14 A. That is certainly an interpretation that could be put on
15 it. I have to say -- I keep saying it time and time
16 again, I was and am a senior cardiologist in the
17 building. The paediatric people are all up the hill.
18 It is much, much easier for John Roylance to contact me
19 than it was to contact them. It was much easier for me
20 to contact the surgeons than it was the paediatricians.
21 I am surprised the paediatricians and paediatric
22 cardiologists were not on that list. But I am used to
23 being asked to do strange things all the time. It did
24 not strike me as being particularly odd.
25 Q. If we go on to a meeting, or record of that meeting, at
0191
1 UBHT 82/83 you record there, in a letter addressed to
2 Mr Dhasmana, a regret, dismay, about finding out how
3 divided and acrimonious the atmosphere was in cardiac
4 services. Who was this letter circulated to?
5 A. I think it was only sent to Janardan. Unless you want
6 to scroll up. Was it sent to Lesley Salmon? (Screen
7 scrolled) It was purely and simply to Janardan
8 Dhasmana. What happened was that as Clinical Director
9 we had meetings of the two limbs, the Associate
10 Directorate of Adult Cardiac Surgery and the Associate
11 Directorate of Adult Cardiology, and as Clinical
12 Director, I went to them both, but not as Chairperson of
13 the meeting. Janardan was chairing the Associate
14 Directorate of Cardiac Surgery, the associate
15 directorate on that particular Tuesday, and I went along
16 and people were just basically being downright
17 unpleasant to each other.
18 Q. So what was the point of telling Mr Dhasmana this fact?
19 It was not to imply that he was one of those who was
20 being unpleasant and acrimonious, was it?
21 A. He certainly was not. One of the other surgeons was
22 being extremely unpleasant to one of the perfusionists.
23 Q. Who was that, the surgeon?
24 A. Mr Hutter.
25 Q. But if we look at JPD 10/5, we see there a letter of
0192
1 personal support that you wrote to Mr Dhasmana in which
2 you describe him -- I am looking at the second
3 paragraph here -- as being a "sincere and gentle
4 individual". Was that your experience of him?
5 A. Yes. He is basically a very nice man.
6 Q. So how do you think he coped, then, with the atmosphere
7 in the meeting that you have just described?
8 A. He could not cope with that sort of thing. It just was
9 not his -- he was too gentle a chap.
10 Q. If we could go to UBHT 61/293, please, this is the
11 record of the meeting to which you have already
12 referred. It is the meeting in the very small room; is
13 that correct?
14 A. Is my name on there? Yes. That is the only meeting
15 I have ever been at with the Department of Health, so it
16 must be the same meeting.
17 Q. Prior to this meeting, what, if anything, had you known
18 then of the involvement of the Department of Health?
19 A. I hesitate to say "nothing", but it must have been
20 virtually nothing.
21 Q. Virtually nothing? What does that mean?
22 A. I think it was nothing. I had no knowledge, for
23 instance, of the Department of Health being involved in
24 the Joshua Loveday operation. I found that out later.
25 Q. If we turn to the second page of the minute, your views
0193
1 are recorded in that minute as amounting firstly to
2 concern. You were said to be very concerned that the
3 Department of Health had become involved. Were you very
4 concerned about that?
5 A. No. I never saw these minutes. I think I have pointed
6 out in correspondence to -- I do not know whether it was
7 the Medical Defence Society, I am not sure, but I have
8 never seen these minutes. An awful lot attributed to me
9 in these minutes was never said by me.
10 Q. Perhaps we can run through it and get your account of
11 what was said by you straight?
12 A. I remember saying very little actually because I had
13 nothing to do with the Department of Health and
14 discretion was the best part of valour, really.
15 Q. Firstly, were you concerned, or very concerned that the
16 Department of Health had become involved?
17 A. I was not. The Department of Health is ultimately
18 concerned with what happens in the hospital, so if they
19 were involved, they were involved. I was not concerned
20 or unconcerned. Obviously I was concerned in that no
21 hospital likes to think it needs the Department of
22 Health to come down and try and sort it out, that
23 certainly was a concern, but if it required the
24 Department of Health to come down and sort it out, so be
25 it.
0194
1 Q. Did you believe that at the time Dr Doyle had been
2 contacted the Trust had not exhausted local procedures?
3 A. As I say, I do not think I said any of this, but who
4 knows. I understand in retrospect that Dr Doyle was
5 contacted by Steve Bolsin. Steve being an expert in
6 audit used to go up to the Department of Health where
7 his views on audit were respected. So he had a direct
8 line to the Department of Health most other individuals
9 do not have. That is what I understood by that.
10 Q. Did you understand when Dr Doyle had been contacted by
11 Steve Bolsin?
12 A. No. I just know it was fairly early on, but quite
13 honestly, this is a block in time from November 1993
14 until the beginning of 1995, and the chronology has long
15 since gone.
16 Q. The comment there is that the Trust had not exhausted
17 local procedures. What local procedures had been
18 invoked by the Trust?
19 A. That comment was never made by me.
20 Q. You go on to say, according to this minute, that in your
21 view the department had been given a biased account of
22 the situation with only one interpretation of the audit
23 results.
24 Is that again a comment that you would recognise,
25 or not?
0195
1 A. As I have said, if I had seen these minutes, they would
2 not have looked anywhere like this. I do not know who
3 made them, but to me, it is almost fiction.
4 Q. Perhaps I can put the question more generally, then.
5 What do you recollect yourself saying in the course of
6 that meeting?
7 A. I say to you that until I saw the minutes of the
8 meeting, I had forgotten completely it had taken place.
9 When I saw the minutes, I said "I did not say any of
10 that". So I have very, very little recall for the
11 meeting. I know for a fact that I would not have said
12 that the cardiac surgical switch operation results were
13 good, because I knew they were not, but I knew that in
14 the age group for Joshua Loveday's operation, they were
15 comparable. So I certainly would not have said that.
16 I agree, I probably said the decision to carry out
17 the switch procedure in January had been agreed by all
18 the clinicians directly involved. I certainly knew that
19 was true. I may well have pointed out the decision to
20 spend what I thought was œ1.5 million on moving the
21 cardiac surgical service up the hill, and that indeed
22 was true. But the first half of that paragraph is
23 complete absolute news to me.
24 Q. If we turn then to UBHT 38/173, this is a letter from
25 you to Dr Roylance, if we can scroll down the
0196
1 page gradually, please, which advises or suggests that
2 Mr Dhasmana ceased to carry out paediatric work and
3 concentrate solely on the adult side of things.
4 Firstly, having looked at that briefly, can we ask
5 you to turn back, please, to WIT 115/23? At the bottom
6 of that page, at N14, you comment that the Chief
7 Executive was reluctant to listen to advice and made it
8 fairly clear to you that as Clinical Director, your
9 suggestions concerning paediatric cardiac services were
10 not particularly welcome.
11 Was that a reference to the receipt or the
12 reaction of Dr Roylance to this letter that we have just
13 seen? Or is it a more general comment?
14 A. It is a general comment, but the impression I got was
15 certainly not helped by the response to letters like
16 that letter, which was basically that my views were
17 unwelcome -- well, I say my views were not welcome; my
18 views were not particularly welcome, shall we say.
19 Well, that was the impression I had from Dr Roylance,
20 I am afraid. To a certain extent he used me when it
21 suited him, but he was not particularly willing to
22 listen to the difficulties.
23 Q. If we turn back to the letter we have just looked at,
24 UBHT 38/173, were you aware of the counter argument to
25 this proposal?
0197
1 A. I am sorry, it is a long time since I have read this
2 letter. Can I have a chance to read it?
3 Q. Please do.
4 A. Is it also possible to use the toilet? I have been
5 drinking a lot of water.
6 MISS GREY: I am sorry, I was running on in the hope I could
7 continue questioning and I have been discourteous as
8 a result.
9 THE CHAIRMAN: Shall we call it a "comfort break" and come
10 back in about three or four minutes, please?
11 (4.10 pm)
12 (A short break)
13 (4.20 pm)
14 MISS GREY: Professor Vann Jones, I do not know if you have
15 now had an opportunity to look at the letter on the
16 screen. It is a letter written by you suggesting
17 Mr Dhasmana cease carrying out paediatric work and carry
18 out adult work where his skills will be much needed, it
19 is said?
20 A. Yes, indeed. This is the letter and I stand by the
21 content of the letter.
22 Q. I think after some discussion, that solution was
23 eventually adopted; is that right?
24 A. That is correct.
25 Q. I asked you, when you commented on Dr Roylance's
0198
1 reaction to suggestions about the paediatric cardiac
2 service, whether you had the reaction from him to that
3 letter in mind. I think your answer was yes, at least
4 in part; is that right?
5 A. No. It was responses to approaches like this that made
6 me answer the question in the way I did, yes.
7 Q. Just sticking with this particular issue for the moment,
8 are you aware that there was, as it were, a counter
9 argument against this proposal along the lines which
10 emphasised Mr Dhasmana's clinical ability as
11 a paediatric cardiac surgeon, and therefore said that it
12 would be unfair to remove him from that sort of work?
13 A. Yes, I was aware of the counter argument.
14 Q. Aware that letters in support, as it were, of
15 Mr Dhasmana were received by the Trust, Dr Roylance,
16 expressing that view?
17 A. No.
18 Q. In that case, I will not take you to them, but Professor
19 Vann Jones, would that perhaps not be an adequate
20 explanation for any perception that you may have gained
21 that Dr Roylance did not welcome your advice on this
22 matter?
23 A. Yes, I think that is a reasonable interpretation. If
24 John Roylance had been getting opinions or advice from
25 two different sources, he was not obliged to take mine,
0199
1 that is for sure. I thought I made a pretty good case
2 for my side, but I know for instance James Wisheart said
3 "One person cannot do all of this and what happens on
4 holidays, if we do not have a skilled paediatric cardiac
5 surgeon in the hospital"; that there were two sides to
6 the argument, I totally accept that. There was
7 a single-handed surgeon operating in Cardiff and my
8 solution to that was that they should cover each other's
9 holidays. I have done that when I was a paediatric
10 cardiologist.
11 Q. In the light of your recognition that there were two
12 sides to this argument, do you think that the manner in
13 which Dr Roylance handled your suggestion, your
14 approach, was a reasonable one?
15 A. I think you can tell when you are dealing with someone
16 as to whether he is receptive to your ideas and wants to
17 cogitate or whether he is dismissive of your ideas and
18 does not want to particularly hear them. I am afraid my
19 impression was the latter.
20 Q. Notwithstanding that, this was a solution that was
21 eventually adopted, so to that extent, it must have been
22 received, contemplated and acted upon?
23 A. What subsequently happened was that I had a meeting with
24 two other Clinical Directors involved and that was the
25 Clinical Director for the Children's Hospital, who was
0200
1 no longer Hyam Joffe, and Chris Monk, who was the
2 Clinical Director for Anaesthesia. We met together and
3 they were in favour of two surgeons continuing to do
4 paediatric cardiac surgery. I was very much against it
5 for the reason that it was, as I say, at that time 117
6 operations and my argument was to have a surgeon just
7 doing operations in somebody else's holiday, or having
8 one surgeon doing 70 operations and one doing 50 is just
9 going to get us back into a mess again because they are
10 both going to become deskilled. There was also
11 subsequently some slight difficulties between Mr Pawade
12 and Mr Dhasmana. So the three of us went and presented
13 a united front to John Roylance and said we thought that
14 Mr Dhasmana should not continue doing paediatric cardiac
15 surgery.
16 Q. If we look at UBHT 146/27, just for the sake really of
17 the transcript and the wider audience, that is a further
18 letter from yourself to Dr Roylance?
19 A. That is precisely the meeting I am describing when we
20 went and presented it to John. And, well ...
21 Q. You said that Dr Roylance was not generally receptive to
22 approaches like this, or advice like this from yourself.
23 What other instances of this sort of behaviour do
24 you have in mind, Professor Vann Jones?
25 A. Can I say first of all I quite like John Roylance.
0201
1 He is an interesting character, so none of this is
2 personal. But John's approach to everything was, if you
3 go along to him with an idea, he would say, "That is
4 great, I really like that idea. What do we stop to pay
5 for it?" If I have heard that once, I have heard it 100
6 times. That is when you hit the buffers, of course.
7 He would say, "You go up and tell the ENT surgeons that
8 they cannot operate because you want to do more bypass
9 operations". You could not get past that shutter. It
10 is not an unpleasant shutter, but it was a shutter,
11 nonetheless.
12 Q. So his paramount concern would come across to you as
13 being one of ensuring that the services would not suffer
14 financially, or there would be no financial drain as
15 a result of a new proposal that you were making?
16 A. That is a generous interpretation. I think there was
17 a resistance to change. I think when you are a Chief
18 Executive, you have to be able to draw a broader picture
19 and see whether there are some areas you should be
20 making an investment and some you should let have
21 a lower priority. Personally I felt that cardiac
22 services in the South West deserved a much higher
23 priority. Undoubtedly, the Chief Executive has to have
24 a broader view and as Mr Francis took me through the 14
25 different hospitals that John Roylance is managing,
0202
1 I appreciate he did have to have a broader view.
2 Q. If we could look, please, at WIT 115/25, to in some ways
3 complete the story of the involvement that you had with
4 this issue, this again is the commentary from Dr Bolsin
5 on your statement. I think that we have dealt with, in
6 essence, most of what he says. If I could ask you to
7 turn down to the bottom of the page, where the comment
8 under the heading "N4" is made, firstly, his
9 recollection is that he cannot remember in terms,
10 I think, presenting any additional figures to Professor
11 Vann Jones. You have talked about a further meeting
12 with him, with Dr Laszlo. Were any further data
13 presented then?
14 A. I am honestly not certain, but the switch operation
15 might have been mentioned.
16 Q. But he also points out that he did not revise the VSD
17 figures until in fact I think we find from other sources
18 the date was in 1995. There was then no discussion of
19 those figures at the further meeting that you can
20 recollect?
21 A. I honestly cannot remember.
22 Q. He then goes on to talk about a social function in
23 December 1995, where it is said that you claimed to his
24 wife and Dr Bolsin that you had known about the problems
25 with paediatric cardiac surgery since the late 1980s.
0203
1 Can you recollect making any such statement to
2 Dr Bolsin at a social function at that date?
3 A. This was Professor Stafford Lightman's Christmas party,
4 to which I had been invited once or twice. I am
5 standing in the corner together with Steve and his
6 wife. I knew he was going to Australia, so I thought it
7 was reasonable to go up and wish him all the best for
8 Australia. He and I had no particular axe to grind;
9 I don't feel one way or the other about Steve. So
10 I spoke to him in a social context.
11 His wife, I am afraid, is a lady who is rather
12 strong-willed, and what was a social pleasantry turned
13 into a sort of grilling and I am afraid it was not all
14 that desperately pleasant. It did end up with Steve,
15 who is twice my size, clapping me on the shoulder and
16 telling me I was a "good man", but it does not look
17 like he got that impression from this. I would very
18 much doubt whether I would be as indiscreet as to say
19 I would not let Mr Wisheart near me with a bargepole.
20 James Wisheart was a surgeon whom all the medical people
21 in Bristol requested to have perform their operations,
22 when he was one of three over all these years.
23 Q. Taking those comments in turn, do you recollect saying
24 anything about knowing about the problems with
25 paediatric cardiac surgery since the late 1980s?
0204
1 A. I think no more than what I have told you before, which
2 is that it was regarded as an average service. Until
3 November 16th 1993, I had no specifics about the
4 service, and certainly I had never heard anyone say
5 there was excessive mortality, but I knew it was
6 regarded as an average unit and I know that in terms of
7 the pecking order of the line of regional centres,
8 compared with some of the other centres like the
9 Brompton, Bristol just could not compare to the
10 Brompton. So I think it has been an average service for
11 many years. I think that is what I was conveying to
12 Steve then. But it was Christmas time, my wife was
13 driving, and --
14 Q. Do you want, Professor Vann Jones, to make any comment
15 on the suggestion that you said something about
16 Dr Bolsin's wife or not?
17 A. I beg your pardon?
18 Q. Do you want to make any comment on the suggestion from
19 Dr Bolsin that you suggested that his wife was too
20 emotionally involved in the situation?
21 A. Steve Bolsin's wife on that occasion, bearing in mind
22 I walked up to him in a situation which was pleasant
23 socially and tried to wish the chap all the best for the
24 future and was expressing sorrow that he had to go to
25 Australia, and I must say she started blasting away.
0205
1 You can do one of two things. You can either stand
2 there and take it and try and get things to calm down or
3 you can walk away. It did not seem to me that I ought
4 to walk away. I may have said to her "You are too
5 emotionally involved in the situation".
6 Q. Then the final comments are said to have been about
7 Mr Wisheart's performance as a surgeon. Firstly, would
8 those relate to adult surgery if they relate to anything
9 at all?
10 A. The last bit is completely and utterly untrue. Towards
11 the end when James Wisheart was doing 80 per cent of his
12 time in administration and 20 per cent in cardiac
13 surgery, I said to James, personally in the corridor --
14 and he was keen to keep a day's operating going; he was
15 a surgeon after all and they all like to keep doing it
16 as long as he can, he said he wanted to keep his surgery
17 going -- I said "Why don't you do some straightforward
18 valve cases and leave it at that?" I almost certainly
19 said -- I may well have said that to her. But that is
20 certainly what I said to James Wisheart to his face, and
21 you can confirm that with James when he gives his
22 evidence.
23 Q. It is implicit in what you are saying that you continued
24 to have regard for Mr Wisheart as an adult cardiac
25 surgeon; is that correct?
0206
1 A. Mr Wisheart and Mr Dhasmana are two people I respect
2 very much.
3 Q. If we can go back to your statement at WIT 115/3, at
4 paragraph 9 -- this is your first statement -- you say
5 that until the founding of the Directorate of Cardiac
6 Services, all you knew about the Department of
7 Paediatric Cardiac Surgery in the Bristol Royal
8 Infirmary was that it took place there. You go on to
9 say that you understood that it was a supra-regional
10 service and funded separately on that basis.
11 If we turn over the page to paragraph 13, we see
12 at paragraph 13 a similar statement, the fourth line
13 down:
14 "Although open paediatric cardiac surgery was
15 carried out at the BRI, all the money for this was
16 ringfenced."
17 Turning to Mr Wisheart's comments on that
18 statement -- to be found at page 18, please --
19 Mr Wisheart comments that the statements are true for
20 infant cardiac surgery under 1 year but funding for
21 children over 1 year of age came with the funds for the
22 adult service.
23 Were you aware of that, Professor Vann Jones?
24 A. I was completely unaware of that, because the money was
25 just sliced off the top and one way or another, it was
0207
1 not available for me, whether it came from the
2 supra-regional service or whether it was sliced off the
3 top to pay for the paediatric service.
4 Q. I think that the point Mr Wisheart is making is that the
5 top-slicing of any funding arose only in the case of the
6 under 1s and everybody else, all the other children,
7 were paid for out of the same budget as the general
8 cardiac surgery budget?
9 A. Well, the impression from my point of view was that the
10 funding was allocated to the children and there was no
11 touching it. I have to say, I tried to get
12 clarification recently about that in case I was mistaken
13 and I have asked all sorts of people, including Lesley
14 Salmon, who was the General Manager at the time,
15 including Janet Maher, the General Manager for surgery.
16 I have not been able to get an answer from any of them
17 how the funding was decided to slice off the funds.
18 James' letter from today, I think it was, was the first
19 time I have heard that there was a division between
20 under 1s and over 1s. As far as I was concerned the
21 money went to the children and was not to be touched.
22 Q. Do you think that that perception played any part in
23 your judgment as to what you were responsible for as the
24 Director of Cardiac Services?
25 A. I felt I was the Director of Adult Cardiac Services.
0208
1 I would not have dreamt of taking up the job of looking
2 after children. It is just a different specialty.
3 I have done enough of it to realise -- I felt like
4 a fish out of water; for three years I did it and I did
5 not want to be a fish out of water again. I would not
6 have taken on the responsibility of looking after
7 children.
8 Q. I think it is right that you did not get a job
9 description for your post as Clinical Director. Was
10 there ever any briefing to you as to what the role
11 encompassed, the responsibilities within it?
12 A. No. I mean, I have been a Clinical Director for four
13 years, you must remember, so I was not coming to it
14 new. Basically, what I think John Roylance wanted was
15 that I should set up lines of demarcation, and I have to
16 say that my idea of lines of demarcation was whether
17 cardiac anaesthetists should be in or out, whether
18 cardiac radiologists should be in or out, never whether
19 children should be in or out. The children so long as
20 I was concerned belonged to children's services, and
21 certainly the clinical responsibilities of a paediatric
22 cardiologist, whom I never saw from one centre to the
23 next, after --
24 Q. So if we looked at membership of the Cardiac Services
25 Management Board -- which you set up; is that correct?
0209
1 A. Yes.
2 Q. -- I think you will find that none of the paediatric
3 cardiologists sat upon that board?
4 A. Absolutely.
5 Q. At page 7 of this witness statement you say there that
6 as Clinical Director -- I am looking at paragraph 25, if
7 we can scroll down, please -- you had a disciplinary
8 role.
9 What did that encompass?
10 A. I have to say, there was only one disciplinary episode
11 in all the time I was Clinical Director, and that was
12 when Mr Hutter drove his car into the carpark
13 attendant! He was trying to skip in behind the other
14 car and the chap tried to stand there and stop him.
15 That was the sole disciplinary action I was involved in.
16 Q. Did your disciplinary role encompass any issues of
17 medical practitioners' performance or competence?
18 A. No.
19 Q. If you heard that a medical practitioner within your
20 directorate was performing incompetently, would it have
21 been your responsibility to take action in any way?
22 A. The one thing I have learned, particularly over the past
23 6 years, or the 6 years I was doing this job, was that
24 the first thing you must do if someone raises criticisms
25 is go and hear the other side of the story. There is
0210
1 always another side to the story. So if someone had
2 raised concerns about someone -- this is something
3 I have learned -- I would always, always, go and ask
4 them what their version of events was. You will often
5 find they are both quite reasonable, there has just been
6 a misunderstanding. But that did not actually arise.
7 Q. That would imply that if there was a dispute you would
8 take responsibility for sorting it out and if the two
9 sides were at odds with each other, you would have to
10 take further steps?
11 A. If it had been within my directorate -- and we are
12 talking about general medicine for four years or adult
13 cardiac services for 2 and a half years -- then that is
14 the line I would have taken.
15 Q. So you are in a position where, if people had been
16 within your directorate, you would have taken
17 responsibility. But does it all return, then, to the
18 issue of the fact that children were not within the
19 compass of your directorate as you saw it?
20 A. On 16th November there was no directorate. It had been
21 three weeks previously that I had been asked to become
22 the Clinical Director. There was a General Manager
23 appointed and that was it. We had barely had our first
24 discussions. I am still a pretty busy clinician, I see
25 roughly 5,000 patients a year and that goes on
0211
1 remorselessly. There was no help for this. In theory
2 there were two sessions of consultant cardiologist's
3 time, but you try and find me one. You cannot. So
4 basically there was no help for this. It was all going
5 to take time. We were three weeks into it when Steve
6 Bolsin came to my office so there was no form, no
7 demarcation, no structure, no budget, and paediatric
8 cardiac services did not exist as a directorate.
9 Q. My question was, really, when we are looking at a period
10 from November 1993 right through to the beginning of
11 1995, as the directorate was formed: was the reason for
12 you not understanding this dispute to be within your
13 compass because you did not understand children to be
14 within your responsibility?
15 A. I never envisaged paediatric services in any form
16 whatsoever coming within the Directorate of Cardiac
17 Services. Our job was to provide an adult cardiac
18 service to the citizens of the South West. That is the
19 way I saw it, not a paediatric service which was
20 a supra-regional service embracing a larger area, and
21 really, I thought it had nothing to do with me. I got
22 involved in this because I happened to be
23 a cardiologist, because I happened to be a fairly senior
24 physician, but I happened to know many of the people at
25 Trust HQ having been a Clinical Director for four years,
0212
1 and I got involved in it as a human being.
2 Q. If we turn to page 14 of your statement, please, at
3 paragraph 50 onwards, you deal with the general issue of
4 investment in health services, cardiac services, by the
5 Regional Health Authority, the Area Health Authority and
6 the Chief Executive, and your general complaint there,
7 if I may put it so, is that there was a general
8 unwillingness to invest in cardiac services.
9 Professor Vann Jones, I can take you to a number
10 of references which would set out the pattern of
11 investment in cardiac services and we can do so if that
12 is of assistance to you, but perhaps I could make the
13 general point that all those bodies concerned will
14 presumably say that their difficult task was to measure
15 and to assess competing demands on a limited budget and
16 that cardiac services, therefore, could only play a part
17 in that overall picture.
18 A. Well, I accept that. Obviously there are competing
19 demands within the Health Service. However, if you look
20 at all our sister units of comparable size, all around
21 us, ours is the only one that is spread over these many
22 different sites. Many of our beds are in a building
23 that is 255, 260, 264 years old. If you go to Cardiff,
24 the surgeons are right beside the cardiologists,
25 outpatients are beside their beds, the cath' labs are
0213
1 beside their beds. If you go to Plymouth, they had the
2 foresight to leave a big hole in the middle of Derriford
3 for a cardiac unit and it is all together. If you go to
4 Oxford, they have a brand new building that they have
5 built in the time that we have been trying to persuade
6 the Regional Health Authority in this part of the world
7 to invest in cardiac services. So to my mind that will
8 not wash -- although I heard yesterday for the first
9 time they are prepared to put up œ2 million to resolve
10 a lot of the property; at least, they did not fall off
11 their seats when they were told the estimate was
12 œ2 million to try and get us a unified, geographically
13 put together unit within the confines of Bristol Royal
14 Infirmary.
15 Q. The background to the Inquiry across this period for
16 cardiac services in general was, was it not, that there
17 was a recognition on the part of the South West Regional
18 Health Authority that the area was historically
19 under-provided for cardiac services and attempts
20 throughout the period to put in some additional funding
21 to rectify that problem?
22 A. It has always been dribs and drabs. Places like Oxford
23 build themselves a new building. What we get is another
24 five beds once every year or two. No-one but no-one
25 grasped the nettle to sort out cardiac services and they
0214
1 still have not done it. When I was Clinical Director
2 I drew up plans to take over the whole of level 6 at
3 Bristol Royal Infirmary to get us beside the surgeons to
4 remove the business of walking 10 minutes to see
5 patients. At the moment they have to come down from the
6 sixth floor, they have to come down, they have to walk
7 through the building, go under Marlborough Street, go
8 back up another building. It is no way to run a cardiac
9 service.
10 Q. Just one further point, Professor Vann Jones. You have
11 described there a deficiency effectively in capital
12 investment. Would you accept that that is a matter for
13 the Regional Health Authority rather than the Area
14 Health Authority or District Health Authority, whom you
15 have named in your statement?
16 A. I think both are responsible. The contracts are
17 negotiated with the Area Health Authority, Avon Health,
18 and they are notoriously under-provided. If you want an
19 example, we have stopped doing elective investigations
20 on patients for 1999/2000 in the middle of August, five
21 months into the financial year.
22 Q. Capital funding would surely be either a matter for the
23 Trust itself, after the creation of the
24 purchaser/provider split, or a matter of allocation from
25 the South West Regional Health Authority. Is that not
0215
1 correct?
2 A. That is correct, yes.
3 MISS GREY: Professor Vann Jones, I have asked a number of
4 questions over a long afternoon. Is there anything that
5 you would like to add or tell the Panel at this stage?
6 A. I would just like to say that I have regarded myself as
7 an adult cardiologist, and I can see in retrospect and
8 hindsight I would have done things differently, for
9 instance, I would have kept a record of every
10 conversation, because never in a million years did
11 I envisage I would be in front of the GMC, in front of
12 a Public Inquiry. I would love to have recall of all
13 the events. Quite honestly, a lot of this was finished
14 and I would just make clear two points to illustrate how
15 peripheral I was regarded to paediatric cardiac events.
16 First of all, there was a Working Party to decide
17 the future of paediatric cardiac surgery and cardiology,
18 and I was not part of it; secondly, they appointed a new
19 paediatric cardiac surgeon and I was not on the
20 interviewing committee whereas Clinical Directors are
21 automatically on the interviewing committee for any post
22 that involves their directorate. So I am not trying to
23 defend myself or wriggle out of any responsibility.
24 I am trying to say that I think my contribution was
25 a positive one, getting involved in something I had no
0216
1 right to get involved in. I am extremely sorry about
2 the outcome for these children, I think it is extremely
3 sad, but I do think our surgeons were not given an even
4 playing-field by any means and my experience from 20
5 years ago of going to do cardiac catheters, I remember
6 doing a pericardial tap on a 2 kilogram baby and the
7 same day going to do an adult cardiac catheter: the
8 relief of doing an adult cardiac catheter compared to
9 trying to tap a pericardial effusion on a 2 kilogram
10 baby is enormous, and they are as different as chalk and
11 cheese.
12 THE CHAIRMAN: Thank you, Professor Vann Jones. The Panel
13 do not at this point have any questions. The afternoon
14 has been long for you and for us. There may be, when we
15 reflect upon the testimony, questions that we would want
16 to take up with you. Should that arise, we would hope
17 that you were able to respond to us in writing with the
18 assistance of Mr Morgan and whomsoever. I hope that is
19 a satisfactory approach for you. I am not suggesting
20 for a moment that there will be any questions, but just
21 in case there may be, that is what I would propose to
22 do.
23 Mr Morgan, do you have any re-examination?
24 MR MORGAN: There is no re-examination, sir.
25 THE CHAIRMAN: I am very grateful to you. Professor Vann
0217
1 Jones, you have been of great assistance to us this
2 afternoon. We appreciate what you have been able to say
3 and that you have found time for us. As I say, we will
4 reflect on what you said and if there are any other
5 matters we wish to bring to your attention, we will do
6 so.
7 For your part, if there are any other things that
8 you wish to add that we have not heard today, please
9 know that we will be grateful to receive them. Thank
10 you very much.
11 PROFESSOR VAN JONES: Thank you very much.
12 MISS GREY: Thank you, sir. We adjourn now and reconvene at
13 10.30 on Monday, when we shall hear from Mr de Leval and
14 from Professor Hunter on the subject of their
15 investigations at the BRI in January and February 1995.
16 THE CHAIRMAN: I am grateful. Thank you, Miss Grey. Thank
17 you, everyone else. We reconvene on Monday at 10.30, as
18 you say.
19 (4.50 pm)
20 (Adjourned until 10.30 am on Monday 11th October 1999)
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2 I N D E X
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5 MRS KAY ARMSTRONG (sworn)
6 Examined by MR MACLEAN ...................... 1
7 Examined by THE PANEL ....................... 68
8 Re-examined by Mr Chambers .................. 69
9
10 MR WILLIAM BOOTH (sworn)
11 Examined by MR MACLEAN ...................... 71
12 Examined by THE PANEL ....................... 93
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14 PROFESSOR VANN JONES (sworn)
15 Examined by MISS GREY ....................... 97
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Published by the Bristol Royal Infirmary Inquiry, July 2001
© Crown Copyright 2001