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Daily transcripts
Hearing summary
24th MARCH 1999
Mr Douglas Bwye opened the concluding day of Block 1 evidence by telling the Inquiry
about his son Jason, who was born in July 1992 at North Devon District Hospital. Following
his birth, he was transferred to the Bristol Children’s Hospital with suspected heart
problems, subsequently diagnosed as transposition of the greater arteries. Jason underwent
a balloon septostomy and his parents were told that he would need a further operation when
he was between 9-12 months old and anticipated taking Jason home soon. However seven days
after Jason’s birth his family were told that Mr Dhasmana would be operating on Jason
the following day at the Bristol Royal Infirmary. Jason died during surgery, when
operating theatre staff were unable to take him off the bypass machine. Mr Bwye told the
Inquiry that he had learned less than a month ago that Jason’s heart had been
retained at the BRI following post mortem.
Mrs Belinda House from Bristol told the Inquiry about her son Ryan who was born with a
heart problem at Southmead Hospital in April 1989. Ryan was diagnosed as having simple
transposition and underwent a balloon septostomy at the Bristol Children’s Hospital
to prepare him for a second operation 11 months later. Ryan had several outpatients
appointments at the Bristol Children’s Hospital with both the paediatric cardiologist
and surgeon Mr Wisheart. In February 1990, Mr Wisheart performed a successful
‘Sennings’ procedure on Ryan. Mrs House had no complaint to make about the
treatment of her son Ryan but she told the Inquiry of her concern regarding the lack of
specialist paediatric facilities and training for staff at the BRI.
|
FULL TRANSCRIPT
1 Day 6, 24th March, 1999
2 (9.30 am)
3 MR LANGSTAFF: Sir, this morning's witnesses are Mr Douglas
4 Bwye followed by Mrs House.
5 Mr Bwye, would you like to come forward, please?
6 Mr Bwye, as you know, we begin the proceedings by
7 asking you to take the oath, so if you would not mind
8 standing, please?
9 MR DOUGLAS STUART BWYE (Sworn):
10 Examined by MR LANGSTAFF:
11 Q. Mr Bwye, it strikes me that the screen in front of you
12 is a little higher than it normally is. Can we adjust
13 that so it is a shade lower but still visible.
14 Mr Bwye, you are Douglas Stuart Bwye?
15 A. That is correct.
16 Q. And you are going to tell us about the death of your son
17 Jason, who was born on 20th July 1992 and sadly died
18 eight days later?
19 A. That is right.
20 Q. You are going to tell us how it was that he was
21 diagnosed as suffering from a transposition of the great
22 arteries, how he went through two operations, the first
23 a septostomy, and second a switch operation, and died at
24 the end of the second?
25 A. That is right.
0001
1 Q. Jason was your second child by your second wife?
2 A. Yes.
3 Q. He was born on 20th July 1992 in North Devon District
4 Hospital?
5 A. That is right.
6 Q. You were present at the birth?
7 A. Yes.
8 Q. And it seemed to you to be a normal birth?
9 A. Yes.
10 Q. You have a means of judging that because you had been
11 present at your wife's previous birth?
12 A. That is right.
13 Q. After the birth, Jason was washed and weighed and you
14 held him?
15 A. That is correct.
16 Q. What did you notice about him and his condition?
17 A. After a few minutes it seemed to me that he was not
18 breathing deeply enough; it was very, very faint, so
19 I thought there was something not right.
20 Q. So what did you do?
21 A. Told one of the nurses that was in the room. She looked
22 at him and told one of the doctors. She took Jason
23 away, I think, to let the doctor see and basically, the
24 doctor came back and said that there was a problem with
25 the breathing.
0002
1 Q. So they put him in an incubator?
2 A. Yes.
3 Q. And you went back to stay with your wife?
4 A. That is right.
5 Q. When did anyone next speak to you about Jason?
6 A. It is a difficult question to answer, that, because it
7 was not necessarily one person coming back and telling
8 me what the situation was. It was sort of on-going all
9 the time. I was asking questions all the time. At the
10 end of the day, I just realised that he was not right
11 and that he was in an incubator, and I was just sort of
12 thinking, "Well, they know what they are doing, so ...
13 Q. Would you like to have a look on your screen -- we will
14 have the document flashed up on my screen first, please,
15 403/35. This is a note, I think, from the Special Care
16 Baby Unit. It reads:
17 "Parents visited and seen by Dr Bradford who
18 explained that baby possibly had pneumonia and that
19 oxygen and antibiotics were necessary at present.
20 Do you remember seeing a Dr Bradford?
21 A. No.
22 Q. Do you remember an explanation being given to you as to
23 what might be wrong with Jason?
24 A. I cannot remember the explanation that was given to me
25 of what they thought was wrong at that time, but shortly
0003
1 after, I was told that it was not what they thought it
2 was and that the oxygen was not in fact helping. They
3 kept upping the level of oxygen up to 100 per cent,
4 I think, and it still was not really having any effect.
5 Q. We will have a look at the clinical note. It is 403/7.
6 What you have there in front of you, Mr Bwye,
7 I think you may have seen some of these records before,
8 although you have not had a very recent opportunity to
9 go through them.
10 If you look at the first entry, it is 20th July,
11 which is the date of birth. We read at the top:
12 "Emergency admission to the SCBU under the charge
13 or care of..." and I think it is probably Dr Bradford,
14 but it does not matter for present purposes.
15 It deals with the birth, an induced birth,
16 initially well, and then secondary apnoea, which is
17 essentially breathing difficulties. It deals with the
18 mother.
19 If we go down, please, to where just above the
20 middle of the screen, it says: "Baby". There is
21 a little arrow, do you see that?
22 A. Yes.
23 Q. It says "Grunting response and peripherally cyanosed."
24 Did it seem to be Jason was not as pink as you
25 expected?
0004
1 A. Before Jason was born, I did not really know what "blue
2 baby" meant, but as soon as he started having problems,
3 I can recall that somebody had told me about his
4 colouring and that it was not right, but I would not
5 have known by looking at it.
6 All I was concerned about was the fact he was not
7 breathing very well.
8 Q. Then: "Examination, pale". The same point, something
9 they would spot and you would not know enough to notice?
10 A. Yes.
11 Q. "Peripherally cyanosed" and various temperatures and so
12 on. If we can down further, you see where it says "CVS"
13 and there is an underlining, that is the cardiovascular
14 system, the heart, and on the right-hand side, a note of
15 the heart sounds, "HS". There is a double question
16 mark, as to whether the apex of the heart was displaced,
17 medially displaced towards the middle of the body.
18 At the very bottom of the page, "Impression, IMP,
19 admit to Special Care Baby Unit with oxygen, chest x-ray
20 and assess by", and "NAB" is the consultant in charge.
21 Can you go over to the next page.
22 "20/7/92, 20.45, now improvement."
23 Do you remember what time of day it was that Jason
24 was born?
25 A. Early evening, I think.
0005
1 Q. So this is a bit later on in the evening?
2 A. Yes.
3 Q. And the chest x-ray comes back, 10 o'clock, 2200 is
4 underneath, 20/7/92, and on the right-hand side,
5 "pneumonia". That is what they thought, I think, that
6 was wrong.
7 Were you told anything about possible pneumonia?
8 A. I cannot remember anything being said about pneumonia to
9 me.
10 Q. Did they tell you that you might have to go somewhere
11 else to have further checks?
12 A. Not at that stage, no.
13 Q. In any event, you went back to speak to your wife and to
14 keep her company, because it must have been
15 a distressing time for you both?
16 A. Yes.
17 Q. You went back to your daughter and you came back on the
18 21st, early in the morning. You say in your
19 statement -- can we have a look at this, please --
20 witness 2/2, paragraph 7, that you arrived back in the
21 hospital the morning of the 21st between 7.30 and 8, and
22 you were immediately informed that "the initial
23 diagnosis of lung problem had now been discounted and
24 they thought there was something wrong with Jason's
25 heart".
0006
1 You cannot now recall anything about the lung
2 problem or the initial thoughts about the lung problem,
3 but you were told at some stage, were you, that there
4 might be something wrong with Jason's heart?
5 A. What happened that morning was virtually as soon as
6 I got to the hospital, as far as I can remember, it had
7 already been decided that they were going to have to
8 move him up to Bristol and it was just a question of,
9 "You have to go up as well, if you can; they are going
10 up; you go up. You cannot do any more here". It was
11 a very quick visit.
12 Q. No choice as to where you were going to go?
13 A. No.
14 Q. Just, "You are off to Bristol"?
15 A. That is right.
16 Q. To fill in the gaps as to what was happening, if we can
17 go back, please, to the last record, 403/8, go down to
18 21st July, 02.15, a quarter past 2 in the morning, at
19 a time you were not actually there, but you can see in
20 the middle of that entry:
21 "Question mark, is this a cyanotic heart lesion."
22 That is obviously the doctor suspecting that there
23 might be a heart problem?
24 A. Yes.
25 Q. About which you obviously learned when you came in in
0007
1 the morning.
2 What time was it that you got sent off to
3 Bristol?
4 A. As soon as I came away from the hospital, I went
5 straight down to my father's to borrow his car, so
6 I could follow the ambulance up. It may have been half
7 past 9, 10 o'clock, something like that, by the time
8 I got the car.
9 Q. Jason went by ambulance, did he?
10 A. Yes.
11 Q. What about Janine?
12 A. She went with him.
13 Q. Who else went in the ambulance, do you know?
14 A. I do not know at all.
15 Q. When you got to Bristol, the Royal Infirmary or the
16 Children's Hospital?
17 A. The Children's Hospital.
18 Q. Were you told where you might find Janine and Jason?
19 A. I was shown to a ward that had a lot of other babies,
20 I think, quite a few other babies in beds. Jason was in
21 one of those beds and my wife was there.
22 Q. Did anyone tell you what might be the problem?
23 A. Yes.
24 Q. Who told you?
25 A. I honestly cannot remember the name of the person that
0008
1 told me, because there were so many different people
2 talking to us and -- because we were actually in the
3 ward at that time, and there was a lot going on, so
4 I cannot remember, but somebody did come to us and
5 explain what the problem was and what they thought the
6 next course of action would have to be.
7 Q. What sort of person: old, young, male, female?
8 A. Male. Under 40.
9 Q. Apparently a doctor, or somebody less significant?
10 A. I imagined it was a doctor, basically, because they
11 looked like a doctor, I suppose.
12 Q. That is really what I was asking. What essentially did
13 that doctor say?
14 A. He told us what the problem was with the heart, about
15 the oxygen flow not being able to get from one side to
16 the other and that the immediate release from that would
17 be to create a hole in the heart to allow the oxygen to
18 pass through, and that that would be fairly easily done,
19 there should be no problem and be done fairly quickly,
20 if we consented to that.
21 Q. Why did you understand it was necessary to create a hole
22 in the heart to mix the blood? What was wrong with the
23 heart generally that gave rise to that problem?
24 A. That the artery that was supposed to be taking the
25 oxygen into the heart was taking it into the wrong
0009
1 chamber, so that although there was oxygen going into
2 the baby, it was not circulating around the body; it was
3 just not going anywhere. So in order for it to go into
4 the right chamber, the hole would allow it to pass
5 through, or allow the blood to pass through that had
6 been oxygenated. It seemed quite straightforward.
7 Q. So the way he explained it seemed quite straightforward?
8 A. Yes.
9 Q. Do you think you understood what he was saying to you?
10 A. Yes.
11 Q. Despite your obvious concern for Jason, you recognised
12 what was necessary?
13 A. That is right.
14 Q. On that basis, did you give consent?
15 A. Yes.
16 Q. At some stage was Jason taken off for a test which you
17 know about, an echocardiogram?
18 A. I cannot remember that specifically happening.
19 Q. So may we have a look, please, at 403/64 on the screen?
20 It is the top entry on the page. It is:
21 "Echo, 21.7.92 [the date of Jason's arrival at the
22 hospital]" and the second line, "Complete TGA" -- that
23 stands for transposition of the great arteries. Some of
24 these terms you have come to know of because you went to
25 the GMC and gave evidence there, I think?
0010
1 A. Yes.
2 Q. You followed the GMC proceedings and read the
3 transcripts of what was said then?
4 A. Yes.
5 Q. It then goes on:
6 "Normal pulmonary valve [I think it is], small PDA
7 [patent ductus arteriosus], normal aorta and no VSD [no
8 hole in the ventricular septum]."
9 Underneath that:
10 "For balloon septostomy", and it goes on to deal
11 with that operation, if we scroll it up, please. It
12 says what the cardiologist managed to do, which is
13 putting a catheter through the atrium and creating with
14 three pulls, a hole between the two chambers, right and
15 left atria of the heart.
16 "Good sized resulting septostomy", and at the
17 bottom are the sats: oxygen saturations gone up from
18 30-50 to the 70s.
19 All that is technical. What did you understand
20 had been achieved by the operation?
21 A. That they had managed to put the hole through from the
22 chambers and it had been successful, and the oxygen was
23 now flowing well, and Jason was okay at that point, out
24 of immediate danger.
25 Q. Did Jason then, after that, stay on the ward?
0011
1 A. For a little while, because we saw him there on that
2 ward.
3 Q. Did the doctor say anything about what happened next,
4 after the hole had been created between the two atria of
5 the heart?
6 A. Do you mean immediately next, or ...
7 Q. Within the future?
8 A. A doctor came and saw us when he told us that that
9 operation had been successful. He then went on to tell
10 us about what the next operation would involve and why.
11 Q. Again, male or female doctor?
12 A. Male.
13 Q. The same doctor who had spoken to you earlier or not?
14 A. I do not think it was the same doctor, no.
15 Q. And approximate age?
16 A. 35.
17 Q. What did he say to you about Jason's condition, now that
18 they had done the septostomy?
19 A. He said his condition was good because it had been
20 successful. When he explained to us what was going to
21 have to happen, he drew a diagram for us. He said that
22 the operation would not have to be done immediately;
23 Jason had up to between 9 and 12 months, because that
24 would be the amount of time it would take for the hole
25 to close up naturally, so after that time they would
0012
1 have to do something.
2 Q. There is a drawing which is in the medical records.
3 I am going to ask you to look at it. It is 403/101.
4 I should tell you that the page immediately before
5 that in the medical records -- let us have a look at
6 that, please, 403/100, we are moving forward a week to
7 the consent which you gave to the operation on
8 28th July. What I do not know -- go back to page 101 --
9 is whether the diagram we see here is one which you saw
10 and if so, whether it was done at this earlier occasion,
11 just after the septostomy, or whether it was done later
12 on when you spoke to Mr Dhasmana in respect of getting
13 consent for the bigger operation later on.
14 Can you help?
15 A. That drawing on there I do not think was done
16 immediately after the septostomy, because in the room at
17 the time I can remember the doctor grabbing a piece of
18 paper to do it on, and as far as I could see, it was
19 scrap paper. I do not remember seeing any of the
20 writing on it, no.
21 Q. So that was probably something which was done later on?
22 A. Yes.
23 Q. We will come back to it in that case.
24 So he drew the diagram for you?
25 A. Yes.
0013
1 Q. What did he tell you that you had to expect over the
2 days, weeks, months to come?
3 A. When he drew the diagram, it was a very basic diagram,
4 and he made it very clear; it was easy to understand,
5 the direction of the oxygen flowing and basically how
6 the arteries had to be swapped over to put that right.
7 He did not really say anything else about the future at
8 all, other than the operation that would have to be
9 done. I cannot really remember anything else being said
10 about it.
11 Q. So you then sat by Jason's bedside and watched the
12 various monitors and so on?
13 A. That is right.
14 Q. And you were told, were you, by the nurses what they
15 were looking for in those monitors?
16 A. The nurse came and pointed out what figures should be
17 shown so that they would know that the baby was keeping
18 okay, and I remember thinking at the time that although
19 she had said it matter-of-factly, it seemed quite
20 crucial, so we sat for ages watching the monitor to make
21 sure the dial or whatever was not moving out of the
22 lines that she said.
23 Q. And it did not?
24 A. It did, a couple of times, yes.
25 Q. What happened then?
0014
1 A. We were sort of "Why is it doing that?", "That is okay,
2 it will go back, it is okay", so in the end we realised
3 it was not so crucial as she had said.
4 Q. So the way it worked was that you were always watching
5 the monitor. Was the nurse always there on hand, or
6 not?
7 A. No.
8 Q. Whenever the monitor went beyond the range you had been
9 told about, it was you who raised, if I can call it the
10 alarm, because that is the way you felt about it?
11 A. Yes.
12 Q. And the nurse came and took a look, did she?
13 A. Yes. Well, there were nurses around all the time,
14 really, because there were other things going on, so
15 I did not actually have to go and get anyone, it was
16 just a question of asking who was nearest, sort of
17 thing.
18 Q. And they were obviously familiar with it, were they?
19 A. Yes.
20 Q. And able to reassure you?
21 A. Yes.
22 Q. What they said was borne out by events, it went outside
23 and came back within the range within a short time?
24 A. Yes.
25 Q. How poorly did you understand Jason to be at that stage?
0015
1 A. At that stage we thought "He is normal again, because he
2 looks normal and they are telling us he is okay now", so
3 we did not think that he was in any immediate danger any
4 more.
5 Q. Indeed, did you go home that evening?
6 A. Yes.
7 Q. If we can just pick it up in the medical records,
8 please, 403/64, it is the bottom of the page, 22nd July,
9 so if he had his septostomy on 21st July it is now the
10 next day. "Stable", and it sets out the blood
11 saturation, "70 to 80, NBM, nil by mouth, intravenous
12 only."
13 So he was on a drip, was he?
14 A. Yes.
15 Q. If we go over to page 403/65, you followed the GMC
16 proceedings carefully, did you, in relation to your son?
17 A. Yes.
18 Q. Was there a suggestion at one time that your son might
19 have had a lung problem and there might have been
20 pneumonia? Do you remember that?
21 A. No. I find it difficult to remember the GMC proceedings
22 exactly, although I did try and follow it.
23 Q. In any event, the first entry on 22nd July, following on
24 the same note, the top of the page, is:
25 "Chest clear."
0016
1 The next entry, 23rd July:
2 "Well, apyrexial", which means having no fever or
3 temperature, "feeding well ... contact Mr Dhasmana."
4 That is obviously the surgeon's own note?
5 A. Yes.
6 Q. You had gone home and you came back to Jason's bedside,
7 did you?
8 A. Yes.
9 Q. Both you and Janine?
10 A. Yes.
11 Q. So you had made arrangements for Jessica, had you?
12 A. That is right, yes.
13 Q. At this stage, in the middle of the week after his
14 birth, what did you think was going to happen?
15 A. Up to then, we thought that he was going to stay for
16 a short period in the hospital until he was well enough
17 to come home, and then he would come home and we were
18 trying to focus on when that day would be.
19 Q. At the bottom of page 65, 23rd July, there is another
20 echo investigation. Do you remember Jason being taken
21 for an investigation, a check, to see what his heart was
22 like?
23 A. No.
24 Q. We can see what actually was recorded there,
25 "Transposition of the great arteries [TGA], no VSD,
0017
1 a good septostomy", that was the success of the previous
2 operation. "Pulmonary valve a little tuckered but
3 3 leaflets with no Doppler evidence of stenosis", that
4 is a narrowing of the artery. No --" the next word
5 escapes me, but "Subpulmonary stenosis. The aorta goes
6 to the right of the pulmonary artery". If we go over,
7 please, 403/66, "One coronary visible. Cannot see the
8 second. Normal aortic arch. PDA shut. No TR or mitral
9 valve problem."
10 Those investigations were carried out. Did anyone
11 ever speak to you about what they found on the checks
12 that they had done on Jason?
13 A. No. All we knew was that during these days that were
14 passing, he was fine; he was, as it says on the note,
15 feeding well and passing stools as he should. When we
16 went, we would look at the chart and we just thought
17 everything was okay. But nobody really went into any
18 detail about any other checks that they had done on him.
19 Q. 25th and 26th July, the notes, if we can just have
20 a look at those:
21 "Well in himself [the note the doctor has made
22 there] ... to discuss with cardiac surgeons".
23 "26th July, ward round of Dr Joffe, stable,
24 apyrexial, feeding well, pink in air, cyanotic spells on
25 strain."
0018
1 Let me ask you about that. His colour was
2 reasonably good?
3 A. Yes.
4 Q. By this stage, had you got to know the difference
5 between the way a baby should look and when a baby was,
6 in quotes, "blue"?
7 A. No.
8 Q. You had not?
9 A. No, because he looked normal. When he looked normal,
10 I never really gave another thought to what he had
11 looked like before.
12 Q. So as far as you were concerned, he was normal?
13 A. That is right.
14 Q. You then expected Jason to come home at some stage, did
15 you?
16 A. Yes.
17 Q. What was said to you about that?
18 A. Nothing was said at that time about it. I had formed
19 that conclusion from when the septostomy was done and
20 the fact he said he had 9 months to 12 months before it
21 had to be done.
22 Q. Who said that to you?
23 A. It was a doctor, but I do not know who. I am just
24 assuming it was a doctor.
25 Q. It is something that obviously sticks in your mind,
0019
1 something you had been told, but you can't recall who
2 said it to you?
3 A. No, because at the time I thought that must be a plus,
4 because he will be that much stronger in 9 months, so
5 I thought that was a good thing.
6 Q. Are you sure that that was said, or something to that
7 effect was said?
8 A. Positive.
9 Q. Even though you cannot remember quite who said it or
10 quite when it was said, or quite the terms in which it
11 was said?
12 A. The reason I remember that was because one of the nurses
13 on the day of the septostomy said to my wife that when
14 he came home, we would have to be careful with infection
15 and if we had any pets, we would have to be very
16 careful, so my wife was that convinced he was coming
17 home imminently that when she got home, she took the
18 dog, or asked me to take the dog to have the dog put
19 down, so the dog would not be there when the baby came
20 back.
21 Q. How long had you had the dog?
22 A. Three and a half years.
23 Q. Did you take him to be put down?
24 A. No, I took him to a rescue centre in Exeter, where they
25 found another home for him, but that is how I know that
0020
1 that was said, because there was no way that that dog
2 would have gone if we had thought that the baby was not
3 coming home at all, straightaway.
4 Q. Your taking the dog to the rescue centre was during that
5 week, was it?
6 A. Yes.
7 Q. What did you know about any change in plans? What did
8 you first know about it?
9 A. The first I knew was that I had a phone call from the
10 hospital which basically said, "If you can come up and
11 sign a consent form", or "If you can get up here
12 quickly, we can organise the operation in the next
13 couple of days", or -- she gave me the day, I cannot
14 remember, but it would have been the next day, I think,
15 to the phone call, because we had to get ready and go
16 straight up.
17 Q. I had not, I think, completed going through the clinical
18 notes with you. Can we have a look, please, at
19 page 403/67?
20 This is 27th July and the same picture:
21 "Stable on air, apyrexial, feeding well. For
22 switch operation tomorrow."
23 Then the various tests which have been put down,
24 the very last of which is "Consent" which is ticked.
25 I will come to that in a moment.
0021
1 So this was something that was discussed with you
2 once the decision had been made, was it, as you
3 understood it?
4 A. I am sorry?
5 Q. Once the decision had been made by the surgeons or
6 cardiologists, the doctors, that they should go ahead
7 and do the operation, you were asked whether you would
8 give your consent to it?
9 A. Yes.
10 Q. You were asked to come up to Bristol. You went up.
11 When you went up to Bristol, was it just you or you and
12 your wife?
13 A. Myself and my wife went up.
14 Q. Who did you see?
15 A. We spoke to somebody who told us that we would have to
16 go to a different part of the hospital. We could stay
17 overnight and it was, I do not know, about 50 yards away
18 from where Jason was being kept in a room, so that was
19 basically it. We arrived there and they said that the
20 operation was being scheduled for tomorrow, "Stay here
21 overnight, somebody will come and tell you a little bit
22 more about it". We put our stuff in that room and then
23 went back and sat with Jason again.
24 Q. So at this stage you had not seen any surgeon?
25 A. No.
0022
1 Q. When did you first see anyone who explained to you what
2 was being done and why it was necessary?
3 A. Probably about an hour after we had been there and we
4 were in the room with Jason, not a doctor, but a nurse
5 that had come in to do normal checks that they did every
6 so often, she came in and we asked her, and she told us
7 that the operation -- what was going to happen, that we
8 would have to go to another hospital, but the surgeon or
9 somebody else would speak to us later on and go through
10 it in more detail.
11 Q. So Jason was in a ward on his own, was he?
12 A. He was in a room on his own.
13 Q. And you waited for the doctor to come and explain, did
14 you?
15 A. Yes.
16 Q. Did he come after an hour, or ...
17 A. No. A doctor did not come. It was Mr Dhasmana that
18 came, eventually, not to Jason's room but to the room
19 that we were staying in, which was down the corridor.
20 He came in to explain to us what was going to happen.
21 Q. Was there anyone with him or was he on his own?
22 A. On his own.
23 Q. What did he say to you?
24 A. He basically told us, explained to us the same thing
25 that the other doctor had explained to us before, about
0023
1 what was going to happen in the operation. The only
2 difference that I can remember is that he did make
3 a point of saying that there were other smaller arteries
4 that had to be moved, rather than just the main ones,
5 which was what I thought it was, just the main
6 arteries. He said they were more difficult than the
7 main arteries. That was the first inkling that we were
8 given that anybody thought that it was not easy. Up to
9 then we thought "This is a straightforward operation
10 that they do all the time".
11 After he said that, we thought "Perhaps it is not
12 quite as straightforward".
13 Q. So you realised this was obviously a serious operation;
14 it was on the heart?
15 A. Yes.
16 Q. It was not quite as easy as might at first have looked?
17 A. That is right.
18 Q. You had been expecting, at least for the last part of
19 the week, that after his first operation which had been
20 a success, Jason was going to come home?
21 A. That is right.
22 Q. He seemed perfectly well to you. There was no problem
23 with his feeding, no problem with his colour. None of
24 the nurses had raised any alarms with you, and you felt
25 quite content to go home and leave him in the hospital
0024
1 until he was ready to come out?
2 A. That is right.
3 Q. So you must have asked --
4 A. Well, no, I am sorry, we did not feel content. It was
5 difficult because we wanted to stay up there but we
6 could not.
7 Q. Because of Jessica?
8 A. Because of Jessica, yes. We did want to be up there,
9 but we were satisfied that he was okay and that nothing
10 was going to happen while we were not there, so ...
11 Q. You were satisfied that he was okay, but not content
12 with him being there, wanting him home, believing he was
13 going to come home. When the operation was suggested to
14 you, you must have asked, "Why is it necessary?"
15 A. No, I did not ask why was it necessary, because I had
16 got the impression from the phone call that they were
17 putting him in because someone else had dropped out.
18 That is what I thought and that we were lucky that it
19 was able to happen so quick. I just thought we were
20 fortunate that this was going to be done straightaway.
21 Q. In your mind's eye, as you have told us, you had Jason's
22 operation pencilled in for 9 months or so later when he
23 was bigger and stronger and better developed, and there
24 was a big difference, obviously, between a 9 months old
25 child and an 8 day old baby?
0025
1 A. That is right.
2 Q. So if that was in your mind's eye, did you say anything
3 to Mr Dhasmana: "Is it not better if he waits a bit,
4 because we do not mind if he waits a bit, he seems to be
5 quite all right"? Nothing like that?
6 A. The thing is, when they said to us it would be 9 to 12
7 months before it was needed, they did not actually say
8 we were going to wait that long. We just had that,
9 well, when he comes home we could have him up to that
10 amount of time and it was any stage during that time.
11 Q. So that was the long-stop.
12 A. That is right, but I was very surprised the phone call
13 came so quickly. It was completely unexpected, because
14 he had not even come home.
15 Q. So I think what you are saying to me is that you did not
16 ask why now, because you assumed that it was all for the
17 best?
18 A. That is right.
19 Q. Although you did not ask, did Mr Dhasmana say anything
20 about why now rather than waiting a bit?
21 A. No.
22 Q. You told us that he explained that the operation was not
23 going to be quite as simple as the other doctor had said
24 to you. Did he say anything about any particular risks
25 involved in the operation?
0026
1 A. He volunteered the 80 per cent success without me
2 asking, because I had already asked previously, when the
3 balloon septostomy was done, and I had been told 70 per
4 cent, so I was not asking him, because as far as I was
5 concerned, I already knew. He volunteered that to me.
6 Q. Let me take it in stages. The time that the balloon
7 septostomy was done, you had asked, and did the 70 per
8 cent relate to the balloon septostomy or to the later
9 operation?
10 A. To the later operation.
11 Q. The person you asked was whom?
12 A. The same doctor that had drawn the diagram for us. The
13 reason I remember that so well is because as soon as he
14 said a 30 per cent chance of failure, I said, "Well, can
15 you tell me why those 30 per cent fail?" But he did not
16 tell me why. He just said "The main thing for you to do
17 is to focus on the fact that other than that, Jason is
18 well". So it looks good, basically.
19 Q. So he did not answer, but gave you some reassurance?
20 A. Yes.
21 Q. When it came to Mr Dhasmana, he volunteered, you say,
22 80 per cent?
23 A. Yes.
24 Q. How did he do that?
25 A. How did I view that?
0027
1 Q. No, how did he do that? What words did he use, that you
2 can recall?
3 A. I cannot remember the exact words. He just said --
4 I think he said something like, "All being well, we
5 would expect 20 per cent chance of failure, but ...".
6 We did not really sort of understand why there was
7 a difference in what he said, but it just did not seem
8 to matter at the time. We just thought, "Just do it",
9 basically.
10 Q. Did you say to him, "The other doctor said 70 per cent,
11 you are saying 20 per cent risk of failure"?
12 A. No.
13 Q. Perhaps it might be obvious, but what did you understand
14 the failure to involve, potentially?
15 A. Death.
16 Q. You understood that at the time?
17 A. Yes.
18 Q. Are you sure that it was 20 per cent that he mentioned,
19 as opposed to 25 per cent?
20 A. I am positive.
21 Q. Because you have had difficulties, I think, recollecting
22 precise words, precise conversations, precise identities
23 throughout the brief period we have already been
24 discussing?
25 A. Yes.
0028
1 Q. But you are convinced that it was 20 per cent?
2 A. Yes.
3 Q. And it was that way round: 20 per cent risk of failure
4 as opposed to 80 per cent chance of success?
5 A. Yes.
6 Q. The reason I ask if you are sure is, if we can go to
7 page 403/68, this is Mr Dhasmana's own entry, 27th July
8 1992.
9 "Seen [that relates to you rather than Jason] for
10 arterial switch repair tomorrow. Nature and risks
11 (25 per cent) explained to parents, agree. Consent" and
12 a tick.
13 So he has made a note at or about the day that he
14 saw you that he had said 25 per cent?
15 A. Yes.
16 Q. If he said 20 per cent, he might -- it might be
17 suggested on his behalf, why should he write 25 per
18 cent? Again, I just ask you: it may be, perhaps that he
19 may have said, "Well, the risk is 20 per cent, it could
20 be more, it could be 20 to 30 per cent, something like
21 that", which would, if you are going to pick one figure,
22 you pick a figure in the middle and you pick 25 per
23 cent. Did it come out like that at all, do you think?
24 A. All I can say to that is two things. Firstly, in view
25 of the fact that first we were told 70, then he told me
0029
1 80, it does not surprise me that the final thing that
2 was written was 75.
3 Q. But he did not know you had been told 70. You did not
4 tell him?
5 A. No. What I mean is, if one can tell me one thing and
6 one can tell me the other, it does not surprise me what
7 gets written down is something else. In view of the
8 type of person that I have learned Mr Dhasmana is, that
9 does not surprise me, that he would write down something
10 that had not been said.
11 Q. In any event, you are certain that he said 20 per cent
12 to you?
13 A. Yes.
14 Q. Why was it that you agreed to the operation?
15 A. Because we wanted Jason to live.
16 Q. If he quoted 50 per cent or 60 per cent, you would still
17 have given consent, would you?
18 A. Yes.
19 Q. Do I take it from what you said that you placed your
20 trust and faith in the doctors?
21 A. Completely.
22 Q. And so whatever they said was in Jason's best interests,
23 you would have agreed to?
24 A. That is right.
25 Q. Can we go back to the little picture that was drawn,
0030
1 which I said I would come back to at a later stage?
2 This picture: was that one drawn by Mr Dhasmana?
3 A. I do not remember that being drawn.
4 Q. You do not?
5 A. I do not even recognise it, only because I have seen
6 another picture drawn by someone else that was similar,
7 but I do not actually recognise that.
8 Q. It is obviously not a picture drawn for Mr Dhasmana's or
9 any doctor's benefit, because they would know the
10 anatomy, so it must have been done for you or your wife
11 at some stage?
12 A. Yes.
13 Q. It is in Jason's records so we assume -- we may be
14 wrong -- that it is to do with Jason and something that
15 one of the doctors, whoever it was, may have said to
16 you?
17 A. Yes.
18 Q. Did more than one person, so far as you can remember,
19 draw diagrams to explain to you what was involved?
20 A. I can only remember one person drawing a diagram.
21 Q. You cannot recall this diagram as being the one that was
22 then drawn, because that was done on a piece of paper
23 which was pulled across towards you?
24 A. That is right.
25 Q. So whoever it was who drew this, if it had anything to
0031
1 do with Jason -- I appreciate it is in his records, it
2 may be a mistake -- but if it is anything to do with
3 Jason, you cannot recall it being done?
4 A. No.
5 Q. If you look at the diagram to the right, you see the
6 diagrams of I think what is intended to be circulation,
7 body and lung, the arrows going around one to the
8 other. Does that ring a bell with you?
9 A. Yes. That diagram is closer to the one that we
10 originally saw than the one on the left: the one on the
11 left is a lot more complicated than we were shown
12 originally.
13 Q. Can I have a look at the whole sheet, please, taking
14 a more distant view?
15 It looks as though it is notes in relation to the
16 giving of consent for treatment. You were asked for
17 consent on two occasions. One was for the septostomy,
18 the second was in relation to the later operation?
19 A. Yes.
20 Q. Does that help at all as to when this diagram may have
21 been drawn, on which occasion?
22 A. No.
23 Q. Did you understand how long the surgery was going to
24 take?
25 A. I cannot remember if anybody told me specifically, but
0032
1 I was under the impression that it should be around
2 about four to five hours, if everything went well.
3 Q. You had to move Jason from the Children's Hospital to
4 the Royal Infirmary for the operation. Were you with
5 him when he had his pre-med?
6 A. Yes.
7 Q. Did you go with him to the Royal Infirmary and say
8 goodbye to him at the theatre?
9 A. Yes.
10 Q. Was he asleep?
11 A. Yes.
12 Q. What arrangements were made for you to wait for the
13 result of the operation?
14 A. We were shown a room that we could stay in by ourselves,
15 and it was suggested that we did not stay in the
16 hospital all the time waiting because it would not be
17 very pleasant, so if we went into Bristol and had
18 something to eat, pass the time, and then headed back
19 around 3 o'clock, the operation should be complete and
20 they should be able to have some news for us.
21 Q. You dropped Jason off, sorry to use that expression, but
22 you left him about what time at the Royal Infirmary?
23 A. I think it may have been half 8, a quarter to 9,
24 9 o'clock, something like that.
25 Q. That may be where you get your five or six hours from,
0033
1 to come back at 3 o'clock?
2 A. Yes.
3 Q. In any event, did you do that?
4 A. Yes.
5 Q. And when you came back, what happened?
6 A. When we went back, I went to reception, told them who we
7 were, and asked how we could find out exactly what was
8 happening. They said they would get somebody to come up
9 and tell us.
10 Q. Did someone come?
11 A. Yes.
12 Q. What did they say?
13 A. They said that he was not out of surgery yet because
14 there had been a problem. That was it, basically.
15 Q. You were worried, obviously?
16 A. Yes.
17 Q. Did you ask what the problem was?
18 A. Yes.
19 Q. What were you told?
20 A. She did not know. All the information she could give us
21 was that he was not out of surgery yet and there has
22 been a complication, a problem, but she did not know
23 exactly what it was.
24 Q. So what happened next that you can specifically
25 remember?
0034
1 A. We went to the room and just waited in there.
2 Q. On your own?
3 A. The two of us, yes. We waited and waited, and after
4 a while a nurse came to see us and said that he was
5 still in surgery; that there had been another
6 complication and the same as the first time, really, she
7 did not really know what was wrong, exactly, but knew
8 that he was still in surgery.
9 Q. What was the next news that you had?
10 A. We waited and waited again, and I think I went to
11 reception again and asked for somebody to come and give
12 us more information.
13 Q. Roughly what time would that have been?
14 A. About 6 o'clockish, just after 6.
15 Q. So the operation had now been going on for about
16 9 hours?
17 A. Yes. That is really why I went to reception, I think,
18 because we started to realise that the baby being, you
19 know, in surgery for all that time, could not be a good
20 thing, so I went to reception and somebody came to see
21 us and this time they gave us a bit more detail and she
22 said that they had tried to take him off -- he was on
23 bypass and they tried to take him off the bypass and
24 they could not take him off the bypass, so they had to
25 reopen him to try and find out why he was not coming off
0035
1 the bypass successfully. That was all that she could
2 say, basically.
3 Q. What was the next that you heard?
4 A. Again, I went back to the room and waited and waited
5 another hour or so, I think. I went to reception again
6 and I do not know if I asked for somebody to come or if
7 there was somebody actually on their way already, but
8 either way, the nurse came back again and told me that
9 he had died; they had not been able to take him off the
10 bypass, or they took him off the bypass and he had had
11 a cardiac arrest while doing it. It is a bit difficult
12 to remember exactly what she said. I was outside the
13 room when that happened, because I thought this was
14 going to be bad news and I wanted to be able to tell my
15 wife myself.
16 I remember her saying to me that she thought I was
17 taking it too well.
18 Q. The nurse saying to you?
19 A. Yes, because I did not really react. The reason for
20 that was because I think I knew that it was going to be
21 bad news, so I was not actually shocked. She asked if
22 I wanted her to come in with me to tell my wife, and she
23 asked if I wanted to see the Chaplain or anybody from
24 a religion to talk to, but we did not. So I think the
25 only other thing I asked was when we would be able to
0036
1 see the baby, and she said that it would be a little
2 while because the baby would have to be prepared,
3 cleaned up, because the operation was not very pleasant,
4 so then we waited again.
5 Q. Do I gather that the way that she dealt with you was
6 sympathetic?
7 A. Yes, up until then. But we waited again and it just
8 seemed too long, so I went to reception again to ask
9 what was happening. I had said to the nurse, "When you
10 bring the baby down, if I am not here, do not go into
11 the room without me to show my wife".
12 Q. Because ...
13 A. I thought it would be better if I was there with my wife
14 when the baby was brought in.
15 Q. To spare some of the upset?
16 A. Yes. When the baby still did not come back after
17 a while, I then went to reception again to ask, and by
18 the time I had got back, the nurse had come back and was
19 already in the room and had given the baby to my wife.
20 Q. So you were upset about that?
21 A. Yes.
22 Q. But as it happened, had Janine taken it better than you
23 had expected?
24 A. I do not think she wanted me to say anything about it to
25 the nurse. I just thought it was a very simple thing to
0037
1 ask, you know. I just thought, because she had not
2 complied with it, it just seemed a bit odd, under the
3 circumstances.
4 Q. Were you able to spend the time you wanted with Jason?
5 A. Yes.
6 Q. You then tell us in your statement, you asked the nurse
7 to leave. She said she could not. You said "Please do"
8 and she did?
9 A. That is right.
10 Q. So there was really no problem with that?
11 A. No.
12 Q. You had long enough with Jason before he was taken away?
13 A. Yes.
14 Q. Was there any further discussion as to what was going to
15 happen now for you, given the shock you had had?
16 A. When the nurse took Jason away, I cannot remember if she
17 came back quickly or it was another nurse came back, and
18 said to us that we would be able to stay in that room
19 overnight, and sort of go home in the morning. She did
20 not think it was a good idea for us under the
21 circumstances to leave and drive home that night, so we
22 were offered the opportunity to stay, and also, if we
23 would like to see anybody who could talk to us about it,
24 help us, a counsellor or someone like that.
25 Q. So you had the choice and the opportunity?
0038
1 A. Yes.
2 Q. And did you take advantage of it, or not?
3 A. No. She also asked if we would like to speak to the
4 surgeon.
5 Q. And you said --
6 A. No.
7 Q. Why?
8 A. As far as we were concerned, we thought the baby had had
9 the best possible attention and that nothing else could
10 have been done and that to start trying to go into
11 details would be a complete waste of time, and would
12 just make it worse for us. All we wanted to do was to
13 leave, get home, and deal with it, basically.
14 Q. You have changed your mind, as is obvious from your
15 statement, about that subsequently. Am I right in
16 thinking that what changed your mind was the matters
17 that led to the GMC Inquiry?
18 A. Yes.
19 Q. And up until when did you go on thinking or believing
20 that Jason had had the best possible treatment?
21 A. Do you mean what date, or what event?
22 Q. Roughly what sort of period of time?
23 A. 1997, I think -- 1996, 1997.
24 Q. So for four or five years, anyway?
25 A. We did not realise, when we first found out that
0039
1 something was not right, we did not realise then what it
2 was, if you know what I mean, that was not right. I was
3 interested in what I had seen on the news and bought
4 a local paper, but it did not really mean that much to
5 me until I had a phone call from the hospital.
6 Q. I will come to that in a moment. I just took a little
7 bit out of your account to contrast the way you felt
8 immediately after the operation with the way that you
9 feel now. That was the purpose of the question. I will
10 come back to that.
11 If I can just pick up the account, you go home,
12 having been offered some support by the hospital?
13 A. Yes.
14 Q. Did you have any phone calls or letters over the next
15 few days from anyone connected with the hospital?
16 A. Yes. We had a phone call the next day from a woman who
17 was asking how we were, giving her condolences.
18 Q. Did she say who she was?
19 A. She did. As far as I can remember, it was Helen
20 Stratton, I think. There were two or three people who
21 all seemed to be doing the same sort of job that we
22 spoke to a couple of times each, so I am not sure, but
23 I think it was Helen Stratton, and also, we had got two
24 cards from the Children's Hospital, bereavement cards,
25 and with one of them was sent the baby's handprint and
0040
1 footprint, but we did not ask --
2 Q. You did not ask?
3 A. It was offered to us and we thought that would be a good
4 thing.
5 Q. Was it a good thing?
6 A. Yes.
7 Q. Did you get a letter, I think, let us have a look at
8 403/88. It is a letter from Dr Martin. The date of it
9 I can tell you is 18th September, so it is a little
10 while later, a couple of months, six weeks later and it
11 speaks perhaps for itself:
12 "You may have lots of questions and
13 uncertainties, you may not feel ready for this yet, but
14 if and when you would like to talk things over, I would
15 be very happy to see you, either up here in Bristol or
16 perhaps at one of my two-monthly visits to Barnstaple."
17 Did you take up that offer?
18 A. No.
19 Q. Did you understand that there was going to be
20 a post-mortem?
21 A. Yes.
22 Q. Were you told about that before the post-mortem took
23 place?
24 A. I was told about that when I asked how quickly Jason
25 could come back, so that the arrangements could be dealt
0041
1 with. It was explained to me that he would not be able
2 to come back quickly because of the circumstances of the
3 death, that somebody would have to look into it, which
4 I assumed that is what they meant, the post-mortem. So
5 that was fine, we understood that, that things had to
6 happen before he could come back.
7 Q. Did you ever see or ask for -- two separate questions
8 there. Did you ever see, first of all, the post-mortem
9 report?
10 A. If that is the report that is in his records that does
11 not give any detail at all, yes. But I am not sure what
12 the --
13 Q. But that was later on when you got his records?
14 A. Yes.
15 Q. So that would be moving four or five years on?
16 A. That is correct.
17 Q. But within the four or five years after the death, you
18 did not see the post-mortem report. Did you ask for it?
19 A. No.
20 Q. So you were, if not happy, at least you understood that
21 that had been done, and you did not want to know what it
22 said in particular?
23 A. As far as we were concerned, after the baby was
24 cremated, we just wanted to deal with what had
25 happened. We just thought that details would just make
0042
1 things worse for us, and it would not accomplish
2 anything. We did not for one minute think that any
3 mistakes could have been made. It just did not enter
4 our heads. We just assumed that everything had been
5 done correctly.
6 Q. Before I come to that question, the question of mistakes
7 and what you feel about that, just staying with the
8 post-mortem and related issues for a moment, you had
9 Jason's body back for cremation?
10 A. Yes.
11 Q. Did you understand that any tissue had been kept?
12 A. No.
13 Q. Have you since realised that that in fact was the case?
14 A. Yes.
15 Q. When did you realise?
16 A. Do you mean when did I realise it might, or when did
17 I know for certain that it had?
18 Q. When did you know for certain that it had?
19 A. Two weeks ago.
20 Q. When, before that, did you realise that it might have
21 been kept?
22 A. Yes.
23 Q. How long before that?
24 A. About two weeks before that. So about a month.
25 Q. So within the last month, you first of all realised some
0043
1 tissue from Jason may have been kept; two weeks ago
2 roughly you realised it had been?
3 A. Yes.
4 Q. Had you ever been asked about whether it could be kept?
5 A. No.
6 Q. What do you feel about not knowing, and then finding
7 out?
8 A. I think they should have told us, but the fact that they
9 did not does not surprise me, because that is life. It
10 just does not surprise me. But I think they should have
11 told us. I do not think they have any right to take
12 tissue from a baby without their parents knowing,
13 whether their baby has died under special circumstances
14 or not. If the parents have not got the right to know,
15 then who has?
16 Q. You have said that in a very matter-of-fact way. In
17 terms of your feelings, were you annoyed to discover
18 that it had happened?
19 A. No, because I have been annoyed at the whole thing, so
20 these extra things that keep coming up at this stage do
21 not really surprise me. It is just, here is another
22 thing that we did not know that they have done, and each
23 thing seems to get worse, so the way we have dealt with
24 it is just to take it on board and just think, "Oh,
25 well, it is just another thing they have done that they
0044
1 should not have done". It cannot be put right, so that
2 is why I am so matter-of-fact about it.
3 Q. How, in your view, ought it to have been dealt with?
4 A. I think that somebody should have said to us that "If
5 there is a post-mortem, the Coroner has the legal right
6 apparently to order retention of certain organs or
7 tissues without the consent of anybody, because that is
8 the law. However, we want you to know exactly what is
9 happening, so although that can be done without your
10 consent, it does not mean to say that we want to do it
11 behind your back".
12 If they had said that, we would have understood;
13 it would have made things different, because we would
14 have consented. If we thought it would help, we would
15 have. But to do it and not find out until after all
16 these years, and the way that we found out, because the
17 Public Inquiry was about to start, just sort of
18 underlines the attitude that the hospital must have
19 had. I do not think, if the Inquiry had come about,
20 that we would know now.
21 Q. If the Inquiry had not come about?
22 A. If there was no Inquiry, I do not think that we would
23 know that there had been organs retained.
24 Q. I stopped you a moment or two ago telling us about how
25 you developed your concerns about what had actually
0045
1 happened during the operation and how you changed your
2 view from being that he had the best of treatment to
3 being very worried that he had not. Indeed, your
4 present position, I think, is that you have a claim
5 against the Trust in respect of the death of Jason?
6 A. That is right.
7 Q. And I think you are anticipating that there may be
8 a settlement in the near future?
9 A. Yes.
10 Q. How did you become aware of your present concerns? You
11 were going to tell us about a phone call or some
12 communication you had had from the Trust?
13 A. First of all, it was on the local news, talking about
14 somebody who had only lived about five miles from where
15 we lived, so that was interesting. We listened.
16 Because it was such an unusual story, I thought it would
17 be in the local paper, so I bought the local paper and
18 it was. I think my wife said to me at that stage, "You
19 should look into it and find out."
20 Q. The "it" you were looking into was what? What was the
21 story about, roughly?
22 A. Yes, that is right, because it concerned the Bristol
23 hospital and because it concerned a baby and a heart
24 problem, it was common with us, so she thought it is
25 worth finding out a bit more about it. I was not so
0046
1 sure, then, because I did not really connect their
2 problem with the problem that we had at all.
3 But then I got a phone call from the hospital,
4 I think it was the next morning to when it had been on
5 the television, and it was just a phone call out of the
6 blue. They just wanted to ask me -- well, they asked
7 me, "Are you happy with what happened at the hospital to
8 your son? Are you happy with what went on and do you
9 have any problem with it?"
10 So I said, "No, none at all."
11 Q. The person to whom you spoke was a he, was it?
12 A. He.
13 Q. How did he introduce himself? Who was it? It could be
14 anyone you were speaking to?
15 A. That is right. He did introduce himself, but I cannot
16 remember who he said he was. I was just stunned that
17 I was getting a phone call from the hospital. What
18 sticks in my mind about that call was that he wanted to
19 speak to my wife specifically because although I had
20 said I was happy with what had happened, he wanted my
21 wife to say it on the phone, and I knew that she would
22 not want to speak to him, so I just said "There is no
23 need to talk to her, because she is quite happy, the
24 same as I am". But he did ask again, was she there and
25 could he speak to her, and I just said "No, there is no
0047
1 point".
2 Q. Roughly when was the phone call?
3 A. It was the next morning to when it had been on the news.
4 Q. Roughly when was that? It was before the GMC hearings,
5 obviously, because you subsequently went there?
6 A. I think it was 1996, 1997, something like that.
7 Q. So some time around about then, you think?
8 A. Yes.
9 Q. I think on an earlier occasion you may have said that
10 it was possibly February 1996. I do not know whether
11 that rings a bell or not?
12 A. It does now that you have said it, yes.
13 Q. So it may have been about then, you think?
14 A. Yes.
15 Q. But you have no other way of dating it, apart from just
16 thinking, well, it was that sort of time ago?
17 A. That is right.
18 Q. And the day after the ...
19 A. Yes.
20 Q. You have told us you were stunned by this approach, out
21 of the blue?
22 A. Yes.
23 Q. Did you speak to anyone about it?
24 A. I phoned up and got the number of the lady that had been
25 on the interview on the television. I do not think
0048
1 I could -- I tried to phone her. I cannot remember how
2 I got the number, but I ended up getting the number of
3 the place that her husband works, and I phoned and spoke
4 to him at work.
5 Q. And as a result?
6 A. He very sort of basically told me what had happened and
7 said to me that if he was me, he would seek advice,
8 further advice on it, or look into it.
9 Q. So you went to whom for advice?
10 A. I made an appointment to go and see the solicitor that
11 he suggested and that he was using.
12 Q. And did you see that solicitor?
13 A. Not at that time, no.
14 Q. But subsequently?
15 A. Yes.
16 Q. Is that your present solicitor, or not?
17 A. Yes.
18 Q. A little while after that, you were asked to come to
19 give evidence at the GMC?
20 A. Yes.
21 Q. Which you did?
22 A. Yes.
23 Q. And you followed the proceedings at the GMC?
24 A. Yes.
25 Q. You told us in your statement about the advice that you
0049
1 have had through your solicitors, what you have picked
2 up listening to or reading the transcripts of the GMC?
3 A. Yes.
4 Q. I think you would be the first to accept that you have
5 to rely on what experts make of the documents and the
6 operation notes?
7 A. That is right, yes.
8 Q. Because of what has happened, you have serious concerns
9 which you would like to have resolved: you would like to
10 know what happened and why?
11 A. That is right.
12 Q. But I think what you would acknowledge is that although
13 you set out complaints in relation to Mr Dhasmana in
14 your statement, that really is for, as it were, experts
15 to resolve?
16 A. Yes.
17 Q. For that reason, I am not going to go through your
18 complaints in detail. They are in your statement and we
19 can see what they would be.
20 A. Yes.
21 Q. I think it is simply perhaps sensible, for future
22 purposes, because I am sure we will probably hear more
23 evidence in relation to Jason's death, to note for the
24 Panel's reference, and put it on the screen at the
25 moment, so it is in the record, just to see what the
0050
1 operation, the handwritten operation note says at
2 403/69.
3 We have there the diagnosis and you will forgive
4 me for going through a note which I know you have seen
5 before, a diagnosis of "transposition of great arteries
6 with balloon septostomy, transferred from the Bristol
7 Children's Hospital to cardiac theatre. Baby looked
8 blue. Once anaesthetised, the oxygen saturation dropped
9 to between 60 and 70 per cent, requiring hand
10 ventilation. On bypass with bicaval cannulation ..."
11 It goes on with some of the details. Underneath
12 the heading: "Once cooled, circulation stopped".
13 Underlined is "Coronary abnormality. The left posterior
14 sinus ..."
15 It notes the left anterior descending and the
16 right coronary artery. The right posterior sinus, the
17 left circumflex. It deals with the operation, the
18 bypass.
19 There is a heading "Problems", if we just scroll
20 down, "Monitoring lines in PA and LA, coming off bypass,
21 persistent hypoxia, oxygen saturation dropping to 67 per
22 cent and repeated attempts failed in spite of inotropic
23 support."
24 We have the indication of the right to left shunt,
25 just below that. The comparison of the atrial
0051
1 saturation, 100 per cent, the arterial saturation 80 per
2 cent, which was indicating a right to left shunt, so
3 back on bypass. The right atrium opened, septostomy
4 properly closed. Looked for ventral septal defect
5 through the tricuspid valve. Nothing seen."
6 The next page, please. And finally, "Came off
7 bypass". It goes on. If we have, please, on my screen
8 first 403/71, let us move it down below the address, if
9 we may. This is a typed note rather full of details in
10 some respects:
11 "Perfusion data. The bypass time, a total of five
12 hours and five minutes. The cross-clamp time of 1 hour
13 31 minutes, circulatory arrest, 1 hour 15 minutes".
14 I draw attention to the findings.
15 If that note, together with 403/72 and 73, could
16 be made part of the record. I do that, Mr Bwye, for
17 completeness's sake so it comes in the right place in
18 the record of these proceedings. I appreciate that you,
19 from your position, cannot yourself comment except from
20 what others have told you about it?
21 A. That is right.
22 Q. I have asked you a lot of questions about the life and
23 death of your son Jason. Is there anything which I have
24 not asked you but which you would like to add to your
25 evidence?
0052
1 A. I cannot think of anything.
2 MR LANGSTAFF: From my point of view, thank you very much.
3 The Panel are perhaps going to have some further
4 questions for you.
5 THE CHAIRMAN: Mr Bwye, do take your time, if there are any
6 other things you would like to add. Do not feel that
7 you are under any pressure. Take some time to reflect
8 and if there is anything else you want to tell us,
9 please do. Recognise of course that you can come back
10 at any time and tell us other things by writing or in
11 some other form. If there is anything now that occurs
12 to you, please tell us.
13 MR BWYE: I cannot really think of anything that I want to
14 ask, thank you.
15 THE CHAIRMAN: Want to ask, or tell us?
16 MR BWYE: I would just like to thank my solicitor for the
17 support he has given me, because it has helped a lot.
18 I think he has dealt with it very well.
19 THE CHAIRMAN: Thank you. We have no questions from the
20 Panel, Mr Bwye. Is there any re-examination?
21 MR TRUSTED: Yes, there is one point, please.
22 Re-examined by MR TRUSTED:
23 MR TRUSTED: Sir, if I could explain, I think there may be
24 an error in the transcript and I want the witness's
25 assistance just with that. It is page 12 in your
0053
1 transcript, margin note, 12.10, the answer to 12.10.
2 The issue concerned is E5, which concerns decisions
3 about where and when surgery should have been done. It
4 is paragraph 10 on page 4 of the statement.
5 Mr Bwye, if I can explain the background to this,
6 the issue concerns the time after the balloon
7 septostomy, when you had a discussion with the doctor
8 whose name you could not give us about the need for
9 future surgery. Do you remember the point I am talking
10 about?
11 A. Yes.
12 Q. The transcript at the point I refer the Panel to said
13 that he, that is the doctor, said that the operation
14 would need to be done immediately. What you said in
15 your statement is this:
16 "I can recall being told that Jason would need
17 a further operation, but that it could be delayed until
18 he was between 9 and 12 months old.
19 A. That is right.
20 Q. Do you think on reflection that the transcript is right
21 when it said that the doctor said he would need the
22 operation immediately?
23 A. Absolutely not.
24 Q. So can I infer from that, we should insert a "not",
25 that "he would not need the operation to be done
0054
1 immediately" at that point?
2 A. That is right. Nobody ever suggested to us it would
3 have to be done immediately.
4 MR TRUSTED: Thank you, sir. I have no further
5 examination.
6 THE CHAIRMAN: Thank you. We will of course check that
7 against the tape and make the appropriate adjustment.
8 MR LANGSTAFF: Mr Bwye, thank you very much indeed for
9 coming to give your evidence. You are free to go or
10 stay as you wish.
11 MR BWYE: Thank you.
12 (The witness withdrew)
13 MR LANGSTAFF: Sir, may we take Mrs House's evidence
14 at 25 past 11?
15 THE CHAIRMAN: Yes. I am grateful, Mr Langstaff.
16 15 minutes, then.
17 (11.10 am)
18 (Adjourned until 11.25 am)
19 (11.25 am)
20 MISS GREY: Sir, the next witness is Miss House, please.
21 Miss House, as you have seen, I think, the evidence here
22 is given on oath. Could I ask you, please, to stand
23 whilst you affirm.
24 MISS BELINDA HOUSE (affirmed):
25 Examined by MISS GREY:
0055
1 Q. Your full name is Belinda Jane House?
2 A. Yes, that is right.
3 Q. You have a partner of many years, Julian Batt?
4 A. Yes.
5 Q. You live with your daughter Megan, who is now aged
6 11 and your son Ryan, who is 9?
7 A. Yes, that is correct.
8 Q. It is about Ryan and his life that you are about to tell
9 us today?
10 A. Yes.
11 Q. You have given a statement to the Inquiry already, and
12 I think you have a copy of that in front of you; that is
13 right, is it not?
14 A. Yes, that is right.
15 Q. You also have, I think, some photographs there which you
16 would like to show to the Panel later on?
17 A. Yes, if I could.
18 Q. Before we begin, I think there are just two small
19 corrections you would like to make to your statement.
20 If we could have up witness 25, please, page 6, if we
21 could look at paragraph 13. If we could have that on
22 the screen, please. It is right you pointed out that
23 about 8 lines down you have referred to Mr Wisheart as
24 "Dr Wisheart" there, and you wanted that corrected?
25 A. Yes, please.
0056
1 Q. If we could turn to page 8 of the statement, to the
2 very bottom of the page you wrote there:
3 "Mr Wisheart wanted to discuss it with other
4 members of the team, which he did after further
5 discussion with us."
6 That is a reference to a discussion about
7 acupuncture treatment?
8 A. Yes.
9 Q. I think you wanted to add in there another sentence
10 "He then allowed the treatment."
11 A. Yes.
12 Q. The sentence would continue "Within a couple of hours
13 there had been a very significant improvement in Ryan's
14 condition."
15 A. Yes.
16 Q. With that, you are happy with the statement, I think, as
17 you put it in, but obviously we will go over it and
18 amplify it now.
19 If I could take you, then, to the beginning of the
20 story to the Panel today, Ryan was born on 6th April
21 1989; is that right?
22 A. Yes, that is correct.
23 Q. And he was born at Southmead Hospital?
24 A. Yes.
25 Q. When he was born, did you and your partner think that
0057
1 there were any problems?
2 A. We thought he was a slightly pale colour, but apart from
3 that, after the first hour or so, no, but as time went
4 on, he had breathing problems during the night and
5 I took him into the nursery, because I thought he needed
6 sucking out, perhaps he had swallowed some fluid or had
7 fluid on his lungs, and I think I took him to the
8 nursery three or four times during the night.
9 Q. What were you told by the nursery staff?
10 A. He was fine, just "get some rest, leave him in the
11 nursery, go back to your bed and get some rest".
12 Q. At what point did you become aware there might be some
13 more serious problems?
14 A. Believe it or not, we did not realise there were any
15 problems until I had been seen by the doctor and
16 discharged, and the paediatric doctor was just about to
17 come and see Ryan to discharge him, and the nurse looked
18 into the cot and just literally wheeled it out of the
19 door without even saying there was a problem, just went,
20 and I presume, to the nursery or to the Special Care
21 Baby Unit.
22 Q. What did you do?
23 A. I just sat on the bed, totally in shock, and then
24 a nurse actually came -- well, she did say the wrong
25 thing, but she said "Have you got any photos of your
0058
1 baby?" which made me think that he was dead or dying.
2 Then shortly after that, I rang my partner and I think
3 he was on his way anyway.
4 Q. Did you then go to try to find Ryan to find out what was
5 happening?
6 A. We were then taken down to the Special Care Baby Unit
7 and taken into a side room where the doctors were very
8 agitated and distressed, and we were told that they
9 thought Ryan had a heart problem, but they did not know
10 what it was and they prepared us for the fact that he
11 may not survive.
12 Q. You say "the doctors". How many people were you dealing
13 with at that time?
14 A. I can remember a nurse walking down with us and a lady,
15 a woman doctor, actually giving us the news, but it was
16 only I think at that time one lady doctor in the room
17 with us.
18 Q. You mentioned that you were told that Ryan had a heart
19 problem, but they did not know, that is the staff at
20 Southmead Hospital, what it was. What were they doing
21 to try and find out what the heart problem was?
22 A. I think at that point they were actually resuscitating
23 him. I think he lacked oxygen, as baby's hearts, just
24 after they are born, I do not remember the name of it
25 but there is a tube which sends oxygen from one side to
0059
1 the other, and that was closing down and Ryan was
2 passing out because of the lack of oxygen. They were
3 trying to resuscitate him but did not know what the
4 problem was because they did not have the correct
5 scanner at Southmead. They did not know what the heart
6 looked like, but they were very, very worried.
7 Q. Did they take steps to find someone with the equipment
8 to help further?
9 A. Well, they were on the phone -- when we were allowed to
10 go into the Special Care Baby Unit after some time,
11 I can remember the doctor on the phone for a great deal
12 of time trying to contact the cardiologist, which later
13 we realised was Mr Joffe, but he was on the phone for
14 hours and hours, just desperately trying to get somebody
15 to come and look at the baby.
16 Q. Did he make contact with the cardiologist eventually?
17 A. Eventually, we were told by a very relieved doctor that
18 he had found Dr Joffe; he was actually in Wales, but he
19 would come back as quickly as he could.
20 Q. Ryan had been born on 6th April. What is the date of
21 the events you are now describing?
22 A. The 6th he was born, the early hours of the morning, if
23 I remember rightly, and then, I am not sure now, the
24 next day -- I think it was the next day, or within the
25 next few hours we were in SCBU, and then that evening
0060
1 I think Mr Joffe arrived to look at Ryan.
2 Q. When you say "SCBU", you mean the Special Care Baby
3 Unit?
4 A. Yes.
5 Q. Dr Joffe arrived that evening. Did he examine Ryan?
6 A. Yes, he examined Ryan. I believe he actually looked on
7 the scanner at Southmead, and he could interpret the
8 scan pictures better than the staff there, obviously,
9 because he was a cardiologist.
10 Q. What did he tell you about Ryan's condition?
11 A. At that point, he thought it was simple transposition of
12 the main arteries. Then we were told if that was the
13 case, there was an operation which would correct this.
14 Q. How did you feel about that?
15 A. Well, totally relieved, because until that point, we
16 thought that he had no hope at all. We thought it was
17 inoperable, we had been given that, so from that point,
18 everything was just wonderful.
19 Q. What did Dr Joffe explain to you that he was proposing
20 to do in order to clarify the diagnosis?
21 A. Dr Joffe actually decided he ought to take Ryan to the
22 Children's Hospital and do an echocardiogram, or
23 something like that, and then a balloon procedure where
24 you actually make a hole through the top chambers of the
25 heart.
0061
1 Q. Was the term "balloon septostomy" used?
2 A. Yes, it was.
3 Q. So were arrangements made to make that transfer?
4 A. Well, that was very traumatic. Mr Joffe told us we had
5 to be at the Children's. The doctor again got on the
6 phone, because he had to arrange for theatre space, at
7 a convenient theatre at the Children's. He spent an
8 awful lot of time doing that, which was very distressing
9 for him. He then found the theatre space and could not
10 find the nurses to staff the theatre. That went on for
11 a very long time, until Julian and I actually suggested,
12 could we pay agency nurses, because we were so
13 desperate, because we knew this procedure had to happen
14 within so many hours.
15 Q. Can I stop you there. You say he was having difficulty
16 finding theatre space. That is theatre space at the
17 Children's Hospital?
18 A. At the Children's Hospital.
19 Q. You then went on to say there was difficulty finding
20 nursing staff?
21 A. Yes.
22 Q. Was that in relation to nursing staff at the Children's
23 Hospital, or in relation to nursing staff to manage the
24 transfer?
25 A. That was both. That was nurses to look after Ryan in
0062
1 the theatre, and also, Ryan needed quite a senior nurse
2 to go with him in the ambulance with the incubator and
3 they also needed a senior nurse left on the SCBU at
4 Southmead Special Care Baby Unit.
5 Q. Were they able to find nurses?
6 A. Yes, finally they found the nurses, so we thought
7 everything was fine, we were on our way, but there was
8 yet another problem.
9 Q. What was that?
10 A. They could not find an ambulance, because the ambulance
11 needed to transfer this incubator -- they told us there
12 were two, possibly three in the whole of Bristol, but
13 I think it was two and they were having great difficulty
14 in finding this particular ambulance. We were saying,
15 "Why can we not just go in a taxi?" but they had to go
16 in this particular ambulance for his safety.
17 Q. Was that in order to use the incubator in which Ryan was
18 actually being cared for?
19 A. Yes, so they could do everything necessary to keep him
20 alive.
21 Q. Were they eventually able to find an ambulance?
22 A. Yes, over the phone. The doctor finally said "Yes, we
23 have found an ambulance", but he said "Do not raise your
24 hopes too much, because if there is an accident on the
25 M5 and that ambulance is needed, we will not be able to
0063
1 get the theatre space". But the ambulance did arrive
2 and he got to the Children's Hospital, but those hours
3 were totally traumatic.
4 Q. If I could just have a look, please, on my screen, at
5 medical record 1988/57, if we could look at the top half
6 of that page, if you just scroll it up a little bit,
7 please, you should have there the record of a cardiac
8 catheterisation procedure carried out by Dr Joffe and
9 just at the very top, we can see that Ryan's name is
10 mentioned, so this is the catheterisation that was
11 carried out that you were about to describe?
12 A. Yes.
13 Q. At the very top of that page you can see a date:
14 7th April 1989?
15 A. Yes.
16 Q. Does that accord with your recollection of when the
17 transfer was made to the Children's Hospital, and
18 therefore the catheterisation was able to take place?
19 A. Yes. That would be right, because it would be the day
20 he was -- yes.
21 Q. So he was born on the 6th and despite the difficulties
22 in arranging for staff --
23 A. All day on the 6th we had the trouble with finding
24 different theatres and everything else, and then the
25 7th, yes, he went across.
0064
1 Q. He was actually transferred on the morning, the
2 afternoon? What time?
3 A. I think it must have been late afternoon, because I can
4 remember when he went back to Southmead, just after the
5 operation, it was dark.
6 Q. So he arrived at the Children's Hospital. Where were
7 you taken at that time?
8 A. He arrived at the Children's Hospital; we met Dr Joffe.
9 We went into the echocardio room, where we could see
10 just the pressures and Dr Joffe explained the oxygen,
11 where it was going on the screen. Ryan was next to us
12 in the incubator. He then explained what exactly he was
13 going to do, then Ryan went into the theatre and we were
14 taken to the Maternity Hospital.
15 Q. What was Dr Joffe's manner in explaining these matters
16 to you?
17 A. Dr Joffe was always very calm; he was always very
18 concerned for all of us, and reassuring, and any
19 question we wanted to ask, we were assured we could ask
20 it and we did. He was very receptive to any questions.
21 He was a very calm and caring person.
22 Q. So a catheterisation procedure was carried out and the
23 balloon septostomy took place. What were you told about
24 the results of that procedure?
25 A. Dr Joffe then came to see us in the Maternity Hospital,
0065
1 which was just across the road. He said everything had
2 gone fine. At that point I asked him if we could go
3 back with Ryan in the ambulance, and he said, yes, that
4 would be fine.
5 Q. When you say "go back with Ryan in the ambulance", to
6 where?
7 A. To Southmead Hospital, because there were no beds
8 available in the Children's. He had to be transferred,
9 I assume after coming out of recovery, he had to go back
10 to the Special Care Baby Unit in Southmead.
11 Q. Were you being told about what should happen to Ryan
12 next? What further treatment was needed?
13 A. They explained he would spend some time on the Special
14 Care Baby Unit, and then, if everything went okay, we
15 could take him home and he would not need an operation
16 then until about 11 months, depending on the state of
17 his heart.
18 Q. If we could just have a look at medical record 1988/56,
19 please, if you could have that on the screen, please,
20 that is a note of a joint cardiac surgical radiological
21 meeting, which took place a little later, 31st May. It
22 is confirming a diagnosis of transposition of the great
23 arteries; that there had been an adequate result from
24 the balloon atrial septostomy, and Ryan would have
25 pre-operative study in about 6 months time.
0066
1 Were you informed of that need at that time?
2 A. We were, but I had forgotten that, because I had not
3 seen his medical notes.
4 Q. Taking you back to the point where Dr Joffe was
5 explaining how the operation had gone, you said Ryan was
6 taken back to Southmead Hospital?
7 A. Yes.
8 Q. What happened to you at that point?
9 A. That, for me, was very traumatic, because we were in the
10 Maternity Hospital because the nurses were very
11 concerned about me, because I had just had a baby, but
12 I was not concerned about myself at that stage, I was
13 more concerned about Ryan. We could actually see the
14 entrance of the Children's Hospital and we were told we
15 could go back in the ambulance, which is something
16 I desperately wanted to do, but we looked out of the
17 window and saw Ryan being put into an ambulance and the
18 ambulance ready to drive off.
19 Q. So what did you try and do?
20 A. I ran straight out of the hospital with Julian, we both
21 ran out together. We ran across the road. We nearly
22 got to the ambulance and it drove off, and I was just so
23 angry, you can't explain it, because my baby was just
24 going off and I had been told I could stay with him.
25 The nurse came out. In all honesty, I was her
0067
1 responsibility, and she was not very happy because I had
2 gone, and I suppose I could have been in danger myself,
3 but I did not see it like that. She was trying to look
4 after me, but all I wanted to do was be with Ryan, and
5 I did not understand at that time.
6 Q. Who had gone with Ryan back to Southmead?
7 A. The senior nurse had gone back with Ryan in the
8 ambulance. Obviously they did not want me in there in
9 case they had to treat me and their priority was Ryan.
10 Q. Did they discuss with you whether Julian would be able
11 to go with Ryan or not?
12 A. They did not discuss the leaving. Mr Joffe said they
13 would arrange for us to go back in the ambulance, so
14 they did not discuss it because, well, we were told we
15 could go and we did not, so there was no discussion.
16 Q. When did you next see Ryan, then?
17 A. A few moments later, we went back to the Special Care
18 Baby Unit, I presume in our car, but I honestly can't
19 remember that time at all.
20 Q. So you are saying you left the Bristol Maternity
21 Hospital?
22 A. Yes, and went back to Southmead, to the Special Care
23 Baby Unit.
24 Q. I think it is right Ryan stayed there for about a week
25 to 10 days before you were able to take him home?
0068
1 A. Yes, that is right.
2 Q. Was he then followed up by Dr Joffe at the outpatients
3 department at the Bristol Children's Hospital?
4 A. Yes, we continued to see Dr Joffe at various times at
5 the outpatients for x-rays and scans, just to make sure
6 his heart was not going into failure.
7 Q. Did there come a time in October 1989 that a further
8 procedure needed to be carried out on Ryan?
9 A. That is right. He was actually taken to the Children's
10 to have a catheter and he stayed in there for about two
11 or three days.
12 Q. Can you remember what the purpose of that catheter was?
13 A. That was just to check the pressures and to check
14 everything was as they had presumed when he was tiny,
15 just to check that the right, suitable operation, we
16 presumed, would be carried out to check the type of
17 operation needed.
18 Q. Could I have a look on my screen, please, at medical
19 record 1988/88.
20 That is part of a consent form. I am not showing
21 you the whole, but it is a consent form which starts:
22 "Consent by parent or guardian, BCH hospital.
23 Patient's name in full, Ryan Batt."
24 His address is given, and then, "I, Julian Batt",
25 and then the address, "the father of Ryan, consents to
0069
1 the submission of my son", and that is the point at
2 which the record you can see is picked up, and the
3 consent form then sets out the nature of the procedure,
4 sets out what is being required by way of consent, and
5 then it is signed, I think, by your partner Julian?
6 A. Yes, that is right.
7 Q. Miss House, were you there when that consent form was
8 signed?
9 A. Yes, and I can remember, we were discussing who was
10 going to sign it. It could only be one of us, so Julian
11 did it, but we both wanted to.
12 Q. The signature of the physician or surgeon who says that
13 he has confirmed he explained to the patient's parents
14 or guardian the nature and purpose of the operation is
15 indecipherable. Can you recollect who explained to
16 procedure to you?
17 A. No, I cannot.
18 Q. Was it Dr Joffe?
19 A. I presume, yes, because until that point, that is the
20 only person I think I had been in contact with.
21 Q. It may perhaps have been someone else?
22 A. It could have been. That does not look like "Joffe" to
23 me.
24 Q. At any rate, the cardiac catheterisation procedure, its
25 purpose was explained to you and it took place?
0070
1 A. Yes.
2 Q. If we could see briefly, please, page 46 of medical
3 record 1988, if you could just scroll up a little, we
4 can see that on the screen. Do you have that,
5 Miss House?
6 A. Yes.
7 Q. That sets out the diagnosis at the top, the
8 transposition of the great arteries. It sets out the
9 history of Ryan's admission for cardiac catheterisation
10 and the history of what had happened initially with his
11 treatment.
12 Moving down to the bottom of the page, the cardiac
13 catheterisation is performed. Confirms transposition of
14 the great arteries, and then it says that the findings
15 were discussed at the joint cardiac surgical meeting,
16 where it was concluded that Ryan was suitable for
17 a Senning repair and Mr Wisheart would be asked to see
18 him in cardiac outpatients on 3rd January 1990.
19 If we could also see, please, page 48. If you can
20 just enlarge, first, the top three lines, please, can we
21 have that on the screen? That is a record of a joint
22 cardiac surgical meeting, 1st November, and present are
23 Doctors Jordan, Joffe, Prendiville, Wilde and Hartnell,
24 but not in fact Mr Wisheart. If you could take that off
25 the screen, please, and show us the main body of the
0071
1 text, including the signature at the bottom. Can you
2 see there again, essentially, much the same thing as has
3 already been shown to you in the record you have just
4 seen, the confirmation of the cardiac catheterisation
5 results, the conclusion that Ryan is suitable for
6 a Senning repair and that Mr Wisheart will be asked to
7 see the patient in the cardiac outpatients department to
8 discuss the operation during the next few months.
9 There is an annotation at the bottom, "appointment
10 3/1/90"?
11 A. Yes.
12 Q. Did you see Mr Wisheart on 3rd January 1990?
13 A. Yes, we did.
14 Q. What did he tell you at that point?
15 A. First of all, he introduced himself, he wanted to know
16 what we thought Ryan's problem was, what we had been
17 told so far. He wanted to allay any misconceptions we
18 had.
19 Q. You say he introduced himself. Had you met him on any
20 previous occasion?
21 A. I do not think we had. I do not think so.
22 Q. He started to explain or ask you about what you
23 understood about Ryan's condition?
24 A. That is right. So we explained, you know, we thought
25 the main arteries were around the wrong way and Ryan
0072
1 would have an operation when he was about 11 months to
2 repair that.
3 Q. What did you understand was the purpose of him asking
4 you those questions?
5 A. So we were quite clear and so we started from the same
6 point, that we were not putting truth upon mistruth, if
7 you see what I mean.
8 Q. So you explained what you understood about Ryan's
9 condition?
10 A. Yes.
11 Q. What did Mr Wisheart explain to you?
12 A. He confirmed what we thought was correct and he had
13 simple transposition, and that there was an operation he
14 could perform called the Sennings, and it was quite
15 a successful operation, but he still did say, I think,
16 there was a 30 per cent chance it could fail.
17 Q. You say "I think". Is that something you have a clear
18 recollection of, or is that something that is rather
19 faint in your mind?
20 A. Well, I could not decide whether it was 30 or 35 per
21 cent, but at the time there was a reason for that,
22 because he would not have survived until -- he would
23 have survived until he was two years old and to me,
24 there was no question about him having an operation.
25 Q. So whether it was 30 or 35 per cent, it made little
0073
1 difference to you?
2 A. Whether it was 1 per cent of survival, I would still
3 have had it done.
4 Q. Because that was Ryan's only chance of surviving for
5 about two years?
6 A. Yes.
7 Q. So he told you that there was an operation called
8 a Sennings procedure?
9 A. Yes.
10 Q. What did you understand that that procedure would
11 involve?
12 A. We understood that it was to redivert the flow within
13 the heart of the blood, because at the moment it was two
14 closed circuits and they wanted to divert the oxygenated
15 to the pumping side.
16 Q. And that would take place within the heart?
17 A. Yes.
18 Q. Did you ask any questions about whether or not
19 a procedure could take place outside the heart?
20 A. Yes. We said "Why cannot the aorta and coronary artery
21 just be swapped over?" because it seemed a lot simpler.
22 He explained to us there was an operation that could do
23 that, called the switch, but there were a lot of
24 problems at the time, because the carotid artery was
25 severed and it stopped the blood actually going to the
0074
1 muscle of the heart. At that point, Ryan would have
2 been too old for that operation.
3 Q. When you say there were a lot of problems because of the
4 treatment of the carotid artery, was that something you
5 understood would be a particular problem in Ryan's case,
6 or was that a general problem with the development of
7 the switch operation?
8 A. We felt that was a general problem in the development of
9 the switch operation.
10 Q. Did you discuss how far developed the switch operation
11 was at that time?
12 A. I remember discussing it a little bit further, and we
13 were given the impression that the switch operation
14 would be -- would, in the future -- well, when it was
15 developed, it would be carried out on babies that were
16 very young, and I felt that Mr Wisheart thought that
17 this would be very traumatic for babies at an early age,
18 because in two weeks -- I know he was waiting for Ryan
19 to be strong enough to have his operation and the two
20 did not add up.
21 Q. You say Mr Wisheart was telling you the switch operation
22 was being developed. Did he discuss with you where it
23 was being developed at the time?
24 A. He did mention America, but I cannot remember any other
25 places.
0075
1 Q. Did he discuss, therefore, whether or not it was being
2 developed in the UK at the time?
3 A. I cannot remember if that was said or not.
4 Q. Can you remember whether there was any discussion of
5 whether it was being offered in Bristol at the time?
6 A. I am pretty sure it was not being offered in Bristol at
7 the time. I think he said that.
8 Q. Would it come as a surprise to you, therefore,
9 Miss House, to learn that at that time there had been
10 approximately 9 arterial switch operations carried out
11 in Bristol?
12 A. Yes.
13 Q. Because your recollection is of Mr Wisheart telling you
14 it had not yet been developed in Bristol?
15 A. I had the impression it was not developed in Bristol.
16 Q. Why do you say you had that impression? Can we just
17 explore that further?
18 A. Because I cannot remember him exactly saying it had been
19 developed in Bristol. It was just a feeling I had.
20 Q. So is it a fair summary to say you were being told that
21 the operation was being developed, but it was at an
22 early stage in its development?
23 A. Yes. I think so.
24 Q. And there was a discussion of the fact that that
25 development was taking place in the USA?
0076
1 A. I cannot say the development is in the USA. I know
2 USA was mentioned, but I cannot remember any other
3 hospitals being mentioned, or any other --
4 Q. At any rate, you got the impression that Ryan was
5 considered to be too old for the arterial switch?
6 A. Yes.
7 Q. And that therefore, partly because of that, partly
8 because the switch was at an early stage of development,
9 a Sennings operation would be the appropriate one?
10 A. Yes.
11 Q. You mentioned that it was suggested there would be
12 a 30 to 35 per cent risk of mortality, even if that was
13 carried out?
14 A. That is right, yes.
15 Q. Was there any discussion of any other risks attached to
16 the operation?
17 A. I know at the time we were very aware that even if he
18 came out of the operation, you know, the recovery time
19 was very crucial and as the days went on, he would
20 become stronger, but it was the first few hours that
21 were very crucial after he had had his operation.
22 Q. How did Mr Wisheart help you to understand the way in
23 which this operation would be carried out?
24 A. He spoke very clearly about it and he drew diagrams to
25 explain to us, and of course, he allowed us to ask any
0077
1 questions, so we explored it. I think that is all.
2 Q. Did you feel that you were being given an adequate
3 opportunity to understand the nature of the operation?
4 A. Totally, yes, because it was an atmosphere where you
5 felt you could ask any questions, whatever question it
6 was. You did not feel as if you were going to be made
7 to look kind of silly by asking any questions. I cannot
8 remember what questions we did ask, but I know we asked
9 a range of questions.
10 Q. Just for the sake of the record, Miss House, I asked you
11 questions based on the suggestion that there had been
12 some 9 switches carried out at Bristol by the time you
13 had that conversation?
14 A. Yes.
15 Q. That is obviously something the Inquiry will have to
16 look into fully and we will need to clarify those
17 figures. We have done a preliminary look through the
18 records. Whether it was 9 or 8 or some other figure is
19 a matter which will have to be confirmed later by
20 detailed investigation.
21 A. Yes.
22 Q. So after your meeting with Mr Wisheart, when did you
23 understand the operation would take place?
24 A. We were told it would depend on how Ryan developed and
25 it could be in a couple of weeks or a couple of months;
0078
1 he did not know. It just depended and we would hear.
2 But we did not know how we would hear, but it would be
3 a couple of weeks or a couple of months.
4 Q. What sort of things would influence the timing of the
5 surgery?
6 A. How Ryan was, whether, when he went in for his heart, to
7 make sure his heart was not enlarging, to check he was
8 not going into anything with heart failure, that is what
9 we presumed. It was individual to Ryan, about the
10 timing of his operation.
11 Q. Was Ryan's state of health a factor in all of this,
12 then?
13 A. Of course. We were told that Mr Wisheart wanted Ryan
14 to be as strong as possible, and he would leave the
15 operation until that point, because there comes a point
16 where the body grows, putting more stress on the heart,
17 and at that point the operation needs to be done.
18 Q. Were you given an exact date or provisional date for
19 the operation?
20 A. No. We were just told we would be contacted.
21 Q. If we could look at page 45, please, of the medical
22 records, on my screen. If we could just enlarge the
23 text, please. Can we have that on the screen, please?
24 This is a part enlargement of a letter from Mr Wisheart,
25 we can see his signature at the end, dated 3rd January
0079
1 1990, so written on the same day that you saw him in
2 outpatients. It is a record of the consultation. It is
3 addressed to Dr Joffe. It says:
4 "Thank you for asking me to see Ryan, who has
5 simple transposition and for whom I have advised that
6 a Senning operation should be carried out. We had the
7 usual discussion of the potential risks and benefits
8 involved. They [you and your partner] have accepted
9 this advice and his name has been placed on the waiting
10 list in the expectation that it will be done in February
11 or March before his first birthday, which is in April."
12 You say you were not given that exact sense of
13 timing at that particular meeting, but did there come
14 a time when you were told or notified that the operation
15 was due to take place?
16 A. That is right. We had a phone call, from, I believe it
17 was Mr Wisheart's secretary, asking us to ring the
18 hospital back and to take Ryan in, I think it was in the
19 next couple of days.
20 Q. So when was he taken into hospital?
21 A. I could not remember the correct date; I thought it was
22 mid-February at some point. I think it turned out to be
23 20th February.
24 Q. I think from the medical records, that is --
25 A. That is not my recollection. I knew it was
0080
1 mid-February.
2 Q. From the medical records, that was the date of the
3 operation. Would it accord with your recollection if we
4 said he went into hospital on 16th February?
5 A. Yes. I thought it was about the 12th, but, yes.
6 Q. If we could look, please, at medical record 8, page 78,
7 again, if you could please enlarge it, take it to below
8 the level of the address. That, again, is a part of the
9 consent form, signed again by your partner rather than
10 yourself: it is a consent form to the submission of Ryan
11 to a course of operative treatment for transposition of
12 the great arteries. Then the nature and purpose has
13 been explained to Julian by Mr or Dr, I think the
14 signature is probably that of Mr Eyers or Dr Eyers. It
15 is dated 16th February 1990. Were you there when that
16 consent form was signed?
17 A. Only one of us could sign the consent form, not both, so
18 we had a discussion about who was going to sign it. It
19 was very difficult not to have a name on something like
20 that, but, yes, we were both there.
21 Q. Can you tell us who explained to you the nature and
22 course of operative treatment that was proposed for
23 Ryan?
24 A. I can remember Mr Wisheart being there, and also
25 a discussion with Sally Masey, the paediatric
0081
1 anaesthetist. I cannot remember anybody else.
2 Q. So if this was taken by a more junior doctor, you can't
3 recollect that particular discussion?
4 A. I cannot recollect that person: I can recollect the
5 discussion of the consent.
6 Q. If I could ask you to look at paragraph 11 of your
7 statement, page 5 of witness 25, paragraph 11, you
8 mention there that you went into the BRI, Ward 5 and
9 that you were relieved that Ryan was to have the
10 operation before his condition weakened. You mentioned
11 that you had previously signed consent forms at the
12 consultation in January. You believe you may also have
13 signed some further forms the day before the operation?
14 A. Yes.
15 Q. Would the further forms be the ones we have just looked
16 at?
17 A. Yes.
18 Q. In fact, do you now recollect whether or not you did
19 sign consent forms at the consultation in January?
20 A. I think we did. I cannot be 100 per cent sure.
21 I thought we did.
22 Q. Just as a matter of detail, we have looked through the
23 medical records and we have not been able to find any.
24 A. All right, so we probably did not.
25 Q. Ryan was taken to the BRI and it must have been the
0082
1 first time that you had encountered that hospital?
2 A. Yes. That ward, anyway.
3 Q. Which ward was he taken to?
4 A. Ward 5.
5 Q. What impression did you form, of the ward when you first
6 saw it?
7 A. We were taken into the nursery, which is the high
8 dependency unit for the children. It was very bright.
9 People were very friendly. I did wonder why there were
10 so few nurses when in the nursery there were children
11 that had just come out of the ITU.
12 Q. But you were seen soon by, you mentioned, Mr Wisheart,
13 and also Sally Masey, the paediatric anaesthetist?
14 A. Yes.
15 Q. What did they explain to you about the operation that
16 was about to take place?
17 A. They just reiterated what we had heard before, about the
18 procedure, open heart surgery, rediverting the flow.
19 They made us very aware of the different pipes and tubes
20 Ryan would be attached to, just so that we knew what to
21 expect. But nothing we heard was new.
22 Q. The operation took place on 20th February. What
23 procedure was followed on the day of the operation?
24 What happened to Ryan?
25 A. The day of the operation he went back into the ITU -- he
0083
1 went into the ITU, where he stayed for the next three
2 and a half weeks.
3 Q. Before the operation, did you see him? Were you there?
4 A. We took him down to the anaesthetic room.
5 Q. Were you there whilst the pre-medication was
6 administered to him?
7 A. Yes, we were.
8 Q. So when you took him down to the anaesthetic room, was
9 he asleep or still awake?
10 A. He was awake until he was given a pre-med, I think it
11 was a mask to give him some sedative, and he went to
12 sleep.
13 Q. So when you said goodbye to him, he was asleep?
14 A. Yes.
15 Q. What did you do then?
16 A. Julian's parents were with us, so we wandered around
17 Bristol. We actually went to the museum. I think we
18 had a cup of tea in the cafe. We went back to the
19 hospital when we were told a phone call may come from
20 the theatre, which I think was about half 2.
21 Q. You say you wandered around Bristol. Whose suggestion
22 was it you should go out of the hospital and around
23 Bristol?
24 A. Well, I do not think we really wanted to sit in the
25 hospital. I feel it was our decision.
0084
1 Q. You mentioned you made a telephone call?
2 A. Yes. Well, we returned to Ward 5 at the time suggested,
3 and then they telephoned down to the theatre to check.
4 Q. What were you told?
5 A. At that point that he would be a bit longer.
6 Q. So when did you first have news of how the operation had
7 gone?
8 A. I think it was an hour or an hour and a half after we
9 expected. I mean, as I recollect it now, it might have
10 been 4 o'clock in the afternoon, but I am not sure.
11 Q. Where were you at that time?
12 A. We were back in Ward 5.
13 Q. In the ward itself?
14 A. There was a room for coffee and for television, for the
15 patients, and I think we had a cup of tea there.
16 Q. Can you just explain to the Panel what arrangements
17 there were or what facilities there were for parents who
18 firstly wanted to wait nearby the ward?
19 A. As I said, there was a tea room where you could make
20 your own tea and sit at tables, or you could sit in easy
21 chairs or watch television. There was a much more
22 private and comfortable room, very small just for one
23 family, so you could also wait there.
24 Q. What about arrangements for you to be with Ryan or near
25 to Ryan whilst he was in ITU?
0085
1 A. The first night of Ryan's operation, we stayed in a room
2 very close to Ward 5. I do not know if it was provided
3 by the Heart Circle, but I think it was specifically for
4 the parents of babies. After that, we were given a room
5 in a house on St Michael's Hill for parents.
6 Q. Do you know who ran or managed that?
7 A. I think it was the Heart Circle again, yes.
8 Q. You were describing waiting for the results of the
9 operation. Who came and told you about how it had gone?
10 A. Well, when Ryan came back from theatre he was taken
11 straight to ITU and we were taken into the ITU by
12 a nurse, to see Ryan, and then Mr Wisheart soon came to
13 explain how it had gone.
14 Q. What did he tell you?
15 A. He said he had found what he presumed he was going to
16 find, which was simple transposition of the main
17 arteries. Until he opened up the heart, he was not
18 going to be sure of that. The Sennings procedure had
19 been carried out very successfully, but I remember him
20 saying he was not out of the woods yet. The next
21 few hours were crucial.
22 Q. How did the next few hours progress, then?
23 A. Every minute seemed like a day. Ryan's condition
24 initially seemed to be going quite well, and then he
25 would have ups and downs and it was a very traumatic
0086
1 time.
2 Q. Were there any particularly serious incidents that you
3 can, looking back on it, still remember?
4 A. The main incident which sticks firmly in our minds, we
5 thought Ryan was going to be out of the ITU in 10 days
6 and it was about six or seven days, something like
7 that. We came back to his bed after having something to
8 eat and Julian noticed the ventilator had actually run
9 out of water, where the ventilator should always have
10 water in it. He alerted the nurse who quickly filled it
11 up, but about 30 seconds later mucus blocked the tube
12 and he was suffocating.
13 At that point the anaesthetists arrived and he was
14 taken back to theatre, because although he had blocked
15 tubes previously, they managed to sort that out on his
16 bed, but at this point he had to be taken down to
17 theatre and a new tube inserted. At this point he had
18 to be sedated at a higher level. He had gone back many
19 steps at that point.
20 Q. Could we look at medical record 8, page 10? If that is
21 up on your screen, please, that contains at the top the
22 record of the operation itself, the Senning operation.
23 It is the brief operation note with Mr Wisheart recorded
24 as being the surgeon, and then the details of the
25 surgery performed are set out.
0087
1 If we could scroll down, please, to the second
2 half of the record, you see there, dated 20th February,
3 at 3.00 pm:
4 "Acute onset of decreased CO, hypoxia and
5 ventilatory alarm. Presumed sputum in extubatory tube.
6 Sucked out. Thick secretions. Anaesthetist called."
7 Then a record of the decreased systolic blood
8 pressure and the dusky appearance for a few seconds.
9 If we could go down to the next page, the date
10 there changes to 21st February:
11 "Patient bagged and continued attempts to clear
12 extubatory tube. Ventilator switched by anaesthetist to
13 servo-C". Then a good recovery is mentioned. "Full
14 reassurance given to parents."
15 If we could take it down to the second half of
16 that page, the date there is the 21st at 6.45, and there
17 the record is:
18 "We are a day post Sennings procedure. Unstable.
19 Blood pressure variable."
20 A little lower down:
21 "Checks x-ray, hypoxic episode due to blocked
22 extubatory tube earlier today."
23 From that it appears the whole of this incident
24 may have taken place on the 21st?
25 A. I am sure they would have had a note there if he had
0088
1 been taken down to theatre, and it does not say he was
2 taken down to theatre.
3 Q. Can I ask you this: this is a record of a particular
4 episode in which there was an alarm, a problem with the
5 ventilator, and it says at the top of that page:
6 "Full reassurance given to parents."
7 Can you recollect such an episode taking place on
8 the 21st, the day after the operation?
9 A. I would not have been able to say it was the 21st, but
10 I remember often they had to readjust his ventilator.
11 I can remember at one point they changed the ventilator
12 for another type, because some ventilators give
13 a pressure and another gives a volume, and obviously
14 when his tube was getting blocked and he was getting
15 a pressure, it was not going in, but if it was giving
16 a volume, it would.
17 This is typical of different things that happened,
18 but this is not the incident that happened when he had
19 to be taken down to the theatre.
20 Q. So the incident you remember is approximately six or
21 seven days later?
22 A. Yes, because I can remember he was getting so much
23 better. He had nearly reached his 10 days and at that
24 point we were expecting him to come out.
25 Q. So if that was caused because the ventilator had run
0089
1 out, can you describe to us who was responsible -- ran
2 out of water, can you describe to us who was responsible
3 for the water at that time?
4 A. Filling up of ventilators was a routine task of the
5 nurses, so it would have been the responsibility of the
6 nurses, but can I say that all the nurses were totally
7 dedicated, but at that time they were put into
8 situations that they were not adequately -- not
9 trained -- well, I suppose they were not paediatric
10 nurses, not all them. Some of them were, but not all of
11 them.
12 Q. Who in particular was responsible for the maintenance of
13 the ventilator at that time? Can you recollect?
14 A. The ITU nurse.
15 Q. Was she a fully qualified nurse?
16 A. Yes, she was fully qualified, but she did not have
17 paediatric training, and I remember, she was -- she had
18 not had a long experience on ITU.
19 Q. Could I ask you to look, please, at paragraph 14 of your
20 statement? That is witness 25/6.
21 I just want to explore that a little further,
22 because you have been describing that incident to the
23 Panel now, and you mentioned there that whilst sitting
24 at Ryan's bedside, your partner Julian noticed the
25 ventilator had run out of water, as the nurse, who was
0090
1 a trainee on the ITU?
2 A. She was a fully qualified nurse, but she was a trainee.
3 She was recently on ITU. I remember her saying she had
4 not been there very long, and these incidents were new
5 to her.
6 Q. Can you remember whether anyone was in charge or
7 supervising her at that point?
8 A. There was always a senior nurse, but no-one directly
9 standing next to her. But, yes, there was always
10 a senior nurse that she could talk to.
11 Q. That setback or that point at which Ryan was rushed back
12 into theatre: did that result, as far as you were aware,
13 in any difference in his condition?
14 A. At that point, they had to sedate him more heavily, and
15 obviously, he was more dependent on the ventilator,
16 because he was more sedated and could not breathe on his
17 own then, so he was fully dependent on the ventilator,
18 whereas before he was gradually breathing for himself.
19 Q. Were there other incidents at that time that alarmed you
20 about the way in which Ryan's progress or recuperation
21 was progressing?
22 A. His general progress, I mean, we realised we were in for
23 a tough ride, after heart surgery, yes, and the
24 forefront of our mind, was, yes, this 30 per cent
25 chance. I presume that was in surgery, but he was still
0091
1 not out of the woods, but there was one other incident,
2 but may I say, the nurses were totally dedicated and
3 always listened to us, but we were by Ryan's bedside
4 every minute of the day and we could see things that
5 were happening to him before the monitors brought it
6 up. When you are there and see the colour of your baby,
7 the nurse that has just come on cannot get quickly into
8 that situation like we were. We returned one day to
9 find Ryan was a dreadfully blue colour, but then looking
10 around we saw the window open and some of his blankets
11 had been removed because the nurse thought he was
12 overheated, because I believe adult patients do get
13 overheated in heart surgery, and then she suddenly
14 became very anxious because of his colour, and we said,
15 "Well, he is cold", and she was very concerned because
16 she thought there was something wrong with his heart.
17 That was very traumatic for her as well.
18 Q. What was done to correct that problem?
19 A. She called a senior nurse and the senior nurse did say,
20 "Yes, warm him up quickly, put space blankets" on,
21 which they did, very thick cotton wool wadding and it
22 was fine, but it indicated to us she was not totally
23 au fait with the requirements of babies.
24 Q. Could we look at medical record 8, page 238? If you
25 could just enlarge the first line, please, if you could
0092
1 bring that up on the screen, please, I do not know
2 whether or not that is legible to you, Miss House?
3 A. Yes.
4 Q. What it says there in the middle paragraph, under
5 "action", is:
6 "Apply space blanket for hypothermia."
7 A. Yes.
8 Q. It may be that is a record of the incident you have just
9 been describing. Would that confirm or match your
10 recollection?
11 A. Possibly, but he did have a very variable temperature.
12 At one point it could go high or low, so this could be
13 a record of any of the incidents, but, yes, it does seem
14 like it.
15 Q. You were talking about the nursing care that Ryan
16 received in general, and what was your general
17 impression?
18 A. My general impression was that they were wonderful
19 people, totally dedicated, hard-working, I cannot praise
20 them enough and to work under such stressful conditions
21 like that and they were each, you know, particularly
22 concerned about each baby. Absolutely wonderful.
23 Q. What impression did you form as to the mix of paediatric
24 and adult skills amongst the nurses on the ward?
25 A. I felt that most of the nurses were more relaxed nursing
0093
1 the adults. Generally, it was the more experienced
2 nurses that would nurse the babies, so I felt there
3 was -- yes, they were more -- they had greater
4 experience in nursing the adults.
5 Q. You mentioned earlier that they were very dedicated.
6 What were the demands that were placed upon them by the
7 conditions in the ward at the time?
8 A. Well, the routine, any demands placed on nurses in the
9 ITU situations, it is a very stressful situation, with
10 emergencies happening quite frequently, and often, when
11 we went back to visit the nurses, they had changed,
12 because I think the turnover in ITU is quite high
13 because of the stress.
14 Q. Did you form any impression as to the equipment and beds
15 and general staffing levels in the ward?
16 A. Yes. The equipment, the ventilator, we were told that
17 the ideal ventilator was a certain type, I cannot
18 remember. A cub ventilator came to mind. If they were
19 lucky they could find one of those but they were not
20 sure because there was a very short supply, so that
21 indicated to us there was a short supply of ventilators
22 when there was a great need, so there must have been
23 a cost. There were empty beds at the time and we asked
24 why. They said there were not the nurses that were
25 needed to look after the patients, so that was why that
0094
1 particular bed was not being used.
2 Q. Who was in charge of Ryan's care at that time?
3 A. Mr Wisheart was always there. He always turned up,
4 especially if there was a problem, but I feel it was
5 more the anaesthetist at that point that were in charge
6 of Ryan's care.
7 Q. You say Mr Wisheart was there all the time. What do you
8 mean by that, more precisely?
9 A. Well, some times we would go to Ryan's bed 9 o'clock in
10 the morning or 12 o'clock at night and Mr Wisheart would
11 be there. I was amazed that he could find time to come
12 in. He had so many other patients, he had his children,
13 his outpatients and everything else, but especially if
14 there was any problem, Mr Wisheart would be there, you
15 know, weeks after he had actually operated on him, to
16 check on Ryan, to check on us, really, to make sure the
17 whole family was okay.
18 Q. So Mr Wisheart was a frequent attender, particularly if
19 there were any problems?
20 A. Yes.
21 Q. But you said the anaesthetist was perhaps more
22 particularly in charge of Ryan's care?
23 A. Yes. At that point a lot of the care was about
24 sedation, so it was the anaesthetist's department and
25 Sally Masey was in charge, really, of Ryan.
0095
1 Q. Did you watch or were you present at any discussions
2 between Mr Wisheart and Dr Masey about how Ryan's care
3 should be handled?
4 A. I cannot remember any discussions -- I do not know what
5 you are implying -- comparing different options. No.
6 I can remember them being there, and I can remember them
7 discussing things together.
8 Q. What sort of impression of the level of collaboration or
9 teamwork did you form?
10 A. Totally, I mean, everything that Mr Wisheart would say
11 would be reiterated by Sally, and the team seemed a very
12 tight-fitting organisation, really. They were all
13 speaking the same language, you know, we never heard
14 a different word from both of them, although I cannot
15 remember them discussing something together in front of
16 us.
17 Q. There were obviously a number of problems that Ryan was
18 suffering from at this stage?
19 A. Yes.
20 Q. Matters such as water retention, kidney problems,
21 reduced cardiac output?
22 A. Yes.
23 Q. Were there any novel approaches that you thought should
24 be tried to his care?
25 A. Well, at one point Ryan appeared to have some kind of
0096
1 kidney failure. He had stopped passing urine after --
2 it was after his tube had become blocked. To us it
3 seemed like the system had gone into shock; other
4 children on the ward had kidney failure. And the
5 children started to blow up, and it was something that
6 was a great concern to the staff because once that
7 happens, their whole system goes into deterioration. We
8 knew this; we had the feeling we had kind of non-verbal
9 messages from the nurses that Ryan was in deep trouble
10 at this point. He had stopped passing urine. There was
11 nothing further they could do, apart from diuretics,
12 which were not working. Ryan was getting bigger and
13 bigger and not passing urine, so we had a friend who was
14 an acupuncturist, and we asked him what he would
15 suggest, and he said he could treat him for that.
16 Mr Wisheart said "I cannot allow the skin to be actually
17 punctured, but I will discuss it with the rest of the
18 team". He did discuss it and he allowed our friend to
19 treat Ryan and within, I suppose, four hours, he started
20 urinating and he was on the road to recovery.
21 I remember Mr Wisheart coming round and he was very
22 pleased with his progress.
23 Q. You say Mr Wisheart went off to discuss it with other
24 members of the team?
25 A. Yes.
0097
1 Q. Were you able to watch him doing that?
2 A. No, we were not there.
3 Q. Does it follow from that, you do not know with whom he
4 discussed it?
5 A. No, I do not know with whom he discussed it.
6 Q. From that, it appears you were obviously very concerned
7 about how Ryan was progressing?
8 A. Yes.
9 Q. What sort of attempts did you make to become involved in
10 Ryan's care?
11 A. At every point we wanted to know what drugs were doing
12 and the levels of the drugs, and whether he would
13 require more of them, or less of them, and what the
14 ideal drugs were, and also, the level of the ventilator,
15 you know, how many breaths per minute, and whether they
16 expected it to be turned down or up. Every question we
17 could ask, we were asking.
18 Q. What sort of response did you get to those questions?
19 A. I feel in the beginning they were, I think the staff
20 were very aware, "Do the parents really want to know the
21 answers?" and as the time went on, when they realised we
22 did want to know the answers and we were going to get
23 the answers, they were very forthcoming. In the end,
24 the nurses were asking us how we felt all the time, as
25 I am sure they did with other parents, "How do you think
0098
1 the baby is?", "What do you think ought to be happening
2 next?"
3 Q. If they were asking you for your opinion on what you
4 thought ought to be happening next, what sort of
5 suggestions for treatment or improvement were you able
6 to make?
7 A. One incident comes to mind. Ryan would not settle with
8 his level of sedation, so I think they were -- they
9 could not seem to get it right. His heart was either
10 going too slow and his body was writhing about, they
11 could not seem to get it right, so I think they were
12 going down in certain units, I do not know, half a ml,
13 0.2 of a ml, I did not know. We said, "Why not go down
14 in 0.05 of a ml?" They said that would not make any
15 difference. We said "Why not try it? It can't do any
16 harm". They said they would do that and he responded to
17 it. He was obviously more sensitive than most babies.
18 Q. Were you given the opportunity to do more practical
19 things for Ryan's care as well?
20 A. Yes, cleaning him, changing nappies. As he got better,
21 I took more and more care in the nursery, which was
22 a high dependency unit. It was total care in bathing,
23 cleaning, changing nappies and feeding. On ITU when he
24 did not have any tubes, we were feeding him.
25 Q. If we could look at medical record 8, page 259, if you
0099
1 could just enlarge, please, the first two columns so we
2 can get the date clearly from that, this is part of the
3 nursing care plan you are just about to see. The only
4 point I would like to take from that is the date. It is
5 17th March, at the very top there. We see that. If we
6 could now look at the next page, 260, if you can see at
7 the bottom of that, if we could have it on screen,
8 please:
9 "Communications" is the last line. You see there,
10 "Mum and Dad helping and doing most of Ryan's care."
11 Is that an accurate summary of events by about
12 that time?
13 A. Yes, because that is --
14 Q. What was that in response to: out of your desire, or was
15 there any pressure or need from the other end?
16 A. I think the nurses read each parent very carefully and
17 they wanted to become involved with the babies, not to
18 off-load any work for them, but just because they knew
19 that was a very important step in the recovery of the
20 child, if everything had come back to normal as soon as
21 possible.
22 Q. You mentioned that after a while Ryan was transferred
23 out of Intensive Care Unit. At what stage did that
24 occur?
25 A. I believe we were on intensive care for three and a half
0100
1 weeks, so after that. We were taking Ryan at that stage
2 round in a little buggy and pushing him round. He was
3 off his ventilator completely, he had a mobile. I have
4 the photos here in intensive care with a mobile and
5 bouncing up and down, so he was fit to go into the
6 nursery.
7 Q. Where was the nursery?
8 A. It was right next-door to Ward 5. A room, I do not
9 know, containing possibly six beds, purely children.
10 Q. Was there any difference, then, in atmosphere between
11 the ITU and the nursery?
12 A. It was a happy place, it was a lot brighter. We did not
13 have the intensive care, the humming of all the
14 ventilators, and of course the children could be
15 children, on their bikes and playing, whatever they
16 wanted to do.
17 Q. You have mentioned that the nursing staff were keen to
18 involve you in Ryan's care?
19 A. Yes.
20 Q. Were you offered any other help, practical assistance,
21 by the hospital?
22 A. Yes, we met Helen Vegoda before the operation, and then,
23 during any problem we had on ITU, she would be there.
24 She was amazing. We never particularly asked for her,
25 but when we needed her, she was there. She was never
0101
1 intrusive, she was just so marvellous, and she set up
2 actual practical help, for instance, I am sure she
3 organised us staying in the house and the room during
4 Ryan's stay in hospital.
5 Q. What other sort of practical matters did she take care
6 of, or try and help you with?
7 A. She was always very concerned with our daughter, who at
8 that point was one year old, making sure she was
9 adequately cared for. If we said she was fine, she
10 would rephrase the question to make sure we were not
11 just saying everything was fine. She was trying to make
12 sure we had enough money to finance bills; she was
13 marvellous.
14 Q. Did you get the impression that if you had said you had
15 been in financial difficulty that there was anything
16 practical she could have done about that?
17 A. Yes. There was a fund which she could give to us. At
18 the time it was œ50 for everyone, just a payment. That
19 was money that had been given to the Heart Circle,
20 I presume, and in the end she did give us this money,
21 although we were saying other people could have it, but
22 she was insistent. I am sure if he we had a bill for
23 œ200, she would have sorted something or written to the
24 people saying why we could not pay it at that time. She
25 was very, very good.
0102
1 Q. So she had access to a fund which you understood was
2 donated, provided by the Heart Circle?
3 A. Yes.
4 Q. You have described in general the nursing care that you
5 were offered, and given high praise of it?
6 A. Yes.
7 Q. Were you aware of any pressures upon the nurses in terms
8 of the time that they had available to care for the
9 patients at the time?
10 A. It was not obvious that they had pressure on them when
11 we were -- you know, they were very calm people; they
12 never said, you know, it is time for me to be off now,
13 but at the time I know the nurses were attending
14 counselling meetings because of the stressful conditions
15 they were under and this was newly being set up and it
16 was being discussed who was going to go to this meeting
17 and what the meetings were like.
18 Q. What stressful things were causing difficulties for them
19 at the time?
20 A. Well, obviously every incident which happened, every
21 emergency incident, can never be planned for, and of
22 course this is stressful. Obviously, all the people in
23 there were very, very ill, otherwise they would not be
24 there, and people died. People regularly died. No
25 matter how many years you worked there, you can never
0103
1 get used to that, I am sure you cannot.
2 Q. If we can look, please, at medical record 8, page 269.
3 If I could ask you to enlarge the first part of that, to
4 get the date, and the nursing care plan heading, please;
5 that again just gives you the date of the record,
6 Miss House. If we could have the next page, page 70,
7 please, again, if you look down towards the bottom of
8 that page to the heading "Communicating":
9 "Parents talking and playing with Ryan. He is
10 alert, sleeping mainly after meals. Parents upset by
11 other happenings in ITU, but happy with Ryan."
12 Can you tell us a little bit about what sort of
13 happenings were perhaps being noted in that record?
14 A. It was a child who had been operated on the same day as
15 Ryan, a little girl.
16 Q. What happened? What was it that was upsetting about
17 that?
18 A. Well, we had had great fun until then, even when Ryan
19 was not urinating we were having competitions about who
20 urinated more and everything was fine, and it seemed
21 like she was going to win the race and get out first,
22 and we took it in light heart, which you have to,
23 otherwise you go completely mad in there. She actually
24 was -- she had made it, she had got out to the nursery.
25 Her heart was fine and the parents were elated, and then
0104
1 she started going downhill and she actually, although
2 her heart was fine, everything was great, she developed
3 septicaemia, and at that time, although they took blood,
4 they could not develop the bugs for about three days and
5 by that time she was dead.
6 Q. So that was obviously upsetting for you, for Julian as
7 well?
8 A. Yes.
9 Q. And the nursing staff: how did they react in terms of
10 morale when this sort of incident took place?
11 A. Totally devastated, because each of those children was
12 their child. For a child to go through the operation
13 she had been through and come out the other side and
14 then to be killed by something like that was evil,
15 horrible. You do not think in this day and age we can
16 succumb to things like that. You think antibiotics,
17 fine, but it is not the case.
18 Q. So that sort of thing would obviously affect the morale
19 of the unit. Were there any other things that you were
20 aware of as affecting it at the time when you were
21 there?
22 A. You are referring to more deaths of babies, I presume?
23 Yes, there were a lot of deaths, but every child that
24 went into that unit would have died anyway. You do not
25 do operations lightly. Ryan would have lived to two
0105
1 years old. We went in knowing that he could die and we
2 felt very, very lucky that he had a problem that could
3 be solved, a skilled surgeon, he was a very tough baby.
4 We did things like got our friend to give him
5 acupuncture; we fed him garlic for an antibiotic. We
6 gave him garlic to improve his bacteria, yoghurt and all
7 sorts of things, cod liver oil, everything. We felt we
8 had to fight to make him survive as much as any other
9 professional there, and of course, we expected Ryan to
10 die any minute, and babies died. I mean, that was it.
11 The nurses did not get used to it, no. But I did not
12 feel it was any worse than it usually is, or anything
13 like that.
14 Q. You have described the nurses and the help and
15 assistance they were giving Ryan. I think it is fair to
16 say that you became friends with some of them over the
17 period of the four weeks or so?
18 A. At that time, yes, you become intensively friendly with
19 these people. You feel you have known them all your
20 life. Now we have left I forget their names and feel
21 dreadful, because at the time intense emotional bonds
22 build up, yes.
23 Q. Did you have a chance to meet and chat with any other
24 support staff on the ward?
25 A. Helen Vegoda. We were always chatting to different
0106
1 types of staff, chatted to the cleaners a lot, who were
2 brilliant, but, no.
3 Q. Can you tell us a little bit more about the cleaning
4 staff, because I think you did have one particular
5 cleaner you used to talk to a little bit more?
6 A. We had one cleaner who was there a long time, she was
7 wonderful. She was rather upset because the cleaning
8 contract had been privatised and they were the same
9 people but they were not allowed to talk to the
10 patients, they had to clean from there to there, they
11 were reprimanded if they were talking and she felt that
12 had taken something away from the patients. They had to
13 clean up at a particular time, and she was concerned
14 that the IT unit was not as well cleaned as it had been
15 previously, but she had allotted times and it did not
16 matter if a new patient was put into that bed space, she
17 was not allowed to clean because she might have cleaned
18 10 minutes previously.
19 Q. So you repeated a concern she expressed to you?
20 A. She expressed this concern to us, yes.
21 Q. That was not something you were in a position to comment
22 upon or judge?
23 A. No, I cannot go into that because I do not know, but it
24 was just on our conversations with her, because we
25 became quite friendly with her.
0107
1 Q. You have described Ryan's progress, his recovery from
2 ITU to the nursery ward on the side. Did there come
3 a time when you were able to take him home?
4 A. Yes, we took him home. I think he was in the nursery
5 for about a week. So five weeks in all, from the time
6 he came in, I believe, we took Ryan home.
7 Q. Did you remain in contact with the Bristol Children's
8 Hospital or Mr Wisheart after this?
9 A. Yes. Well, every time we went back to the Children's
10 Hospital for check-ups, which I think, I cannot
11 remember, were every month to start with, we then took
12 Ryan back to Ward 5 and that is how I know the nurses.
13 There was a high turnover, because gradually, as the
14 months went on, there was less nurses we knew, but also
15 we saw Mr Wisheart again, yes.
16 Q. I think you have remained in contact sporadically with
17 him since then?
18 A. I found a letter the other day thanking the children
19 from Mr Wisheart, because we went to a meeting in 1993,
20 I found from the records, when he was talking at our
21 Health Centre, and we introduced ourselves and said
22 "This is Ryan, isn't he tough, isn't he well", and then
23 the children sent him a picture shortly after that, and
24 he wrote a note saying thankyou.
25 Q. If we could look at medical record 8, page 61, if you
0108
1 could just scroll it up so the address is not visible,
2 please, is that the letter which was sent to Mr Wisheart
3 after the talk we have just been describing?
4 A. That is right. The reason for sending that letter was
5 that Megan, our daughter, had drawn a card and
6 a picture.
7 Q. If we look, please, at page 60, again, could you scroll
8 it up so the address is not visible? Then put it on the
9 screen, please. I think that must be the letter and
10 a copy of the letter that Mr Wisheart wrote to you?
11 A. That is right, yes.
12 Q. I think it follows from what you have been telling the
13 Panel today that the impression you formed of the care
14 that was given to you, or given Ryan whilst at the Royal
15 Infirmary, was a very high standard?
16 A. Yes, it was a very high standard, but, although saying
17 that we felt it was our place to make sure it was a high
18 standard as well. Not that it changed, not that it got
19 to a higher standard because of us, but we wanted to be
20 involved in that, and we felt happy being involved in
21 that. But it was a very high standard at every stage,
22 and every baby is different and these people are
23 responding to different situations, every baby with
24 a simple transposition is slightly different and does
25 different things.
0109
1 Q. If I can press you on that a little bit, you have seen
2 in the records, and you have described yourself,
3 incidents during which things did go wrong?
4 A. Yes.
5 Q. How did you see that impact on your judgment about the
6 care that was offered to Ryan at that time?
7 A. Things are bound to go wrong, for the reasons I have
8 just stated, that everything human being is different
9 and reacts differently. Ryan reacted most strangely to
10 the drugs that another baby would have reacted perfectly
11 okay to. I know at one point there was great discussion
12 because the actual drugs he was on, I am not sure
13 whether they were opiate based drugs, he just did not
14 respond at all. Then they changed the drugs and he was
15 fine, but that was very unexpected as well. It is more
16 of an art than a science, when it comes to this stage,
17 I think.
18 Q. I think you have brought some photographs you wanted to
19 show to the Panel and then put into the record. Can
20 I just ask you, before you leave the microphone, the
21 captions on the photographs, when were they added?
22 A. The captions on the photographs, I have taken a few out
23 of the album. I actually wrote them last night.
24 I wanted to give an indication of what happened at
25 Southmead in what was about the first week of his heart
0110
1 operation, so they are not accurate.
2 Q. I think it is right they are simply factual statements
3 as to where Ryan was at any one time?
4 A. Yes, a date and where he was, and that was it.
5 THE CHAIRMAN: Miss Grey, if there is a description, it will
6 be picked up on the microphone.
7 A. That is Ryan at Southmead just after he was born.
8 I thought he was a healthy, fat baby.
9 Then a few hours later, all wired up.
10 Still there. This is when he had just come back
11 from the Children's.
12 Then we leap to February 1990, just before Ryan
13 had his operation: quite a high colour, but he is okay,
14 as long as he did not get cold.
15 Then soon after surgery. Heart drain still in.
16 Heart drain is out. I presume it is about two weeks
17 after surgery. Starting to blow up.
18 Just on oxygen then. He is okay. This is in the
19 ITU as well. He 'escaped' into the nursery, and all the
20 nurses were like that (indicating); it is like they were
21 their own children. They were brilliant.
22 That is just an example of care. That is Megan,
23 the physiotherapist and a play-leader or something.
24 MISS GREY: Thank you. I have asked a certain number of
25 questions. Is there anything else you would like to
0111
1 feel or draw out of what has been said to the Panel
2 already today?
3 A. Just that I feel the doctors worked with very, very sick
4 babies, all of whom would have died in very difficult
5 circumstances and there has naturally been so much media
6 concern with this case and a lot of it is very untrue,
7 and I just hope you have the courage in your hearts to
8 get the truth, and not to find just what the public want
9 to hear. Because there is a lot of -- thousands of
10 babies and adults out there that would not be here.
11 MISS GREY: Thank you, Miss House. Do the Panel have any
12 questions?
13 Examined by THE PANEL:
14 PROFESSOR JARMAN: Was there an occasion when a nurse who
15 had been on the ward also came back at night-time
16 wearing a different uniform?
17 A. Yes. They did tend to have different uniforms, but one
18 night it was a different uniform again, so in our usual
19 way, we said, "Why have you got a different uniform
20 on?" She said "I am actually employed as an agency
21 nurse, not by the NHS". We said "Why is that?" She
22 said "I can do the next shift as an agency nurse,
23 whereas I would not be allowed to do that as an NHS
24 nurse". Because she was an agency nurse, she was
25 suddenly a different person. We felt this was too much
0112
1 of a strain on these people, but, yes.
2 THE CHAIRMAN: I have one question, if I may. You were
3 moving about in the first days after Ryan's birth. Who
4 was looking after you? Do you think the care you were
5 receiving was appropriate, since you were pretty
6 important to Ryan?
7 A. That is why I think the nurses were getting very
8 agitated with me, because I did not really want care at
9 that time; I just wanted to see to Ryan. You know, they
10 would have loved me to have lain down in a bed and just
11 said, "Oh, yes, I feel awful", but I was not going to do
12 that. So all credit to them. I was an awful patient.
13 They tried desperately, they tried to get angry with me,
14 to do everything, but I would not sit still. I think
15 the adrenalin was too much. I think if you have just
16 had a child, you just want to be with them.
17 THE CHAIRMAN: Thank you. Is there any re-examination?
18 Re-examined by MR SHARP:
19 MR SHARP: One or two matters, please.
20 Just picking up on that last point, when you were
21 at Southmead and it was apparent there was a problem,
22 your statement reads as if you felt that you were really
23 abandoned to some extent by the nursing and medical
24 staff there, while they concentrated on Ryan. Did you
25 feel there was any alternative approach that could have
0113
1 been adopted?
2 A. In hindsight, yes, but at the time, I did not know what
3 to expect, but once Ryan had had his operation in Ward 5
4 and we met people like Helen Vegoda, we thought, "Why
5 couldn't you have been there in Southmead", because that
6 is when we desperately needed somebody, but at the time,
7 we just thought, we accepted it, "That is how things
8 are; they have to deal with the baby and they do not
9 have time for us".
10 Q. So once you got to the BRI, you found that there were
11 support systems which automatically cut in?
12 A. Yes, magically cut in, I would say, because I do not
13 know whether anybody asked for Helen Vegoda to come up
14 to Ward 5 when we particularly needed her. We did not
15 ask for her, but she would be there, a great support.
16 Q. Whilst you were in the BMH --
17 A. Back a few months earlier, yes.
18 Q. -- was there any consideration of you needing support as
19 opposed to medical attention?
20 A. No, it was just medical attention. They were just
21 thinking, "This woman has just had a baby, she should
22 not be running about", but no, it was not support, it
23 was more medical attention they desperately wanted me to
24 have, but I was not having it.
25 Q. Secondly, you have dealt with the question of the
0114
1 accommodation that was provided for you whilst Ryan was
2 undergoing his operation?
3 A. Yes.
4 Q. And you told us that you were provided with a room?
5 A. Yes.
6 Q. Nearby?
7 A. Yes.
8 Q. For one night, two nights?
9 A. Yes, that room was specifically kept for parents of
10 children that had recently had heart surgery -- well
11 that had heart surgery that day. We were lucky enough
12 to stay in the room a couple of days. I presume there
13 were no other parents that needed it. It was better
14 than my bedroom at home. It was really wonderful. You
15 would never have imagined you were in hospital, there
16 were pictures on the wall, very comfortable.
17 Q. You have described a waiting room for parents which was
18 a reasonable size?
19 A. Yes, it was a cosy room. I would say it was small, but
20 it felt nicer in that way because it was designed for
21 one family. I think there were a couple of cosy chairs,
22 the lighting was soft, pictures, nice wallpaper.
23 Q. So that was the quiet room?
24 A. Yes, the quiet room.
25 Q. There was another bigger room?
0115
1 A. Then there was the actual patients', I suppose,
2 patients-come-visitors room with a television, easy
3 chairs, a kitchen area.
4 Q. So in terms of provision for you while you are waiting
5 for your child to undergo the operation, did you feel
6 that the provision was adequate?
7 A. Yes. Yes. It was adequate. I mean, they could not
8 make it any easier while waiting for an operation,
9 I should think. I felt happier going out of the
10 hospital, really.
11 Q. Can I turn to the question of Ward 5? Ward 5 is a mixed
12 ward?
13 A. Yes.
14 Q. You have described the nursery off the main ward where
15 the children could be children?
16 A. Yes.
17 Q. But being a mixed ward, you know that Ward 5 had adults?
18 A. Yes.
19 Q. There have been observations by other witnesses about
20 how that worked. What was your perception of the
21 consequences of having a mixed ward?
22 A. I felt -- well, I know that the adults actually, when
23 they came round, were very distressed to see the
24 babies. I have heard other witnesses say they felt the
25 other way round, seeing the adults there, but I know
0116
1 a couple of adults, they were very upset to see the
2 babies there. I suppose it just brought it home to
3 them. They realised what pain and agonies they were
4 going through and how frightened they were. They saw
5 the babies and they thought -- they could relate to that
6 and it really upset them. That is the reservations
7 I would have, as well as, obviously, the specialist
8 nursing and the different conditions required, but
9 emotionally, the adults were upset to see the babies.
10 MR SHARP: Thank you.
11 THE CHAIRMAN: Thank you, Miss House, for coming to talk to
12 us and sharing Ryan's story with us. It is
13 particularly, I think, pleasing to see that Ryan is able
14 to see his mother talking to us.
15 MISS HOUSE: That is right. He is very interested. He did
16 not know much about it in those days.
17 THE CHAIRMAN: So we are all very grateful. We know that we
18 will be here for some time, so if there is anything else
19 you wish to tell us, in whatever form, please feel free
20 and know that you can do so at any time. For today,
21 thank you very much indeed.
22 THE WITNESS: Thank you.
23 (The witness withdrew)
24 MR LANGSTAFF: Sir, after yesterday's longer day than anyone
25 had anticipated, it is perhaps fortuitous that we should
0117
1 finish today rather earlier than anyone had anticipated,
2 and in a sense, the early finish marks the move from
3 Block 1 of the evidence in which, as you have seen,
4 representatives of parents with very different
5 perspectives have told us of their views and
6 experiences.
7 Tomorrow we move away from parents, although
8 remembering as I indicated in my opening that parents
9 are always in the background and essentially that is
10 what this whole Inquiry is about, we move to look at the
11 national context in which the care at Bristol was
12 provided.
13 We shall hear from three doctors, Dr Swanton, who
14 will speak to us on behalf of the British Cardiac
15 Society, Dr Godman, who will talk to us on behalf of the
16 British Paediatric Cardiac Association, and finally,
17 Dr Ratcliffe, from the Paediatric Intensive Care
18 Society. Their evidence will relate to those societies,
19 their views, and will give us something of the history
20 over the 12 year period which this Inquiry spans.
21 THE CHAIRMAN: Thank you. I am very grateful, Mr Langstaff,
22 so we will reconvene tomorrow morning at 9.30. Thank
23 you.
24 (1.00 pm)
25 (Adjourned until 9.30 am on Thursday, 25th March 1999)
0118
1
2
3
4
5
6 I N D E X
7
8
9 MR DOUGLAS STUART BWYE (sworn)....................... 1
10 Examined by MR LANGSTAFF............................. 1
11 Re-examined by MR TRUSTED............................ 53
12
13 MISS BELINDA HOUSE (affirmed)........................ 55
14 Examined by MISS GREY................................ 55
15 Examined by THE PANEL............................... 112
16 Re-examined by MR SHARP............................. 113
17
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Published by the Bristol Royal Infirmary Inquiry, July 2001
© Crown Copyright 2001