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Daily transcripts
Hearing summary
1st November 1999
The Inquiry oral hearings focus this week on the results of two major reviews, the
analysis of six data sources relevant to the Inquiry and the clinical case note review, an
independent analysis of 80 sets of clinical case notes, which will complete two important
pieces in the Inquiry’s jigsaw.
The Inquiry will also hear evidence this week from parents and clinicians. They will
describe their experiences at the Bristol Royal Infirmary and comment on the issue of
concerns being raised about paediatric cardiac surgery at the hospital between 1984 and
1995.
Today the Inquiry heard evidence from four parents whose children underwent complex
cardiac surgery at the Bristol Royal Infirmary and the Bristol Children’s Hospital.
Susan Francombe from Somerset told the Inquiry about her daughter Rebecca, who was born
in October 1995 with a congenital heart defect.
Robert Briggs from South Wales recounted his experience of the treatment of his
daughter Laura, who was born in July 1988.
Tony Collins from Wiltshire gave evidence about his son Alan’s care in Bristol,
following the diagnosis of a heart defect after his birth in April 1987.
Paul Roberts concluded the day’s evidence by telling the Inquiry about his son
Andrew, who was born in January 1983, and was diagnosed with a heart defect and referred
to Bristol in 1985.
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FULL TRANSCRIPT
1 Day 68, 1st November 1999
2 (10.30 am)
3 THE CHAIRMAN: Good morning, everyone. Good morning
4 Mr Langstaff.
5 MR LANGSTAFF: Good morning, sir.
6 STATEMENT BY THE CHAIRMAN re FUTURE PROCEEDINGS
7 THE CHAIRMAN: I thought before we start I would just say
8 a few words, if I may, because perhaps this is a good
9 time to reflect on the stage we have reached in this,
10 which is Phase I of the Inquiry.
11 We have already heard here in the chamber from
12 more than 100 witnesses, each with a story to tell or
13 a view to give and we have received nearly 350 written
14 statements. Nearly 150 of those are from parents and we
15 expect that there will be another 100 or so from parents
16 still to come.
17 The Panel have sat and listened now to 275 hours,
18 which is over 11 days, of evidence.
19 It seems a very long time ago since we started
20 these hearings in Bristol. In fact, it was only in
21 March. It seems longer still when we held the Inquiry's
22 preliminary hearing, although that was only 12 months
23 ago.
24 On both of those occasions I warned that there
25 would be harrowing times ahead for many of us, and so it
0001
1 has proved on occasions as we have listened to evidence
2 which some have found hard to bear.
3 We finish here on December 16th, now only some few
4 short weeks away, yet for some, they may prove to be the
5 most difficult and harrowing weeks of all.
6 As I have said, I cannot banish the pain that some
7 of you are feeling, and will feel, but I will do all in
8 my power to make it as bearable as possible.
9 The next few weeks will see us take evidence from
10 people whose names have become familiar to many of you
11 via the news media. It may be timely, therefore, to
12 request the assistance of the media in the times that
13 lie ahead.
14 I have said that this Inquiry will be open, will
15 be accessible and will be inclusive -- as inclusive as
16 possible. I am aware that the issues we will be
17 covering and the people we will be hearing from will
18 attract widespread public and news media attention.
19 This is quite proper. I recognise the legitimate
20 interests that the media has in reporting on behalf of
21 the public what takes place at this Inquiry, and I will
22 continue to extend every assistance I can so that they
23 are properly able to carry out their role.
24 I remind them also, however, as I have told others
25 with an interest in our work, that much of the evidence
0002
1 we hear is of a very delicate and sensitive nature.
2 Many involved with this Inquiry suffered and continue to
3 suffer. I will ask the media, therefore, to respect the
4 dignity and the privacy of all the witnesses, both
5 inside and away from this chamber. I would also remind
6 them that the witnesses we call have a duty to tell
7 their story to this Inquiry first. Later, when it is
8 appropriate, I am sure that those who wish to speak to
9 the media will co-operate fully.
10 For now I would ask those whom we anticipate
11 hearing from in the next few weeks to reserve their
12 accounts for when they appear here.
13 I hope those comments are helpful. Mr Langstaff?
14 MR LANGSTAFF RE THIS WEEK'S TIMETABLE
15 MR LANGSTAFF: Sir, today's hearing is the 68th day of this
16 Inquiry, and perhaps I should, before we begin with the
17 evidence of Mrs Susan Francombe, just outline, in the
18 light of your comments, what lies in store for the
19 Inquiry and those who follow the Inquiry this week.
20 Today we shall hear, after Mrs Francombe, from
21 Mr Briggs, Mr Collins and Mr Roberts, all of whom are
22 parents with a story to tell; tomorrow, beginning at
23 9.30, from Professor Gordon Stirrat who is the former
24 Chairman of the Division of Obstetrics and Gynaecology
25 at the UBHT, and then, not earlier than 10.30, from
0003
1 Professor John Farndon, Professor of Surgery at the
2 University of Bristol.
3 On Wednesday and Thursday we shall explore the
4 preliminary findings of the various statistical
5 exercises which have been conducted by experts who will
6 be providing evidence of what they have uncovered from
7 looking at, on Wednesday, the various local key data
8 sources which were identified by the Inquiry back in the
9 summer, and that will be followed on the same day,
10 Wednesday, by a view, in the light of that statistical
11 material, as to what part that plays in the jigsaw of
12 which it forms a part -- and it is perhaps worth saying
13 at this stage, only a part -- in the deliberations which
14 the Panel will have to make.
15 On Thursday there will be a review of the clinical
16 case notes in respect of each and every child who was
17 treated at Bristol. As is well known, a statistical
18 selection was made of 80 cases for detailed study, and
19 although you, sir, have mentioned the number of hours
20 that the Inquiry has sat, it is perhaps worth
21 remembering that those who have given evidence to the
22 Inquiry and those who have been involved in exercises
23 such as this have themselves spent very many
24 more hours. I am told that each of the 80 cases has
25 involved something like 15 hours of consultant time from
0004
1 busy practising expert clinicians, so that the exercise
2 has had an enormous input in terms of man and
3 woman hours.
4 That report will be a factual summary of where, at
5 this stage, that survey has reached. It is worth also
6 again at this stage noting that not only were the 80
7 cases looked at once, each of them by a team of five
8 clinicians, but 15 have been looked at for a second time
9 so that there is a cross-check on the validity of any
10 conclusions that you, the Panel, may wish to draw from
11 that material.
12 As is the case with Tuesday, both of those days,
13 Wednesday and Thursday, begin at 9.30.
14 Sir, enough for the future. We have kept
15 Mrs Francombe waiting for long enough. Mrs Francombe,
16 would you like to come forward, please?
17 Mrs Francombe, would you mind standing to take the
18 affirmation?
19 MRS SUSAN FRANCOMBE (AFFIRMED):
20 Examined by MR LANGSTAFF:
21 Q. Mrs Francombe, you are Susan Francombe?
22 A. Yes.
23 Q. And you like to be known as Susan?
24 A. Yes.
25 Q. Your husband Nick sits in the front row. He is
0005
1 a solicitor and if re-examination is required, he is
2 here to do that for you?
3 A. Yes.
4 Q. You are going to tell us about the life, over four days,
5 of your daughter Rebecca who was born on 15th October --
6 A. 14th.
7 Q. I am sorry, 14th October 1986, I beg your pardon -- in
8 Taunton, and who died very late on 18th October here in
9 Bristol?
10 A. Yes.
11 Q. You made two witness statements for the purposes of this
12 Inquiry. I wonder if we could have the first on the
13 screen, please. It is WIT 349/1. This is the first of
14 the statements which you attach to a questionnaire from
15 the Inquiry?
16 A. Yes.
17 Q. If we turn over to page 3, that is the end, I think, is
18 it, of the statement?
19 A. Of that part, yes.
20 Q. There is one alteration I think you want to make which
21 is at the top of the same page, paragraph 28. You were
22 told, I think, of the death in the early hours of the
23 19th?
24 A. That is right.
25 Q. And that is what you meant to convey, because you have
0006
1 seen the medical notes. You do remember that she died
2 in the hospital very shortly before midnight on the
3 18th?
4 A. Yes.
5 Q. You made a second statement which begins at 349/4. If
6 we go over to 349/7, is that your signature at the end?
7 A. Yes.
8 Q. Are the contents of those statements, with the one
9 correction that we made, true and accurate?
10 A. Yes.
11 Q. Was Rebecca your first child?
12 A. Yes.
13 Q. And you have had other children since and they are well
14 and fine?
15 A. Yes.
16 Q. She was born, as I have said, and as you have told us,
17 in Musgrove Park Hospital, Taunton, on 14th October.
18 On the 15th she was diagnosed as having a problem?
19 A. Yes.
20 Q. What seemed to be the problem?
21 A. I was told she had a heart murmur, that they had found
22 a heart murmur after they were checking her. I think
23 they were giving her a bath, because in those days they
24 kept the babies in the nurseries and the nurse said when
25 they were bathing her they noticed that she was going
0007
1 blue, and picked up a heart murmur.
2 Q. So what decision had been made by them that you were
3 asked to agree to?
4 A. She was brought to me for a cuddle, as long as I cuddled
5 her under the bedclothes, because she was getting cold,
6 and they said they were taking her to the Special Care
7 Unit for further investigations, which they did.
8 Then, when we went to see her in special care, we
9 were told that it would need further investigation and
10 they would send her to Bristol for that because they
11 could not do the investigations at Taunton.
12 Q. So how did she go to Bristol?
13 A. She was taken by ambulance in the incubator with
14 a nurse. I had to follow behind in another ambulance
15 and my husband followed behind that in his car.
16 Q. You came, then, what, to the Bristol Maternity Hospital?
17 A. I was brought straight to the Maternity Hospital, yes.
18 Q. Where was Rebecca?
19 A. She was taken to the Children's Hospital.
20 Q. So you were on opposite sides of the road. Did you see
21 Rebecca there?
22 A. Later on I was taken over there, but I think I waited
23 for my husband and they said they were settling her in,
24 checking her in at the Children's Hospital while I had
25 to be checked in at the Maternity Hospital, so I did not
0008
1 go straight over; I went later on.
2 Q. And you appreciated why you needed to go to the
3 Maternity Hospital while your sick daughter was at the
4 Children's Hospital?
5 A. Yes. I had just given birth and so they said "You have
6 to go to the Maternity Hospital".
7 Q. What did you next hear of the progress of your
8 daughter's condition?
9 A. From what I remember, they said, yes, it was obviously
10 more serious than just a heart murmur. I cannot
11 remember whether it was after a first investigation or
12 a second investigation, but they had come to some
13 conclusions that there was a growth across the right
14 ventricle that was impeding her circulation.
15 Q. Creating a double chamber?
16 A. Yes, and I knew she was on a drug to keep a valve open
17 that should have shut. They did explain things and at
18 the time I understood them, but because I am not
19 medically trained, I cannot remember all the terms.
20 Q. It is now what, just over 13 years ago?
21 A. Yes.
22 Q. How clear, in general terms, is your recollection of
23 what happened as opposed to your impression of what
24 happened?
25 A. Certain things are very clear. Certain things stand out
0009
1 in my mind, certain pictures from throughout almost five
2 days of her life. Other things are a blur and I do find
3 difficult to remember.
4 Q. Again, just moving forward a little, because you have
5 told us about the death of Rebecca, is it the case that
6 some memories you may very well have shut off --
7 A. Yes.
8 Q. -- in your mind and perhaps have only had to, or found
9 that you did remember them recently?
10 A. Yes. Some things I have not gone over and over, but in
11 the light of the past two or three months, since
12 I decided to contribute to the Inquiry, things have come
13 to light, things have got stirred up. For example,
14 I have since read her medical records, in the past two
15 weeks, which I had never seen before.
16 Q. Going back, then, to what would now be 16th October,
17 back in 1986, you were told, you have indicated,
18 something about the nature of Rebecca's condition, that
19 she had a double-chambered right heart and some form of
20 growth maybe there?
21 A. Yes.
22 Q. Needing drugs to keep ducts open. Who was it who told
23 you that?
24 A. I do not think it was Mr Dhasmana and I cannot remember
25 who it was. I cannot remember the names.
0010
1 Q. But the way in which you were told, was it, do you
2 think, informative? Was it brusque? How would you
3 characterise it?
4 A. We were always informed -- I do remember always
5 understanding it at the time and in a very caring manner
6 and I always remember that.
7 Q. And was it you on your own, or was it you with your
8 husband?
9 A. Most of the time, we were together. I seem to think
10 I was on my own when I had the cardiac catheterisation
11 explained to me because it was all done in a rush. My
12 husband just had to keep going back to Taunton.
13 Q. Did you have a sense of rush when matters were explained
14 to you, or not?
15 A. Not when we were speaking. No.
16 Q. So despite the evident rush, people took time with you
17 to explain and make sure you understood?
18 A. Yes.
19 Q. You mentioned Mr Dhasmana. He was to do, and did, the
20 operation, did he?
21 A. Yes.
22 Q. When do you think, looking back, you first met him?
23 A. It was either on the evening of the 16th or the 17th.
24 I think when they had obviously decided that surgery was
25 the only option. He had said that he had seen Rebecca
0011
1 as well as seeing the results of the catheterisation and
2 the cardiogram, the previous investigations. He drew us
3 pictures of what that had shown and explained that
4 surgery definitely was the only option; that he had not
5 seen a heart formed in that way ever before, but he
6 either said he was going to or later told us that he had
7 consulted other cardiac surgeons in a London hospital.
8 Q. So he gave you the impression, did he, that this was
9 something which he had not met before?
10 A. Yes.
11 Q. But he was informing himself about how best to deal with
12 it?
13 A. Yes.
14 Q. You have seen, I think, subsequently, the diagrams which
15 were produced at pathology, by the pathologist?
16 A. Yes.
17 Q. If we can just for a moment have a look at that on the
18 screen, it is MR 692/32. What we are looking at is the
19 top left-hand of the page, which shows a view of a heart
20 with a somewhat abnormal external structure, and lower
21 down the page, what was revealed after the event in
22 perhaps greater detail, obviously, than the black line
23 drawings would demonstrate beforehand.
24 Broadly are those giving the same picture, albeit
25 three-dimensionally, perhaps, as you were given by
0012
1 Mr Dhasmana when he drew the pictures for you?
2 A. Are these done after the surgery?
3 Q. They were done after the event.
4 A. Yes.
5 Q. Can we go back to your statement at page 349/2? Did he
6 give you any estimate of the likelihood of success of
7 the operation?
8 A. This is something that my husband and I do not agree on,
9 but I think it was less than 10 per cent. About 10 per
10 cent.
11 Q. What is the disagreement?
12 A. I thought he had said 50:50, but my husband remembers it
13 was less than 10 per cent. I am quite prepared to think
14 that I have blanked that out. My husband is better at
15 remembering things than me.
16 Q. What you do remember is Mr Dhasmana indicating that he
17 had never come across the particular problem before?
18 A. Yes.
19 Q. So plainly, any estimate of success he was giving you
20 was in that context?
21 A. Yes.
22 Q. And what was the alternative to the operation?
23 A. That she would have died.
24 Q. So there was no alternative?
25 A. There was no alternative.
0013
1 Q. You gave consent for the operation, plainly. Again, if
2 we can just for a moment look at part of the medical
3 record and go to page 692/105, turn it through
4 90 degrees and go down towards the bottom half, could we
5 highlight number 8, please, right across the page?
6 "Awaiting surgery, booked a.m. 18th October", this
7 is a nursing care plan, "to prepare adequately for
8 surgery and to take care of the parents' emotional
9 needs."
10 It is probably obvious, but you must have been
11 very upset and anxious?
12 A. Yes.
13 Q. We see on the right-hand side "to ensure that parents
14 are aware of procedures", and that is ticked, so that
15 was done, was it?
16 A. Yes.
17 Q. "Consent", a tick to that, so that was done, and
18 "Encourage physical contact with the child before the
19 operation."
20 That was done, was it?
21 A. We held her hand, yes.
22 Q. So not only do you recollect this having happened, but
23 there is evidence in the medical notes that it did, and
24 it is all there recorded for us?
25 A. Yes.
0014
1 Q. You then had to wait while the operation was conducted.
2 Where were you; in the Maternity Hospital?
3 A. In the Maternity Hospital, yes.
4 Q. And the two of you were there and waiting?
5 A. Yes.
6 Q. Did you at any stage leave from the Maternity Hospital
7 to go to the Royal Infirmary?
8 A. Not while she was having her operation.
9 Q. But afterwards?
10 A. We were telephoned to say that she was back in the Royal
11 Infirmary, having come through the operation
12 successfully, and we were taken there to see her.
13 By the time we actually got there --
14 Q. You are jumping ahead a little bit. What you deal with
15 in your statement at page 349/5 is the taxi ride that
16 you had from one to the other?
17 A. Yes.
18 Q. Can we have WIT 349/5, please? It is paragraph 4.
19 You went down from the Maternity Hospital to the Royal
20 Infirmary by taxi with a nurse?
21 A. Yes.
22 Q. And what grade of nurse?
23 A. A trainee nurse.
24 Q. How do you know that?
25 A. She had a badge on.
0015
1 Q. Was she young?
2 A. Very young, yes.
3 Q. You comment as though you do not want to tell us what
4 she said, the unfortunate and insensitive comment that
5 you have recollected, and then excuse it.
6 What sort of thing was it?
7 A. It did stick in our mind, mainly because it was such
8 a contrast to the complete care and support we felt when
9 we were surrounded, with Rebecca, by the nurses and the
10 doctors. We were being taken on this journey. I cannot
11 remember the exact words, but it was something like,
12 "Well, if she dies, you will know that the best was
13 done for her". She obviously felt very uncomfortable
14 with us, completely out of her depth. That is why it
15 stuck in our mind.
16 Q. Because of the inappropriateness of the comment, or
17 because she seemed out of her depth?
18 A. Both.
19 Q. Or because of the contrast?
20 A. And that as well, I think, yes.
21 Q. You say there was a contrast. What was it a contrast
22 with? Just expand on that a little.
23 A. Whenever we were with Rebecca in the Children's
24 Hospital, the nurses were there -- we were just amazed
25 at how much they cared for Rebecca and supported us in
0016
1 caring for Rebecca. In a way, it almost -- well, it
2 made us feel as if she was in the safest hands, and we
3 did feel confident in their confidence and care,
4 although we did know the risks, but it was as though the
5 nurses never ever said -- I was encouraged to express
6 milk for when she needed it and I changed her nappy
7 once, but, you know, "This is what you are going to have
8 to do later on". They were very, very supportive and
9 very caring.
10 Q. When you got to the Royal Infirmary, did you see
11 Mr Dhasmana?
12 A. He was there, yes.
13 Q. Did he say anything about the operation?
14 A. By the time we got there, she had taken a turn for the
15 worse and I think they were trying to -- probably
16 resuscitate her.
17 Q. So when was that? About half 7 in the evening?
18 Thereabouts?
19 A. It was early evening.
20 Q. Did you stay with her?
21 A. We did see her, but we were encouraged to go away, which
22 is something that I have regretted ever since.
23 Q. If we can go back to page 3 of your first statement, the
24 top of the page:
25 "We were told that although the operation itself
0017
1 had gone well, she was now very poorly indeed."
2 A. Yes.
3 Q. Who was it who told you the operation itself had gone
4 well?
5 A. I cannot remember.
6 Q. You have seen, I think, this morning -- you had seen
7 earlier -- a letter that Mr Dhasmana had written to your
8 general practitioner?
9 A. Yes.
10 Q. Referring to the operation as having gone "reasonably
11 well".
12 A. Yes.
13 Q. In case it should be thought there is a contrast between
14 the two, the "well" and the "reasonably well", do you
15 have a view in your own mind, or you and your husband
16 have a view in your minds as to what the word
17 "reasonably" might mean there?
18 A. I think that the word "reasonably" is added because the
19 outcome is that she died. How can anybody say it went
20 well if she died? But I think the actual operation
21 itself was done -- he did what was set out to be done
22 and it was done successfully.
23 Q. Indeed, you have seen in the postmortem report an
24 acknowledgment to that effect?
25 A. That is right, yes.
0018
1 Q. You went, then, away from the hospital. You were not
2 there when she died. You were told about that in the
3 early hours of the following morning. You describe what
4 then happened, and because it will be important for
5 later questions, was there anything said to you, that
6 you recollect, about a postmortem?
7 A. We were told that she would have to have a postmortem.
8 Q. Did it sink in at the time?
9 A. No, I do not think so.
10 Q. The overall impression that you have of the surgical
11 care, brief though it was, and the care generally from
12 the team, was what?
13 A. That they were doing their best: the best that they
14 could. They were thorough and caring, took their time
15 with us and did everything they could for Rebecca.
16 Q. After doing your best to come to terms with the death of
17 Rebecca, did you ever discover what had been found out
18 at postmortem?
19 A. No.
20 Q. Within months, or indeed, within a few years of the
21 death?
22 A. No.
23 Q. It follows that no-one told you?
24 A. No.
25 Q. But did you, for your part, actually ask?
0019
1 A. No.
2 Q. You wrote, I think, a note of appreciation to
3 Mr Dhasmana. Let us have a look at it. It is
4 MR 2181/12. Do not put it on the screen generally
5 first. Can we please scroll down to the date? Can we
6 eliminate the address and the telephone number, please?
7 Now can we look at the letter generally on the screen.
8 This is 21st January 1987, so it is some three or
9 four months later. You are writing to Mr Dhasmana.
10 Shall we scroll down and read all the letter, and turn
11 over the page.
12 It speaks perhaps for itself. Did you mean what
13 you wrote?
14 A. We did.
15 Q. You say that you received a personal letter from
16 Mr Dhasmana?
17 A. Yes.
18 Q. Offering his sympathy, and you read that, you tell us in
19 your statement, as consistent with your experience of
20 him throughout the treatment that you had had?
21 A. Yes.
22 Q. You subsequently saw the postmortem report. Let us have
23 a look at that. It is at MR 692/27. Can we go down to
24 the bottom of the page, please?
25 THE CHAIRMAN: Mr Langstaff, just in case, perhaps we should
0020
1 go higher up and take the address out?
2 MR LANGSTAFF: Certainly. Can we now go down to the bottom
3 again? What is said there is that the brain was being
4 reserved for further examination. You knew there was
5 going to be a postmortem. Did you know anything about
6 the retention of tissue?
7 A. No.
8 Q. What was the first you knew or understood that the heart
9 had been retained?
10 A. Having gone as far as filling in a questionnaire and
11 being asked to make a statement, I decided that I would
12 find out all I could, as it was being stirred up.
13 Following certain headlines in the papers, that was the
14 first I heard that tissue had been retained in
15 connection with the Bristol children, and I telephoned
16 the Bristol hospital and made an enquiry, not really
17 knowing how I would think, and I received a letter back
18 saying they had in fact kept Rebecca's heart, lungs,
19 liver and brain, which we found very upsetting, and
20 a shock. A big shock.
21 Q. You might, perhaps, have understood the need to retain
22 the heart, particularly since it was obviously so
23 unusual a condition?
24 A. Yes.
25 Q. The brain you might have picked up from the postmortem
0021
1 report when you got it?
2 A. At the same time, I then decided that I would ask to see
3 her medical records. I received the medical records
4 after receiving the letter about the heart and organ
5 retention, but I did realise that it was down on
6 Rebecca's notes and also on a letter that was sent to
7 our GP, so he would have known that the brain was kept.
8 Q. Did you ever understand any reasoning for the keeping of
9 the lung and the liver?
10 A. No.
11 Q. Is there anything in the notes about the fact that they
12 had been retained?
13 A. I cannot see anything in the notes that the lungs and
14 the liver have also been retained.
15 Q. So this is something which you only discovered and would
16 have discovered from no other source than
17 Mr Barrington's letter to you?
18 A. That is right.
19 Q. You say that you had no knowledge that the heart or
20 other organs had been retained. Was the body of Rebecca
21 released to you for burial or cremation?
22 A. Yes. The body was picked up by the funeral directors.
23 They arranged that. We decided to have her cremated but
24 we were told by the funeral directors that there would
25 be no ashes and we could not have a gravestone for her.
0022
1 Q. So you had nothing to remember her by?
2 A. So we had nothing. We thought we were as low as you
3 could get. That made it worse. That was awful.
4 Q. When Rebecca was released to the undertakers for
5 cremation, did you see her again?
6 A. No.
7 Q. You say at the end -- we can pick it up on your
8 statement, the very last page, page 7 of your statement,
9 WIT 349/7, on 6th October -- that when you wrote this
10 you were still considering how to respond to a letter
11 from Mr Barrington which had caused you considerable
12 distress?
13 A. Yes.
14 Q. What decision had you made?
15 A. Since then, my husband and I have been talking to our
16 local Rector and he has agreed to bury her in the church
17 of which we are now a community. We have moved from
18 where we had lived. The Rector had to get permission
19 from higher up in the diocese because he said it was
20 such an unusual request. We feel it is something we
21 very much want to do. In many ways I had not realised
22 how important it was to me and how much I had regretted
23 not having a headstone. It is something where we almost
24 have been given a second chance.
25 Q. So the irony may be that, despite the distress,
0023
1 something has come of good out of it?
2 A. Yes.
3 Q. And you have a headstone, a place to grieve?
4 A. Yes.
5 Q. Can I just explore a little with you what it was about
6 the knowledge that organs had been retained that made it
7 so distressing for you?
8 A. I think the most important thing is that we were not
9 asked at the time. I am a reasonable person and I am
10 quite sure we would have said yes, although, I mean, you
11 do not know how you will react until you are in those
12 situations. But I know I felt if another baby could be
13 helped by the retention and if that was the reason, then
14 we would have said yes, but the fact that they were kept
15 without our knowledge and presumably we were never ever
16 going to be informed, came as a very, very big shock.
17 Everybody copes with grief in a different way.
18 There has been a lot of grief just in this small area.
19 Everybody copes with it in a different way and you do
20 not know how you are going to cope with it -- I have
21 forgotten what I was going to say now.
22 Q. Let me pick up the question of coping for the moment.
23 Immediately after the death you had the caring
24 experience you had been through with the Bristol
25 hospitals, and Rebecca had died and you had the
0024
1 cremation.
2 Was there any aftercare or follow-up to deal with
3 the great sense of loss which you had?
4 A. No. I very much have a feeling that -- I mean, I was
5 lucky enough to have a strong husband for support, but
6 it was almost us two and the rest of the world, which
7 seemed to me just to be alien. There was just us two.
8 Q. Looking back on it, would you have welcomed some
9 aftercare or bereavement counselling, or something along
10 those lines?
11 A. To have known that there was somebody else perhaps out
12 there would have helped, if someone could have pointed
13 us in the right direction.
14 Q. It is easy to say it now. You would not have found it
15 intrusive, do you think?
16 A. I am not sure. Obviously I was still under the care of
17 the community midwife, and again, because this was
18 a small rural area, I felt she had not seen many cases,
19 if any, where a baby had died. The GP only once came to
20 see us and all he did was prescribe Valium and went
21 again. They did not seem to be able to say "Here is an
22 address that you can go to, at the right time for you".
23 Q. So you felt isolated from the caring services?
24 A. Yes.
25 Q. You were living in a small community. Had you lived
0025
1 there for long? Do not tell us where it is, but had you
2 lived there for long?
3 A. A couple of years, but neither of us worked in that --
4 we both sort of commuted, went out to work.
5 Q. So you did not have the village network that might
6 otherwise have helped?
7 A. No. I mean, once you have children the network is
8 amazing, but I had not reached that yet.
9 Q. So just picking up on a couple of messages that may come
10 from what you have to say, to get your reaction to them:
11 one of the things that you have highlighted for us is
12 the way in which you found it supportive of the nurses
13 in Bristol to say "when" Rebecca was going to come home,
14 never "if".
15 One of the views we have had expressed to us at
16 the Inquiry -- this is from a Mr Bradley -- would be
17 that it might be better to be less optimistic, because
18 then one might be prepared for the shock of death, which
19 is always a shock, whenever it occurs.
20 How would you balance those views? Is it just
21 a question of individual personality? Is there
22 a general policy that you would like to see?
23 A. Everybody is different. A case like this throws up such
24 confusing and complex emotions. Just in myself,
25 I remember thinking -- you know, you think one thing and
0026
1 then you think another. If they had said more, "if",
2 but then I think maybe if I had been stronger, my
3 biggest wish and my regret is I let them say "You need
4 your rest" and I did not say "Can I stay?", so I was not
5 with her.
6 Maybe if they had said "if"; if maybe I had been
7 stronger; if maybe I had spent more time with her --
8 I look back and think, although they were looking after
9 me, now I think I did not spend all the time I could
10 have with her, and I wish I had. Maybe if they had
11 known how important it would have been, they might have
12 let me stay.
13 Q. Again, thinking back on it, is it better, do you think,
14 to have it spelt out as a matter of general policy to
15 a parent what organs might be retained and why they
16 might be retained, or is it better simply to say, "There
17 is going to be a postmortem and some organs may be
18 retained", if that is going to be helpful to other
19 children? How would you --
20 A. I would like to have known, because suddenly, in the
21 turmoil we have had in the past month, all I have had is
22 a letter that organs have been retained. You have these
23 horrible images, well, how have they been retained?
24 What have they done to them? Did they ever use them?
25 Were they ever useful? I would like to think they have
0027
1 been useful, but I do not know.
2 Q. I have asked you a lot of questions which arise out of
3 your statements. The rest of the statements we have and
4 we have read, and none of it, therefore, is overlooked,
5 but it may be that you think that in the questions
6 I have asked I have not stressed sufficiently something
7 that you may wish to say, or you may want to amplify one
8 of the answers you have given. If so, now is your
9 chance.
10 A. The thing that comes over is that everybody has
11 suffered, but everybody is grieving in their own way and
12 there is not a right way to grieve, so sometimes, when
13 I have heard screaming headlines, it has actually caused
14 more pain to someone like me who does not go out and
15 shout and make a fuss. When you said, "Did you not ask
16 to see her notes?", and why have I only done it 13 years
17 down the line, I just want to remember my baby as she
18 was born. She was born and we did have a few hours of
19 that joy that you get with your first born baby, and
20 I think it was important for my husband and I to try and
21 remember her like that.
22 MR LANGSTAFF: Thank you very much indeed for coming and
23 giving us your evidence. If there is anything further
24 that you want to add, you will be told by the
25 Chairman -- the Panel may ask one or two questions in
0028
1 a moment. You will be told by the Chairman that if you
2 want to add something, you not only should feel free to
3 do so but we would like you to do so. So if there is
4 something which you feel, looking back on it, you may
5 have missed, this is not the end. You can add to it.
6 The Panel may have some questions for you.
7 THE CHAIRMAN: No, we have no questions. I just reiterate
8 what Mr Langstaff has just said: that if there are other
9 matters, you can put in a supplementary statement if
10 there are other things you want to tell us and we will
11 be happy to receive them.
12 Is there any re-examination?
13 MR FRANCOMBE: Yes, please, I just have one or two
14 questions.
15 THE CHAIRMAN: Come forward and have the microphone.
16 RE-EXAMINED BY MR FRANCOMBE:
17 Q. Sue, you have talked about the lack of aftercare
18 provision. I have a quite clear recollection,
19 particularly after hearing you give evidence this
20 morning, of a fairly clear distinction between the
21 considerable efforts and care that were made while
22 Rebecca was being treated and during her operation, and
23 then almost a situation where the shutters seemed to go
24 down thereafter and we just came away and there was
25 really nothing there.
0029
1 Would that be a fair summary of how it felt for
2 you?
3 A. Yes. It was almost as if we shut the door from Bristol
4 in a nice way -- that is why Bristol is an emotive place
5 for me, because this is where Rebecca was alive. We
6 shut the door and there was the rest of the world.
7 I can understand why they were carrying on, but they had
8 nothing to do with us. There were lots of instances of
9 a doctor saying, "Go away and have another one".
10 Q. It was very fairly put to you that some people might
11 find counselling or offers of counselling or offers of
12 that nature intrusive. Again, my thought is that just
13 the ability to be able to share what has happened to you
14 with somebody else that has perhaps had a similar
15 experience would have been useful. I think I had
16 a feeling that nobody really seemed to understand what
17 was going on inside me, and I think perhaps you had the
18 same sort of feeling. Would that be right?
19 A. Very much. I have only, in the past six months, met
20 someone else, by pure coincidence in many ways, who had
21 lost a baby who was operated on in Bristol. It suddenly
22 makes you realise that you are not going mad, to speak
23 to somebody else.
24 Q. So would you agree that, at the very least, some sort of
25 formal structure to be able to put bereaved parents in
0030
1 touch with others who have had similar experiences might
2 be a useful way of helping them cope with their grief?
3 A. Yes. At the least, an address or a phone number,
4 because even if you did not want to do it that day --
5 I mean, I have had phone numbers pinned up on my notice
6 board and it has taken me several weeks to pluck of
7 courage, several months to pluck up courage to even
8 ring, several years to pluck up courage and do anything
9 about contacting anyone to do with Bristol.
10 MR FRANCOMBE: Thank you very much. Thank you, sir.
11 THE CHAIRMAN: Mr Francombe, thank you, particularly for the
12 general point you make at the end, which is clearly
13 something the Panel have very much in mind.
14 Mrs Francombe, thank you very much for coming and
15 telling us Rebecca's story. We are very grateful.
16 MR LANGSTAFF: Sir, I wonder if we should perhaps now have
17 a short break before Mr Briggs at, perhaps, 12.05.
18 THE CHAIRMAN: Yes, shall we break until just after noon
19 then? Thank you, Mr Langstaff.
20 (11.51 am)
21 (A short break)
22 (12.05 pm)
23 STATEMENT BY MR LANGSTAFF re COUNSELLING SERVICE
24 MR LANGSTAFF: Sir, before Miss Grey calls Mr Briggs to give
25 his evidence in the Inquiry, can I just pick up a theme
0031
1 that was explored with Mrs Francombe. The theme is that
2 of counselling and support. I pick it up conscious that
3 this part of the evidence, bringing back memories of
4 children's care, is always likely to be distressing, and
5 bearing in mind that later this week we will make public
6 the reports on the care of some 80 children, amongst
7 whom 40 died. Some of those reports may very well
8 indicate that care was either better or worse than
9 the parent had imagined. As you indicated earlier, as
10 the Inquiry has throughout indicated, any parent whose
11 child is involved in that review has been told and has
12 been offered the sight of the report which the reviewing
13 team has prepared.
14 The report is in many cases very brief and in many
15 cases it does not give much detail by way of
16 information. But can I just say that there is available
17 to those parents and indeed to others two forms of
18 support. Whilst the Inquiry is in session there is in
19 attendance at least one member of counselling staff who
20 can provide immediate help if it is needed, if it is
21 asked for. That is available.
22 But, beyond the hours that the Inquiry sits, there
23 may be a need -- plainly the Inquiry itself cannot, it
24 is not designed to, provide long-term counselling and
25 support. All it can be is, as it were, a gateway
0032
1 through which those who want to avail themselves of
2 counselling and support may do so.
3 To that end the Inquiry has arranged for ICAS,
4 that is the Independent Counselling Advice Services
5 national support centre to provide first-line support
6 and immediate advice to those parents who have received
7 the clinical casenotes review report on their child and
8 wish it, or for that matter parents who have been
9 distressed by the substance of the Inquiry.
10 The service that ICAS provide is 24 hours
11 per day. It is available on a freephone, and I shall
12 repeat this in case the press present wish to report
13 it. It is freephone 0800 316 0130. That is freephone
14 0800 316 0130. The service has been available from
15 Thursday, 28th October. It will be available for
16 a month.
17 The counsellors who are staffing the helpline are
18 fully briefed for calls. They will ask which
19 organisation are you calling from. Callers may remain
20 anonymous, but they will be required to tell
21 the counsellor that they have been given the number by
22 the Bristol Royal Infirmary public Inquiry office.
23 Sir, I hope that may be helpful to those who
24 listened with care to what Mrs Francombe had to say.
25 THE CHAIRMAN: Yes, thank you. It reflects what we said two
0033
1 weeks ago in terms of making available services. I am
2 glad that you are able to spell them out in more
3 detail. It is very important that we seek to do this.
4 We cannot offer the long-term help that, as you
5 indicate, may sometimes be needed because we are here
6 for only a brief period more. But we can provide
7 immediate help and support and the opportunity to make
8 contact with those who can provide longer term help if
9 it is needed and called for. So thank you very much.
10 Miss Grey?
11 MISS GREY: Could I ask Mr Briggs, please, to come and give
12 evidence.
13 Sir, Mr Briggs is represented by Mr Christopher
14 Sharp. Could you stand, Mr Briggs, to take the oath or
15 affirm?
16 MR ROBERT JOHN BRIGGS (SWORN):
17 Examined by MISS GREY:
18 Q. Thank you. You are Robert John Briggs and you have
19 given a statement to this Inquiry; is that right?
20 A. Yes.
21 Q. Is the statement the work of you or has it been made
22 after discussion with anyone else?
23 A. It was made along with my wife. It was a joint
24 statement effectively.
25 Q. So I think if there are parts which reflect her
0034
1 knowledge of events and you are stretched by, you will
2 be telling the Inquiry that, is that right?
3 A. Yes.
4 Q. If we could look, please, at WIT 136, page 1. Is that
5 the first page of that statement?
6 A. Yes.
7 Q. And I think you would prefer to be called Robert
8 throughout this hearing; is that right?
9 A. Yes.
10 Q. If we can turn, please, to page 7 of the statement; is
11 that your signature there then?
12 A. Yes, it is.
13 Q. And, subject to the points we have been talking about,
14 about the discussion with your wife to help you make
15 this statement, is this true to the best of your
16 knowledge and belief?
17 A. It is.
18 Q. You have come here to tell us today of the events
19 surrounding surgery, in particular to your second child,
20 Laura; is that right?
21 A. That is right.
22 Q. If we go back, please, to page 1 of the statement,
23 we see there at paragraph 2 that Laura was born at
24 the Princess of Wales Hospital in Bridgend on 28th July
25 1988?
0035
1 A. Yes.
2 Q. And at first everything seemed well; is that right?
3 A. That is right.
4 Q. So what was the first indication of trouble, then?
5 A. She started to feed less frequently and, as it says in
6 the statement, she started to make some grunting noises
7 that gave us some concern.
8 Q. So you went to see a GP, a locum. After you had
9 a little bit of discussion with him, you persuaded him
10 to refer Laura to the Princess of Wales Hospital in
11 Bridgend?
12 A. That is right.
13 Q. So she was admitted, you say at paragraph 3 of
14 the statement, on 24th September 1988. It follows
15 therefore that all the events that are described in this
16 statement took place when Laura was about 2 months old;
17 is that correct?
18 A. That is right, yes.
19 Q. If we turn over the page, please, you were seen
20 initially by a paediatrician who ordered a heart X-ray.
21 At that stage you learned that the heart was enlarged.
22 Laura's heart was failing and she was put in intensive
23 care. You then mentioned that you were seen by
24 a consultant the following day. Can you recollect what
25 speciality was the consultant who examined her and saw
0036
1 you at that stage?
2 A. To the best of my knowledge it was paediatric
3 consultant.
4 Q. And it was that person who contacted the Children's
5 Hospital and arranged for a transfer to be made?
6 A. As far as I know, yes.
7 Q. What were you told about the necessity of sending Laura
8 to Bristol?
9 A. Only that it was the nearest hospital to Bridgend that
10 had facilities for children's heart complaints.
11 Q. Did they say anything about how often they had to send
12 children to Bristol?
13 A. No.
14 Q. Did you question this in any way or discuss it further?
15 A. We did not feel the need to at that time.
16 Q. So the referral was made to the Children's Hospital in
17 Bristol. Laura was taken there. How was she taken
18 there?
19 A. She was taken there by ambulance.
20 Q. Were you able to travel with her or did you travel
21 separately?
22 A. My wife travelled with her.
23 Q. And what was Laura's condition at the time?
24 A. At the time of the --
25 Q. At the time of the transfer.
0037
1 A. At the time of the transfer. I guess -- little change
2 from the point at which we had actually taken her into
3 the Princess of Wales Hospital. All they had been able
4 to do at the hospital that I can recall was they helped
5 her with oxygen. So consequently she was still very
6 much as she had been when we had taken her to
7 the hospital.
8 Q. What was your impression then of how the transfer to
9 Bristol was handled?
10 A. It was handled well. The ambulance driver was
11 a neighbour of ours which eased things as well. So he
12 wanted to pay particular attention and make certain that
13 everything went well. It was a good transfer.
14 Q. At a later stage you talk about concerns on a transfer
15 from the Bristol Royal Infirmary to the Children's
16 Hospital, this being after the operation. At this stage
17 was there any reason to worry about any damage or danger
18 or risk to Laura's health because of the transfer?
19 A. No, we did not think so.
20 Q. You move on to say that at the Children's Hospital you
21 saw Dr Joffe who arranged various tests to be taken.
22 After diagnosis had been made, they were able to
23 ascertain that the problem lay with the aortic valve?
24 A. Yes.
25 Q. Can you give us a little more detail about the problem
0038
1 that was explained to you by Dr Joffe at that time?
2 A. Yes. To put it into a bit of context, before that, as we
3 mentioned in the statement, the original thought was
4 that the muscle of the heart was enlarged and that that
5 condition was one that would be very difficult to do
6 anything about. Consequently they came back -- or
7 Dr Joffe came back and explained that it was the aortic
8 valve. It was explained to us that it had narrowed and
9 that this was something that they would be able to
10 operate on with a view to enlarging the valve.
11 From our point of view, given the first news about
12 the muscle, it was relatively good news.
13 Q. "Aortic valve stenosis" is that a phrase used at
14 the time?
15 A. Yes, that is it.
16 Q. You give evidence, if I may say so, in a very definite
17 way, but we are looking back at events some 11 years ago
18 now. What in general is the state of your recollection
19 of events at Bristol at this time?
20 A. My wife has a better recall of the events 11 years ago.
21 Consequently, if you ask me questions on that basis,
22 I will let you know if my recall is not quite so good.
23 But it is a long time ago.
24 Q. What is yours like then, do you think?
25 A. Given the events that were taking place, it is still
0039
1 relatively good I think. As I say, my wife was at
2 the hospital full-time while Laura was there. We also
3 had a three-year-old son at the time, so I tended to be
4 back and forth between home and hospital so I probably
5 spent about 50 per cent of the time there.
6 Q. How long was the journey to get back home again?
7 A. About an hour.
8 Q. How was it coping with both having a child at home and
9 a child in hospital at the time?
10 A. We did have both sets of grandparents available to look
11 after our other child, which did make it easier.
12 Q. You have described at paragraph 5 the diagnosis from
13 Dr Joffe and you then go on at paragraph 6 to say that
14 he arranged for your wife to meet with Mr Wisheart.
15 Were you present at that meeting?
16 A. Yes, I was.
17 Q. And it was he who suggested that an operation would be
18 required. What was the alternative to an operation?
19 A. I have no recollection that there was any alternative to
20 an operation at that particular point in time.
21 The heart would fail without an operation, was our
22 understanding of the situation.
23 Q. Would that take place in a short period of time or was
24 that a long-term problem?
25 A. I do not know the answer to that definitively. Implicit
0040
1 I think the answer was a relatively short period of
2 time.
3 Q. As it happened, the operation took place without
4 discharging Laura from care. Does that help you on its
5 urgency?
6 A. It certainly helps to -- it points out the fact that,
7 yes, there was an urgent need to do something about that
8 heart valve, yes.
9 Q. Turning over the page, please, to paragraph 7, you
10 describe there the nature of the operation being
11 described to you by Mr Wisheart, but you mention
12 the fact that there were several meetings at that time.
13 Can you help us as to the process whereby you were
14 informed about the nature of the operation and its
15 risks? Was this something that happened in one formal
16 meeting or over a period of time?
17 A. I can recall more than one meeting. I can recall that
18 Mr Wisheart was prepared to talk about the chances of
19 success of the operation. I can also recall another
20 meeting where at least one younger colleague was present
21 and drew diagrams to explain just exactly what
22 the problem was with Laura's heart and what they were
23 going to do.
24 Q. Laura had been admitted to the Children's Hospital. Was
25 it there that you saw Mr Wisheart or was it down in
0041
1 the Royal Infirmary?
2 A. It was at the Children's Hospital.
3 Q. Did it take place at Laura's bedside, these discussions,
4 or in an office?
5 A. At Laura's bedside.
6 Q. If they took place at the bedside, who would normally be
7 present then?
8 A. A number of people, I would say. We tended to see
9 doctors -- certainly more than one would be in
10 attendance. My recall is not great. Possibly there
11 would have been a nurse there as well. I can tell you
12 no more.
13 Q. If the discussions about Laura's care and the operation
14 were taking place across a series of meetings rather
15 than one big formal meeting, as it were, was that
16 something that was helpful to you in understanding what
17 was going on or not?
18 A. It was helpful because you could have a meeting, you
19 could have things explained to you to a certain degree
20 and at that point you then had time to think about it
21 and it was quite useful that people would come and talk
22 to us again and we would be able to ask questions, yes.
23 So that was a good thing.
24 Q. If we look at paragraph 7, you have spoken about several
25 meetings you had at that time. Are these the bedside
0042
1 discussions that you are now recollecting?
2 A. Yes. Doctors had to come and visit anyway as they did
3 their rounds, so again they would involve us at that
4 point.
5 Q. You say that it was explained to you very fully and
6 sympathetically. Who was making these full and
7 sympathetic explanations?
8 A. Initially we had Mr Wisheart explaining to us. Later
9 Mr Dhasmana became the surgeon in charge of the case,
10 and also a number of other doctors who were in
11 attendance. I cannot give you any names, I am afraid.
12 Q. So when you speak about one of Mr Wisheart's colleagues,
13 you cannot recollect his name?
14 A. I am afraid not.
15 Q. Was it someone who was a more junior surgical colleague,
16 do you think?
17 A. It would have been a more junior colleague, yes.
18 Q. Did you have the impression that that person was
19 involved in surgery or in cardiology, or is it difficult
20 to know?
21 A. The doctors did tend to explain which side of the care
22 was theirs. So we did understand there were those on
23 the surgical side and those who were not.
24 Q. You had discussions ultimately both with Mr Wisheart and
25 Dr Dhasmana. You have spoken in general terms of
0043
1 everyone explaining things very fully and also
2 sympathetically. When speaking of Mr Dhasmana you speak
3 of him being very patient and reassuring. Were there
4 any differences in approach or style between the two
5 surgeons that you can recollect?
6 A. No, not really. No, I do not think so. No.
7 Q. So your experience, for instance, of Mr Dhasmana being
8 very patient and reassuring is one that could equally be
9 applied to Mr Wisheart, is it?
10 A. Yes.
11 Q. And when you say you were appreciative of the fact that
12 he took the time to explain everything to you fully,
13 again speaking of Mr Dhasmana at that stage, that also
14 applies to Mr Wisheart, does it?
15 A. Yes, it does.
16 Q. It is implicit in everything you have been saying that
17 you ultimately gave your formal consent to
18 the operation.
19 A. Yes.
20 Q. Are you able to help us as to when that took place?
21 A. To the best of my recall it was the day before.
22 Q. Did that follow the long discussion with Mr Dhasmana in
23 which a percentage risk was given for the operation?
24 A. It did follow that, yes.
25 Q. And when the formal consent was taken, was that taken by
0044
1 a junior colleague or was it taken by Mr Dhasmana?
2 A. I cannot recall that.
3 Q. Turning back to your statement, paragraph 8, you speak
4 there about being very happy with the nursing care, and
5 that in particular because the staff were more
6 experienced at looking after babies with conditions such
7 as Laura, that ease communicated itself to you. Is that
8 a fair summary?
9 A. It did. I think the fact that we had the experience at
10 the hospital in Bridgend first underlined that.
11 The nurses at Bridgend were exceedingly careful and
12 cautious in everything they did because for them it was
13 an unusual case, I would imagine. So consequently at
14 Bristol we were reassured that we were in the right
15 place.
16 Q. Were you and your wife able to participate in Laura's
17 care at all?
18 A. My wife was there all of the time. But I cannot
19 recall -- in terms of "care", what do you mean? She was
20 able to do the things that a mother would want to do.
21 But I cannot recall that she did anything other than
22 after the operation learn about how to administer
23 the various drugs that she would need when she came
24 home.
25 Q. But it sounds from what you are saying as if the nurses
0045
1 did involve her in doing those things for Laura that she
2 could do?
3 A. Yes, very much so.
4 Q. Scanning down to paragraph 9, you talk about being told
5 that the operation would be undertaken by Mr Dhasmana
6 and meeting with him. You speak there of an 80 to 90
7 per cent chance of the operation being successful. If
8 the operation was unsuccessful, what did you understand
9 would happen?
10 A. Laura would have died.
11 Q. Was that word used to you?
12 A. I cannot remember, but we definitely understood that
13 that was the case.
14 Q. Speaking of the precise percentages, 80 to 90 per cent
15 chance of the operation being successful, again is that
16 something that you can recollect clearly at this
17 distance?
18 A. Yes, we can. One of the things that my wife and myself
19 were very worried about at the outset was that Laura was
20 about ten weeks old when the operation was carried out.
21 Consequently that was a great worry to us, that she was
22 so young having the operation. So in some respects 80
23 to 90 per cent was certainly for me -- it was a good
24 percentage for me. If the doctors had given me a lower
25 percentage, it would not have come as a surprise.
0046
1 Q. But 80 to 90 came across as being reassuring because it
2 was a high probability of success?
3 A. Yes.
4 Q. If we could just look briefly, please, at the operation
5 note, this is at MR 1043, page 59. You will need to
6 redact an address, please. If you could just take out
7 the address first, please. Thank you very much.
8 You should have on the screen now in front of you
9 the first page of an operation note. It notes that
10 the surgeon was Mr Dhasmana, supported by Dr Chatterjee
11 and Dr Khan. Then there is an anaesthetist's mark,
12 Dr Bolsin. Can you recollect having any contact with
13 Dr Bolsin?
14 A. I cannot recollect either way, I am afraid.
15 Q. Laura was transferred down to the Royal Infirmary before
16 the operation.
17 A. Yes.
18 Q. How long in advance was that transfer made?
19 A. A day or two, I think.
20 Q. So she was on the ward at the BRI for a day or two?
21 A. Mm-hm.
22 Q. Before the operation took place?
23 A. Yes.
24 Q. Can you remember any anaesthetist coming around to see
25 you beforehand?
0047
1 A. I have a vague recollection, yes.
2 Q. A vague recollection of what?
3 A. Of an anaesthetist visiting us, yes.
4 Q. And of discussing what?
5 A. Basically -- no, I would be guessing. I have no recall
6 of that. I just have a recollection of an anaesthetist
7 before the operation.
8 Q. Can you recollect whether that person was male or
9 female?
10 A. No.
11 Q. So it could have been that you were visited by Dr Bolsin
12 but you are unable to recollect one way or the other?
13 A. Correct.
14 Q. Or to recollect the terms of any discussions with that
15 person?
16 A. I am afraid that is right, yes.
17 Q. Going back to your statement then, please, WIT 136,
18 page 4, paragraph 10 you mention seeing a counsellor,
19 Helen Vegoda. That was helpful, was it?
20 A. It was helpful, yes.
21 Q. How did she become involved?
22 A. I cannot recall how we were made -- how we made contact
23 with Helen, but I know she had a position within
24 the hospital at the time and an office at the hospital.
25 I cannot recall how we made contact.
0048
1 Q. Moving on down the statement you talk about the split
2 site and particular the transfer, paragraph 11. You say
3 there was no problem with the actual transfer. How was
4 that accomplished, by ambulance?
5 A. Yes, by ambulance.
6 Q. Again, were you able to travel with her or not?
7 A. My wife travelled with her, yes.
8 Q. You mentioned again that the nursing staff in the BRI
9 were also quite relaxed and reassuring because of that,
10 is that right?
11 A. Yes.
12 Q. The operation was in fact put back until the early
13 afternoon. Are you able to help us why that delay took
14 place?
15 A. It was just something to do with the order and
16 the priority of the operations. It is just a decision
17 that somebody else was going to go first.
18 Q. Was that also surgery being conducted by Mr Dhasmana,
19 do you know?
20 A. As far as we knew, yes.
21 Q. So Mr Dhasmana took as you understand it one operation
22 and then Laura's case and then still operating on
23 another patient thereafter, is that right?
24 A. That was our understanding, yes.
25 Q. Would that description of the hours that he was
0049
1 operating throughout be consistent with what you saw of
2 his working hours, the times he was on the ward at
3 the BRI and the BCH?
4 A. Yes, it would be. He certainly put in a lot of hours.
5 Q. You telephoned to the hospital at about 4 o'clock and
6 you were told that Laura was still in surgery. Had
7 the surgery taken as long as you had expected or had it
8 taken longer?
9 A. It had taken longer.
10 Q. How long had you been told it was likely to take?
11 A. I think we were told it would be something like four
12 hours.
13 Q. And in practice do you know how long it took?
14 A. We think it took something like five to six.
15 Q. If we can look please at the medical record again, at
16 medical record 1043, page 21. This is a record of
17 the transfer back from the BRI to the ward in
18 the Children's Hospital. The first thing to note is
19 that the date is 11th October 1988. I think in your
20 statement you suggest she was transferred back on
21 the Monday?
22 A. Right.
23 Q. This would actually be the Tuesday after the operation.
24 Does that make sense to you?
25 A. That is fine, yes.
0050
1 Q. If we scan down a little bit, just five lines down, it
2 says:
3 "Noted to have pneumothorax on 9th October 1988
4 and a chest drain was inserted."
5 Is this the incident that you mentioned in your
6 statement when you mentioned a problem arose with
7 a collapsed lung?
8 A. Yes, I think so.
9 Q. How was that handled from the point of view of telling
10 you what was going on and reassuring you perhaps, if you
11 needed it, that Laura was not in any danger?
12 A. We were told by a doctor, we do recall, an Australian
13 doctor, as to what had happened, what the problem was.
14 We were told that from his perspective it was fairly
15 routine. He would perform surgery on the ward. Again,
16 obviously it was concern to us. We were reassured by
17 what he told us, and it was a fairly quick operation and
18 we were back in to see Laura fairly quickly.
19 Q. So you were asked to leave the ward, were you, whilst it
20 took place?
21 A. Yes.
22 Q. And then you came in shortly afterwards and were able to
23 see her again?
24 A. Yes.
25 Q. Just looking again just to complete looking at this
0051
1 note, we can see that when she was first examined back
2 at BCH after she had been transferred, Laura was first
3 seen according to this note at 6 o'clock at night. Do
4 you see 1800 at the top? If we scroll down a little we
5 can see the note "on examination". This is at
6 the bottom. "Not pyrexial", so not feverish, "pink and
7 well perfused". Then she has a regular pulse there of
8 130 noted. So when she first came back to
9 the Children's Hospital everything seemed to be going
10 all right, is that right?
11 A. That is right.
12 Q. How was she transferred back?
13 A. Again it was ambulance.
14 Q. With your wife accompanying her again?
15 A. Yes.
16 Q. And were you there at the time or not?
17 A. I do not think I was there, no.
18 Q. So what happened next then that you know of?
19 A. As far as we recalled it Laura's temperature and heart
20 rate shot up when she was back on the ward at the sick
21 Children's Hospital. A number of things were tried to
22 bring the situation back into control. We recall ice
23 being one of the things that was tried to bring
24 the temperature down, or as we thought bring
25 the temperature down. That is the incident I think that
0052
1 we remember.
2 Q. Were you in Bristol at the time?
3 A. Yes, I was there then. I was not in the ambulance
4 earlier. I should say the recollection there is still
5 stronger from my wife than from me.
6 Q. So if we go on then, please, to page 19 of these medical
7 records, we can see what appears to be a medical note of
8 the same incident. Can we have that on screen? Do you
9 have that now?
10 A. I have it, yes.
11 Q. This is a count starting at 19.30, so 7.30 the same
12 evening. In particular it seems the heart rate has gone
13 up to 210 beats per minute. But there are other signs
14 which are positive in that the blood pressure is
15 maintained, Laura is not distressed, she is still pink
16 and well perfused. Then there is a note "no response to
17 facial ice or sinus massage". Do you remember both
18 those steps being taken?
19 A. I remember the ice, not the sinus massage.
20 Q. Then it says, "No further action. Subsided after 5
21 minutes." How long did this instance seem to last when
22 you were involved in it?
23 A. It seemed longer, but I could not give you a time.
24 Q. Is that because every moment seems to be a long one when
25 you are worried about your child?
0053
1 A. More than likely.
2 Q. She is then seen by Mr Dhasmana. Can you remember him
3 coming?
4 A. I cannot remember that, no.
5 Q. There is no note here at any rate of Laura's temperature
6 rising suddenly. Is that something you remember?
7 A. It is possible. It is just an assumption we made
8 because of the application of ice.
9 Q. You say in your statement, and I am looking now at
10 WIT 136, page 6, at the top of the page that you were
11 told at the time that this instant may have arisen
12 because of the transfer from one site to another. Do
13 you recollect being told that?
14 A. That is my wife's recollection.
15 Q. So are you able to help us any further as to who said
16 that, firstly?
17 A. I cannot.
18 Q. Or when it was said?
19 A. No.
20 Q. Or are you able to help us on the matter of what
21 impression you were given by the staff as to whether or
22 not this was a potentially serious matter or something
23 that was rather more routine than that?
24 A. I cannot give you an answer to that.
25 Q. You say there that in retrospect you feel it was
0054
1 a little undesirable that she should have been moved so
2 soon after her operation. The operation took place on
3 Friday. She was moved on Tuesday; a gap between the 9th
4 I think and the 11th. Can you help us as to why she was
5 moved? Did anyone explain that to you?
6 A. It was explained. I think one of the things that we
7 came to understand was the availability of beds and
8 facilities at the Royal Infirmary was one issue.
9 The other thing was I think there was a preference for
10 Laura to be at the sick Children's Hospital. They were
11 the two factors.
12 Q. And why was it preferable her to be there?
13 A. I have no idea.
14 Q. Which ward did she get put back on in the Children's
15 Hospital?
16 A. Initially she was in an intensive care unit.
17 Q. And then after that she was moved down to a more general
18 ward, or not?
19 A. When you say "general ward" I am not so sure it was
20 a general ward. It was a ward similar to that in which
21 she had been put in when originally we came to
22 the hospital.
23 Q. But she was discharged from that rather than being
24 discharged from intensive care?
25 A. Yes.
0055
1 Q. You then deal at paragraph 16 with seeing both
2 Mr Dhasmana and Dr Joffe again and a discussion whether
3 or not a further operation might be needed. Has that
4 had to take place or not?
5 A. It has not.
6 Q. And Laura is well?
7 A. Laura is well, yes.
8 Q. At the bottom, the concluding comments, you talk about
9 the appreciation you have, you and your wife I think; is
10 that right?
11 A. Very much so.
12 Q. Of Mr Dhasmana, not merely because your daughter's life
13 was saved, although I do not use the word "merely" in
14 any appropriate sense, but also you say because he
15 conducted himself in a very caring and conscientious
16 way.
17 A. Yes.
18 Q. What was your overall impression then of the way in
19 which Mr Dhasmana handled Laura's care?
20 A. We thought it was first class. We thought that he not
21 only took care of the professional side of it with
22 the surgery but he was a very caring doctor, we felt.
23 Q. If we go over the page to the last page of your
24 statement you mention the time he spent in
25 the hospital. You also go on to say that, beyond
0056
1 the time and attention he gave, you were completely
2 confident in his great skill as a surgeon. On what is
3 that judgment of his skill based?
4 A. I think before the events that had unfolded occurred we
5 were ignorant of what was going on. So our initial
6 confidence was just based on a general confidence in
7 the skills of doctors. But we were reassured by
8 Dr Dhasmana while we were there. Our confidence was
9 probably greater before the operation and, subsequent to
10 the operation, obviously given that Laura is now well
11 that comes into that comment that we have made in
12 the statement.
13 Q. So essentially your judgment is based on the experience
14 you had in working with Dr Dhasmana in this instance?
15 A. Yes.
16 Q. And Laura's care in this case?
17 A. Yes.
18 Q. And that judgment that you formed has remained unchanged
19 to this day, is that right?
20 A. In terms of Laura's care, yes.
21 Q. In terms of Laura's care, is there any other factor that
22 you would want to bring into the picture now?
23 A. No.
24 Q. So you say in other words that your confidence in
25 Mr Dhasmana remains the case to this day?
0057
1 A. Yes.
2 Q. Robert, I have asked you a number of questions in taking
3 you through the statement, and you will appreciate of
4 course that it has been read and therefore forms part of
5 the evidence before the Inquiry. Is there anything else
6 that you would like to draw out or to say to the panel
7 in this opportunity to give evidence?
8 A. Not really, other than to underline again that our
9 experience was a very good experience both in Bridgend
10 and at both hospitals in Bristol.
11 MISS GREY: Thank you. The panel may have some questions.
12 THE CHAIRMAN: Mr Briggs, there are no questions from
13 the panel. Mr Sharp?
14 Examined by MR SHARP:
15 MR SHARP: Just a couple of points, if you will. One short
16 point: you were not there all the time; your wife was.
17 Do you know how she managed while you were away? Was
18 she looked after in any way? Provided with
19 accommodation?
20 A. Yes, she was provided with accommodation and made very
21 comfortable while she was there.
22 MR SHARP: Can I ask you, please, to go to paragraph 7 of
23 the statement which is on page 3. In there you say, it
24 is just over halfway down the paragraph:
25 "As far as I can recall no-one talked of 'not
0058
1 operating' as an option, and it was implicit in
2 everything that was discussed that there was no real
3 prospect of Laura surviving very long without an
4 operation."
5 To what extent were you looking for -- you said
6 earlier on that it was never actually said in so many
7 words -- someone to say the unsayable?
8 A. I do not think we were looking for anybody to say it.
9 It was understood. Even though we have said that it was
10 only very implicit in what was being said, nobody needed
11 to say it. It was completely understood.
12 Q. Thank you. Nobody needed to say it.
13 A. No.
14 Q. You have said that your understanding was that there was
15 a 80 to 90 per cent chance of the operation being
16 successful.
17 A. Yes.
18 Q. And you found that reassuring.
19 A. Yes.
20 Q. Did your wife have any different perception to yourself
21 of the prospects of success in how she approached it?
22 A. Yes, my wife's viewpoint on it was different. She
23 worried about the 10 to 20 per cent risk of failure.
24 Q. So there was a difference in perception from your
25 starting point?
0059
1 A. Yes.
2 Q. Did that derive simply from the difference in attitude
3 of you as people or from different meetings or
4 discussions you had had with doctors?
5 A. From our different viewpoints as people.
6 Q. You mentioned your meeting with Helen Vegoda.
7 A. Yes.
8 Q. How much dealing did you have with the heart circle and
9 with Helen Vegoda?
10 A. We saw Helen several times. She was available quite
11 a lot of the time that we were there if we needed to see
12 her. We also saw people from the heart circle, and
13 Helen Vegoda arranged for a family to come and meet us
14 where one of the children had had very similar heart
15 surgery. So it was very, again, reassuring to be able
16 to speak to somebody who had already been through it and
17 to draw on their experiences.
18 Q. After the treatment was over and you had gone back to
19 Bridgend, have you maintained any contact with the heart
20 circle?
21 A. Yes, we have. We are still members of the heart
22 circle. Bridgend itself as a town has its own heart
23 circle now which is linked into Bristol, and my wife is
24 Treasurer of that heart circle.
25 Q. Finally, what was it that persuaded you and your wife
0060
1 that your story needed to be told here?
2 A. We have seen much of what has been said on the news
3 about Dr Dhasmana and Mr Wisheart. We have every
4 sympathy for the tragic cases that have occurred. We do
5 feel, though, that they must have done many, many good
6 things. Laura is one of the examples where in this case
7 it was Dr Dhasmana, he saved our daughter's life, and
8 I am very pleased to be able to come and tell that
9 story.
10 MR SHARP: Thank you, sir.
11 THE CHAIRMAN: Mr Sharp, thank you. Thank you, Mr Briggs,
12 for coming and telling us Laura's story, a happy story.
13 We are very obliged to you.
14 A. Thank you.
15 MISS GREY: Sir, I wonder if that would be a convenient
16 moment to break perhaps for lunch. Perhaps a short
17 break of 30, 35, 40 minutes; at your convenience.
18 THE CHAIRMAN: Miss Grey, you always tax my mathematics when
19 you say something like that, which are now a matter of
20 notoriety. I will say 1.35, which I think will amount
21 to 40 minutes break. Shall we say that?
22 MISS GREY: Thank you.
23 (12.55 pm)
24 (The short adjournment)
25 (1.45 pm)
0061
1 MR LANGSTAFF: Sir, our next witness is Mr Tony Collins.
2 Mr Collins, would you mind standing to take the oath,
3 please?
4 MR TONY COLLINS (SWORN):
5 Examined by MR LANGSTAFF:
6 Q. Mr Collins, your full name is Tony James Edgar Stanley
7 Collins, is it?
8 A. Yes, it is.
9 Q. You want to be known as Tony?
10 A. Yes.
11 Q. Before we come to your statement, you are going to tell
12 us about the birth and then various operations which
13 your son Alan had?
14 A. Yes.
15 Q. Is Alan here in the hearing chamber?
16 A. Yes, just over there.
17 Q. Did he in fact come because he expressed the wish to
18 come and listen?
19 A. Yes.
20 Q. I think Alan now lives with his mother rather than with
21 you full-time?
22 A. Yes, that is correct.
23 Q. Because you are separated?
24 A. Yes.
25 Q. Have you discussed the contents of the statement you
0062
1 are about to tell us about, with your wife?
2 A. Yes, on several occasions.
3 Q. And to what extent does she agree or disagree with what
4 you have to say?
5 A. She agrees with everything I have had to say and she
6 supports me in everything we have talked about together.
7 Q. Let us look at that statement. It is WIT 21/1, where it
8 begins. Can we go to page 9, please? 12th March was
9 when you signed the statement. That is your signature?
10 A. Yes.
11 Q. Tony, if we just look further up that page, if we may,
12 at another correction which was made to paragraph 34,
13 when you made the statement Alan was 11 years old?
14 A. Yes.
15 Q. For our purposes, of course, we take his age as at
16 today's date and he is now 12?
17 A. Yes.
18 Q. So we have to read your evidence subject to that
19 correction. Subject to that, is what you say in your
20 statement true and accurate?
21 A. Yes.
22 Q. What I want to do is take you back to the very first
23 page. Go down to the bottom. Indeed, we see the date
24 that was his birth day, and then it explains why you
25 made the statement he was 11 and is now 12. 22nd April
0063
1 1987, in Swindon?
2 A. Yes.
3 Q. Did you know from any medical source that there was
4 a problem with Alan within the first four weeks of life?
5 A. No, none at all.
6 Q. Did you have any idea from any other source that there
7 might be a problem?
8 A. Not from another source, but just from what me and my
9 wife had observed.
10 Q. What was that?
11 A. That Alan would spend most of his evenings having to be
12 kept upright in bed with his mother holding him, because
13 he was very sick, vomiting all the time and just not
14 sleeping.
15 Q. Was Alan your first son?
16 A. No, second.
17 Q. So you had already had experience of a baby?
18 A. Yes.
19 Q. And in fact, is Alan's brother much older?
20 A. He is a year older.
21 Q. So it had only been a year before, thereabouts, that you
22 had been caring for another baby?
23 A. Yes.
24 Q. Was the experience with the brother very different?
25 A. Yes. James was fine in his sleep and not at all sick.
0064
1 I would say he was no problem, but I am sure his Mum
2 would not say that!
3 Q. So, being concerned as you were as his parents, what
4 help did you get from the medical profession at this
5 stage?
6 A. None at all, really. We would take Alan to see his GP,
7 although I would like to say it was not his own GP, it
8 was several GPs at the practice he belonged to, and they
9 would basically be telling me and June that Alan was
10 just a very sickly baby and we were over-anxious parents
11 and that we were not to worry. At one point we were
12 told that Alan just had thrush.
13 Q. Had thrush?
14 A. Yes.
15 Q. How did things come to a head?
16 A. Alan was a month old, roughly. June had taken Alan over
17 to see the doctor once again because he had been very
18 sick the night before and I knew he was not very well.
19 I had gone to work. I came home to my house, which was
20 all in darkness, to find a note on the table basically
21 saying that Alan had been taken to PMH by his Mum.
22 Q. "PMH" is Princess Margaret Hospital in Swindon, is it?
23 A. Yes.
24 Q. So you went there?
25 A. Yes.
0065
1 Q. Had they found that there was a serious problem for
2 which Alan required urgent treatment?
3 A. Yes. They had said that Alan had a problem with his
4 heart and that he was not being able to breathe
5 properly, and there were several other minor
6 complications due to a problem with his heart, and that
7 he needed to go to a children's hospital somewhere in
8 the country to correct the heart problem that he had.
9 Q. So they could not deal with him there, at Princess
10 Margaret's?
11 A. No. They kept him there overnight to stabilise him, but
12 also because they needed to find a bed in another
13 hospital that could actually deal with the problem. So
14 the PMH could not actually deal with his problem at that
15 time.
16 Q. Did they mention where he might go, the number of
17 possibilities, or not?
18 A. No, there was no hospital mentioned. I was just under
19 the impression they were trying to find a bed somewhere
20 in the Intensive Care Unit that dealt with cardiac
21 problems.
22 Q. So it was not a question of saying, "Would you prefer to
23 go to Birmingham or Great Ormond Street or Southampton
24 or Bristol"?
25 A. No.
0066
1 Q. It was just to try and find him a place somewhere, and
2 they got Bristol?
3 A. Yes.
4 Q. The next morning was what, 20th May 1987?
5 A. Yes.
6 Q. You give us these dates. Do they come from a diary,
7 or ...
8 A. While we were in Bristol, not actually as such a diary,
9 but I actually kept notes for the first week or so that
10 Alan was in hospital. I had taken this from when he
11 first arrived at the PMH hospital until he came to
12 Bristol. It was not a diary, just notes I kept in
13 a baby book.
14 Q. For ... ?
15 A. One reason was for when, as I assumed Alan would get
16 older, before the Bristol problems came into the press,
17 we could look back and say "This is what actually
18 happened to you when you were a baby, Alan", giving him
19 dates, et cetera.
20 Q. There was an ambulance arranged to take him from Swindon
21 to Bristol?
22 A. Yes, in the early hours of the morning of that day.
23 Q. Were there any difficulties?
24 A. There were difficulties in the sense that when the
25 ambulance arrived at Princess Margaret's Hospital, the
0067
1 ambulance crew were not sure if the incubator Alan was
2 in would actually work in the ambulance they were going
3 to use, and we had an agency nurse who had only come on
4 duty and a doctor who had only just come on duty and
5 none of them knew much about what had happened to Alan
6 during the previous night. For all that, they were very
7 good and Alan got to Bristol with no problems.
8 Q. You are looking at things with the benefit of
9 hindsight. At the time, what you say in your statement
10 is by way of almost a complaint about their lack of
11 recognition of your feelings at the time?
12 A. Yes. I think so, in the sense that my wife, at the
13 time, was included in going in the ambulance with Alan,
14 et cetera, but I was actually told I would have to catch
15 a train to Bristol because there would be no room in the
16 ambulance with me and the doctor and the nurse and the
17 rest of the people who were involved, to which the
18 Sister who had actually come down from the ward with us
19 insisted I did go in the ambulance, so I did go in the
20 ambulance eventually, but there was a bit of an argument
21 beforehand as to whether I should go in the ambulance or
22 go by train.
23 Q. In your mind, why in particular did you want to go with
24 your son?
25 A. I found it very difficult that they were saying to me
0068
1 I possibly could not go in the ambulance with my son,
2 given that I was being told he may not be alive when
3 I got to Bristol. Also I had never been to Bristol in
4 my life before, so I did not know where the Children's
5 Hospital was, but also I did not know if Alan was going
6 to be alive when I got there.
7 Q. It was the nurse who picked that up?
8 A. Yes.
9 Q. The Sister, and insisted on your behalf?
10 A. Yes.
11 Q. You mentioned two other problems with the transfer. One
12 was the staff being fresh to Alan's case, the nurse and
13 the doctor, and the other being a query as to whether
14 the incubator would suit the ambulance or not.
15 You say, however, that everything in the event
16 worked out fine?
17 A. Yes.
18 Q. So do you have a criticism about that, or not?
19 A. Only in that I think we should have possibly had one of
20 the staff who actually looked after Alan during the
21 night to come with us in the ambulance, because she
22 would have known about Alan's care; although saying
23 that, the agency nurse was very good. Also, the
24 ambulance crew should have known whether the incubator
25 would have worked in the ambulance before we left
0069
1 Swindon and not left it to the last moment; being told
2 Alan might not survive, and then being put in an
3 ambulance not knowing whether the equipment is going to
4 work.
5 Q. I have taken you through your complaints about the way
6 in which you were dealt with by your GPs, or the GPs
7 from the practice you attended, and the ambulance
8 transfer in order to ask you whether, when there is
9 something about which you feel you should complain, you
10 are the sort of person that does so?
11 A. Yes. If I feel I have a complaint, then I make sure
12 people know I have a complaint.
13 Q. What do you say about the care that Alan received once
14 he got to Bristol?
15 A. I would say the care that Alan received when he actually
16 arrived in Bristol was second to none in the country.
17 He could not have asked for a better surgeon and the
18 staff there were brilliant, so I have no problems with
19 Bristol at all.
20 Q. And can you give me an expansion of what you mean by
21 "brilliant"?
22 A. When we arrived, we were met by several staff at the
23 hospital who took time to explain to us exactly what was
24 going to be happening with Alan, and what the procedures
25 would be. We were given a room to stay in, and there
0070
1 was always somebody there if we needed to talk, and
2 everything was just explained to us from the moment we
3 arrived.
4 Q. So by being "brilliant", what you mean is you had full
5 explanations?
6 A. Yes.
7 Q. That is what you have emphasised, I think?
8 A. Yes.
9 Q. Is that, do you think, the most important thing to give
10 parents who, like you, would be upset and perhaps
11 emotional?
12 A. Yes, I think because, up to actually arriving in
13 Bristol, I did not feel as if we were really being that
14 involved in what was happening with Alan. Once we
15 arrived in Bristol and the staff talked to us and
16 explained things to us, I felt as if we were being
17 brought in and had a lot more to do with our son's care
18 and what was going on with him.
19 Q. So the importance of giving you information and telling
20 you what was happening was to make you feel included?
21 A. Yes.
22 Q. Did they include you and your wife in other aspects of
23 Alan's care?
24 A. More so June, being his mother, in the sense of changing
25 nappies, et cetera. I should not say it, but that was
0071
1 down to June. But, yes, we were sort of more looking
2 after what was actually going on with Alan as opposed to
3 what had happened in Swindon.
4 Q. And you say "the staff". "The staff" can cover lots of
5 different types of medical professions. Who did you
6 have in mind?
7 A. Talking, you could almost say, from the lady cleaning
8 the ward to the surgeon would always be available to
9 talk to you if you needed to talk, whether it was about
10 Alan or any other issue on your mind at the time.
11 A member of staff was always available.
12 Q. Who was it who first made you feel included?
13 A. From the moment we actually arrived in the hospital, it
14 would have been the Sister from the Accident & Emergency
15 unit, whom we met at the entrance to the hospital.
16 Q. Alan went to the Bristol Children's Hospital?
17 A. Yes.
18 Q. So he was there in the Accident & Emergency ward?
19 A. Yes.
20 Q. Was he then whisked away for various tests?
21 A. Yes. They did a few tests in the Accident & Emergency,
22 but then he was taken to the Intensive Care Unit, where
23 we actually saw Alan again. We were taken up just after
24 Alan had been taken up to the Accident & Emergency
25 unit. He was taken there for tests before he had the
0072
1 operation.
2 Q. How long after he arrived at Bristol did he have the
3 operation?
4 A. I think we arrived in Bristol between half 8 or 9 in the
5 morning and his operation was early afternoon, because
6 obviously they did all the tests beforehand.
7 Q. So within that short period of time, you felt that you
8 had a full picture, you were included?
9 A. Yes.
10 Q. And understood what was happening?
11 A. Yes.
12 Q. What did you understand the problem to be?
13 A. We had had it explained to us several times, but
14 I understood the problem to be Alan had a blocked and
15 narrow aorta.
16 Q. Did anyone draw a picture of it for you?
17 A. Yes, Mr Wisheart had actually drawn pictures when we saw
18 him of what the problem was and what he was going to do
19 to repair it, and also Mr Jordan and Dr Joffe came to
20 see us and all drew pictures at that time of what was
21 going to happen.
22 Q. I wonder if we can have on the screen MR 3136/88? Let
23 us scroll down to just below the heading "operation
24 note", blanking out the ... scroll down just below the
25 date. Can we highlight, do you think, the diagram which
0073
1 is across the top? It is very faint on the
2 photocopying.
3 We have that on the screen: does that ring any
4 bells?
5 A. It is such a long time ago, no, not really.
6 Q. I think what has been described in the picture is
7 a narrowing of the aorta after one of the connections,
8 the arterial connections, and a couple of lines showing
9 the bit that was going to be cut out so that the ends
10 could be joined together?
11 A. Yes.
12 Q. Is that your understanding of what would happen?
13 A. Yes.
14 Q. What was told to you about any risks and chances?
15 A. Mr Wisheart and Dr Jordan and Dr Joffe had all told us
16 that Alan's chances were not particularly good because
17 of the amount of time he had been unwell leading up to
18 being in Bristol, so the chances of his survival were
19 not very good at all. I could not actually put
20 a percentage on it, but I think it was less than 50 per
21 cent.
22 Q. Do you say you could not put a percentage?
23 A. They told me but I cannot remember now what it was.
24 I just know it was a little below 50 per cent.
25 Q. You say they possibly gave you a percentage?
0074
1 A. I am sure they gave me a percentage, but when I say it
2 is possible, I just do not recall myself.
3 Q. Would the quoting of a different percentage have made
4 any difference to your decision to agree the operation
5 should go ahead?
6 A. No, not at all.
7 Q. Why not?
8 A. The situation we were in to begin with was the fact that
9 Alan either needed to have the operation or he was not
10 going to survive, so you can look at that and say there
11 is no option, really. Given an option now, we would
12 still have let Alan have the operation.
13 Q. So it did not really matter what odds were quoted
14 because he had to have the operation?
15 A. Yes, it was imperative.
16 Q. If pushed, you really do not remember whether you were
17 quoted odds or not?
18 A. No. There were so many things happening on the day with
19 Alan having to have this operation and all the rest of
20 it, that odds and -- lots of different things we were
21 told did not really register in the sense of all we were
22 worried about was that Alan survived the operation.
23 Q. One day you had been at work, the next day you were in
24 Bristol?
25 A. Yes.
0075
1 Q. A strange place to you, was it?
2 A. Yes, very strange. Like I said earlier, I had never
3 been to Bristol previous to then.
4 Q. What did the doctors explain would be the nature of the
5 operation? They drew diagrams which you cannot
6 remember. What did they say they were going to do?
7 A. They said they would have to take a piece out from the
8 aorta, which was the main artery, and rejoin the two
9 pieces, basically, to let the blood flow properly
10 thorough his heart.
11 Q. Did that sound to you simply like a matter of "internal
12 plumbing" -- I do not want to minimise it -- or was
13 there more risk to it than that?
14 A. I think because it was a heart operation you feel there
15 is more risk to it, but internal plumbing, yes, I would
16 say that was probably right.
17 Q. What other risks were mentioned to you?
18 A. They said because of -- not the amount of time of the
19 operation, but they said there was a possible chance
20 Alan could have brain damage or be paralysed from the
21 waist down, the ultimate one being the fact he may not
22 survive.
23 Q. "They" said?
24 A. The doctors, Mr Wisheart, Mr Jordan.
25 Q. Do you remember which of the two said it?
0076
1 A. No, because we had seen several doctors throughout
2 the hours before his operation. There were so many
3 different doctors coming to see us, I could not recall
4 which one said it.
5 Q. Roughly how much time did the doctors, whether it was
6 Dr Jordan or Mr Wisheart, spend with you and your wife
7 making sure that you understood things?
8 A. As I said, we saw several doctors, so to put a time on
9 it, it was almost from the moment we had gone up to the
10 Intensive Care Unit to Alan going down to theatre.
11 There was always somebody there explaining to us what
12 the procedure was going to be, so I could not say how
13 long a certain doctor was going to spend with us,
14 because it seemed like there was going to be somebody
15 there all the time.
16 Q. You tell us in your statement -- I am not going to take
17 you through the details of it because the Panel have
18 read it and we can all take it as read -- about the
19 operation and how you came to see Alan in intensive care
20 and then of course he was connected to all sorts of
21 tubes and equipment?
22 A. Yes.
23 Q. You described that as a shock, but you had been warned?
24 A. Yes. While Alan was down the theatre, we had actually
25 been taken into the Intensive Care Unit and seen other
0077
1 babies who had various tubes et cetera attached to
2 them. Having said that, when Alan did come back from
3 surgery, I did actually go in and see Alan, whereas
4 previous to him going down to surgery, I could not
5 actually take myself into the intensive care unit to see
6 Alan. So although it was a shock, I was prepared in the
7 sense I had seen other children in that position, but
8 not my own son.
9 Q. Who had taken you in?
10 A. One of the nurses from the intensive care unit.
11 Q. Again a general comment: do you think it is helpful to
12 a parent to be shown other children with the tubes and
13 the wires and the monitors, or not?
14 A. Yes, I think it has to be helpful to actually go in and
15 be shown what to expect when your child comes back from
16 surgery. Even though it is still going to be a shock,
17 it is sort of -- it makes it a bit easier, because you
18 are almost knowing what to expect.
19 Q. You think it lessened the shock for you?
20 A. Yes, I think so.
21 Q. You have told us in your statement as well, page 8,
22 WIT 21/8, at the foot of the page, about Helen Vegoda
23 and her presence during Alan's stay in the Children's
24 Hospital.
25 Where did Alan stay after the operation? Which
0078
1 hospital?
2 A. He was in the Bristol Children's Hospital throughout.
3 Q. So he was operated at the Infirmary, was he?
4 A. Not as far as I know. We actually went to the Bristol
5 Children's Hospital and then we were asked if we wanted
6 to go off for a walk while Alan was operated on and
7 I actually came back to the Children's Hospital where
8 Alan was still then, so we never actually had anything
9 to do with the BRI.
10 Q. So throughout, as you recall at the Children's Hospital,
11 and seeing Helen Vegoda and seeing him in intensive
12 care. How long was he in intensive care for, roughly?
13 A. About a week, I think.
14 Q. After that, he has been back, I think, to check and to
15 have a further small operation on his aorta. That was
16 in 1990, was it?
17 A. Yes.
18 Q. And more recently, on 1st April 1996, he went back again
19 and this time he was treated by Mr Pawade, with the
20 cardiologist being Dr Hayes?
21 A. Yes.
22 Q. So you have seen the Bristol Children's Hospital and
23 your son has had surgery there on three separate
24 occasions over the years since 1987. Have you seen any
25 trends in the way in which care has developed over that
0079
1 period?
2 A. No, not really. I think the care that Alan received
3 back in 1987 has been no different to what he is
4 receiving now, really, or from Mr Pawade. I have the
5 same respect for Mr Pawade as I have for Mr Wisheart,
6 but I do not see any difference in the way Alan has been
7 treated.
8 Q. So what is it about their approach that in particular
9 you value?
10 A. They are as caring as they have always been. We have
11 always had all the information that we have ever needed
12 to do with Alan's care throughout, whoever has looked
13 after him in Bristol.
14 Q. So it is the caring approach and the amount of
15 information that you feel has kept you fully informed on
16 every occasion?
17 A. Yes.
18 Q. When you came to give evidence to the Inquiry, you are
19 a member, I think, of the Surgeons' Support Group?
20 A. Yes.
21 Q. And Mr Sharp is here today to represent you. What, if
22 any, message would you like to convey to the Panel about
23 the care, particularly having had the opportunity that
24 you have to see it over various periods of time since
25 1987?
0080
1 A. I would just like to say basically that I think the care
2 is no worse or no better than it was in 1987 and that
3 the surgeon, Mr Wisheart back in 1987, could not have
4 done more, or any more than anybody else, given the
5 circumstances, for Alan or any other child. I just
6 think he has been made a bit of a scapegoat for what has
7 been seen by many to be a bit of a disaster throughout
8 the Health Service.
9 Q. And you judge his performance because of your own
10 personal experience with Alan, do you?
11 A. Yes.
12 Q. And just again, following up that last comment that you
13 made, what are you seeing as the disaster which is
14 general throughout the Health Service?
15 A. Since Bristol has come into the headlines, it seems
16 hospitals are popping up all over the place now with
17 having different -- I am sorry, I have lost the words --
18 different statistics for the operations. When you
19 compare a lot of them, there does not seem to be much
20 difference between Bristol and any other hospital, which
21 makes mention, if people are talking that Bristol has
22 been a disaster, then you are talking about every
23 hospital in the country has been a disaster, at the
24 present time.
25 Q. I have asked you a number of questions. Is there
0081
1 anything which I have not asked you which you would like
2 nonetheless to tell us about, or anything which you
3 would like to add or to explain further?
4 A. No. Only that I do not think Alan could have had any
5 better care than he actually received from Bristol, or
6 the surgeon or surgical team at that time, or at the
7 present time.
8 MR LANGSTAFF: That is all the questions I am going to ask
9 you, Mr Collins. There may be some questions from the
10 Panel and there may be a question or two from Mr Sharp.
11 THE CHAIRMAN: Mr Collins, the panel has no questions.
12 Mr Sharp?
13 MR SHARP: Sir, I have had the opportunity of discussing the
14 questions with Mr Langstaff and I think everything has
15 come out, thank you.
16 THE CHAIRMAN: I am very grateful to you. Mr Collins, thank
17 you very much indeed for coming to talk to us this
18 afternoon. I know we are all delighted that Alan was
19 here and able to see his Dad giving evidence. We are
20 very grateful and wish you both well. Thank you.
21 (The witness withdrew)
22 MR LANGSTAFF: Sir, I cannot recollect that we mentioned
23 publicly to Mr Collins, that if he wants to add
24 anything, he may do so at a later stage. I have done so
25 privately, but while he is in the hearing chamber,
0082
1 I will say that publicly.
2 THE CHAIRMAN: The omission was mine. Thank you for
3 reminding me in such a delicate way. Mr Sharp will have
4 heard, so that is the most important thing.
5 MR LANGSTAFF: Sir, I wonder if it will be convenient to
6 take a quarter of an hour break before we have our final
7 witness of the day, Mr Roberts?
8 THE CHAIRMAN: Shall we do that and therefore reconvene at
9 2.25?
10 (2.15 pm)
11 (A short break)
12 (2.35 pm)
13 MISS GREY: Sir, our last witness this afternoon is Mr Paul
14 Anthony Roberts. Mr Roberts again is represented by
15 Mr Sharp today. Could you please stand whilst you take
16 the oath?
17 MR PAUL ANTHONY ROBERTS (SWORN):
18 Examined by MISS GREY:
19 Q. Mr Roberts, I think you would like to be known as Paul
20 throughout this evidence-giving process?
21 A. That is fine, thank you.
22 Q. You have provided a statement to the Inquiry. If we
23 could have a look, please, at WIT 141/1, this is the
24 first page, is it right, of the statement you have
25 given?
0083
1 A. Yes, it is.
2 Q. If we go to page 8, is that your signature there?
3 A. Yes, it is.
4 Q. Did you make this statement from your own recollection
5 solely, or was it made after discussion with anyone
6 else?
7 A. With my wife.
8 Q. Does she agree with its contents to the best of your
9 knowledge?
10 A. Yes, she does.
11 Q. So you made it after discussion of events with her?
12 A. I did.
13 Q. Does it represent the best of your knowledge,
14 information and belief?
15 A. It does.
16 Q. If we go back, please, to page 1, we see there that you
17 are married to your wife, Muriel, and you have one child
18 Andrew, now aged 16?
19 A. That is correct.
20 Q. It is about Andrew and his treatment at the Bristol
21 Royal Infirmary and the Children's Hospital which you
22 have come to tell us today?
23 A. Yes.
24 Q. Andrew was born, we learn, back in January 1983 at the
25 Royal United Hospital in Bath and that would be your
0084
1 closer hospital, would it?
2 A. It is.
3 Q. Born in January 1983 and we are talking in this
4 statement about events which took place when Andrew was
5 about two years, two and a quarter years old; is that
6 right?
7 A. Yes, that is correct.
8 Q. So in 1985?
9 A. Yes.
10 Q. That is some considerable time ago. How good is your
11 recollection of events at that time?
12 A. I think fairly good.
13 Q. If you are trying to remember the detail of
14 a conversation with a doctor or with your wife perhaps
15 about Andrew's care at the time, with what sort of
16 clarity does it come back to you?
17 A. Well, it is slightly difficult, so many emotions are
18 going on at the time, but we both felt that we asked
19 everything we needed to ask and everything was explained
20 to us at Bristol to our satisfaction at the time.
21 Q. Your child was diagnosed shortly after his birth as
22 having Down's syndrome?
23 A. Yes.
24 Q. That must obviously have come as a considerable shock to
25 you at the time?
0085
1 A. Yes, it was.
2 Q. We are now also talking about events involving heart
3 surgery, heart defects. What was your emotional state
4 in trying to cope with these at the time of the events
5 we are talking about?
6 A. I do not know how to really answer that. It was a great
7 shock. We were only just really coming to terms with
8 the fact that Andrew had Down's syndrome, and then you
9 were suddenly told that he has a heart murmur. They did
10 not really know, first of all they thought it was just
11 a heart murmur and it might go away, so it was not as
12 though everything happened within the course of a couple
13 of weeks. Andrew was monitored over the first sort of
14 12 months, and it came to later on that he had a hole in
15 the heart, then it came to that it was a larger hole in
16 the heart and incorporated all four chambers, so it was
17 a gradual thing rather than having the whole thing
18 thrown at you in one go.
19 So, yes, there was the emotion of being told that
20 there was a murmur; then being told he had a hole in the
21 heart, and first of all people were saying, "A hole in
22 the heart, sir, is quite commonplace these days". Then
23 you are told it is not a straightforward hole in the
24 heart because it was larger and higher up.
25 So, yes, it was a lot to take in at the time, but
0086
1 we had a lot of help by the people who were looking
2 after us.
3 Q. If there was a lot to take in at the time, although it
4 was coming at you gradually, or in a number of steps,
5 what sort of steps did you take to try and make sure
6 that when you were being told things, you understood
7 them and you retained them?
8 A. Possibly sort of -- a lot of the people around us at the
9 time, we had an extremely good health visitor. We had
10 a health visitor who also lived across the road from
11 us. We just talked to everybody we could. That was the
12 biggest help, really. We just kept on talking to
13 everybody at the hospital, friends, and eventually, as
14 I say, that helped us through it, really.
15 Q. So you were asking or talking to people about Andrew's
16 condition repeatedly?
17 A. Yes.
18 Q. If we go back to your statement, then, please, back to
19 page 1, you tell us of Andrew's birth and the fact that
20 he had Down's syndrome, and also that it was soon noted
21 that he had a heart murmur. After three months,
22 paragraph 3, you say that you discovered that he had
23 a hole in the heart?
24 A. Yes.
25 Q. At that stage, I think you have just told us, that must
0087
1 have come as a real shock?
2 A. Yes, very much so.
3 Q. That was discovered at Bath, at that stage?
4 A. Yes.
5 Q. And you say in your statement that "they" arranged to
6 refer Andrew to Dr Joffe at the Bristol Children's
7 Hospital?
8 A. Yes.
9 Q. Who do you mean by "they"?
10 A. The consultant we were under at Bath.
11 Q. What sort of a consultant was that? Can you remember
12 what his specialty was?
13 A. He was a paediatric consultant.
14 Q. No other options were discussed with you. Can you
15 remember what you were told about why Bristol was
16 a suitable place to go?
17 A. If we go back, we were actually told by Dr Joffe that it
18 was a hole in the heart. In Bath they just told us it
19 was a murmur.
20 Q. So that was after you had first seen Dr Joffe at the
21 Children's Hospital?
22 A. Yes. We saw Dr Joffe, were told it was a heart ...
23 then, I cannot remember exactly how long, but shortly
24 after that Dr Joffe actually told us that it was this
25 larger hole, higher up.
0088
1 Q. To take you back to the stage before you had seen
2 Dr Joffe, you had not yet been to the Children's
3 Hospital?
4 A. Yes.
5 Q. And Bath had merely told you that there was a heart
6 murmur and that you needed to be referred to Bristol?
7 A. Yes.
8 Q. Can you remember anything that was said about Bristol
9 and why you should go there?
10 A. To be honest, I cannot. It was just -- they said "We
11 will put you in contact, we will refer you to Bristol",
12 and that was it.
13 Q. At that point, I think you did go to Bristol. You saw
14 Dr Joffe over a series of occasions before surgery took
15 place; is that right?
16 A. Yes.
17 Q. And was the process of coming to understand Andrew's
18 diagnosis a gradual one, or was it all explained to you
19 on the first occasion?
20 A. No, it was a gradual one.
21 Q. If we look at paragraph 4 of your statement, over the
22 page, please, page 2, we can see that the first
23 explanation I think that you were given by Dr Joffe is
24 set out there. And you describe him telling you that
25 there was an altogether larger hole than had previously
0089
1 been suspected, incorporating all four chambers.
2 Can you remember the medical label that was
3 attached to the condition?
4 A. He had a larger hole and an AV canal. I do not know the
5 actual --
6 Q. Would, for instance, "atrioventricular septal defect"
7 have been mentioned?
8 A. I believe it was, yes.
9 Q. Or "AV septal defect"?
10 A. Yes.
11 Q. That was the condition Andrew was suffering from;
12 is that right?
13 A. Yes.
14 Q. So you were given to understand that surgery would be
15 needed?
16 A. Yes.
17 Q. What was the point of the surgery to be?
18 A. To patch the hole and to make a repair to the AV canal.
19 Q. And it was to be carried out, is this right, when Andrew
20 was about two or two and a half years old?
21 A. Yes.
22 Q. Was it Dr Joffe who suggested that that timing was
23 suitable?
24 A. Yes. Yes, it came from Dr Joffe first. I mean, when
25 the extent of the hole was raised, we were actually told
0090
1 at the time that if no surgery was given, then it would
2 be very unlikely that Andrew would make five or six,
3 because of the damage to other organs that would be
4 caused.
5 So as I say, at the time you are going through all
6 these emotions. So far as we were concerned, if he was
7 going to have a life, then, you know, we had to go
8 through the operation.
9 Q. So he needed it before he was five or six. What was the
10 purpose of waiting until he was two or two and a half?
11 A. They just explained that because of the condition Andrew
12 was in at the time, he was very thin, underweight, they
13 would like to leave it until he was about two for this
14 particular operation. They felt that it would be
15 better.
16 Q. A matter, then, of building up his strength; is that
17 right?
18 A. His strength, yes.
19 Q. So the initial discussions then were with Dr Joffe.
20 A. Yes.
21 Q. How did he explain to you the condition that Andrew was
22 suffering from?
23 A. With Dr Joffe and Mr Wisheart, they both started to try
24 to explain it to us and then ended up actually drawing
25 a diagram, and bringing my wife and I round and actually
0091
1 showing us in quite detail actually what the problem was
2 and the reasons for actually having to do it.
3 Q. So both medical practitioners, both doctors, used
4 diagrams to help explain things?
5 A. Yes.
6 Q. And both you and your wife were there at the time?
7 A. Yes.
8 Q. Was that helpful, to have two of you?
9 A. Definitely.
10 Q. Why was that?
11 A. So that you can discuss it afterwards and make sure
12 you both heard it exactly the same, because it is
13 difficult. We would go home and say, "Did so-and-so say
14 this, or did he say that?" It is just helpful to
15 discuss things.
16 Q. Sometimes, did you not hear the same things from the
17 doctors?
18 A. No, so on further meetings, we would ask the question
19 again, because we could not agree and that was very
20 helpful.
21 Q. If you did not agree, was that because you were having
22 difficulties in remembering things, or was it because
23 the same thing had been heard in different ways by the
24 two of you?
25 A. I think so, yes.
0092
1 Q. The second option?
2 A. The second option, yes.
3 Q. Because of a different approach or temperament between
4 the two of you?
5 A. Yes, I would say.
6 Q. So some people might hear things in a more optimistic
7 vein than others might, for instance?
8 A. Yes. This happened a couple of times. I was very
9 optimistic, and then my wife would say "Hang on, that
10 didn't really mean that". I said I thought it did, so
11 we would check again and ask again. This happened on
12 a couple of occasions.
13 Q. You would check again and ask again: what do you mean by
14 that?
15 A. We would both decide what we thought it was, and then
16 when we met Dr Joffe again, we would say "At the
17 so-and-so meeting, was this right or was that right?"
18 and he would explain it again and either I would
19 apologise to my wife or she would to me.
20 Q. So you were able to go back to Dr Joffe for further
21 clarification or information about what you had heard on
22 a previous occasion?
23 A. That was one of the things that we found good at
24 Bristol: everybody always said "Look, do not be
25 frightened to ask anything, please come back to us any
0093
1 time you like".
2 Q. So did you take them up on that offer? Did you ever
3 ring them up, for instance?
4 A. Not really, no, because everything went fairly smoothly,
5 except for when Andrew, which we will move on to later,
6 was taken back in with this infection. They had always
7 said, you know, "Don't hesitate to give us a ring if you
8 have any problems", and we had called our GP out on this
9 particular occasion --
10 Q. Leaving that aside, just before we come to the first
11 operation when Andrew was just over two years old, you
12 did not have to call up Dr Joffe for any further
13 information. Why? Because you were seeing him often
14 enough already?
15 A. We were seeing him often enough.
16 Q. Just scrolling down the page a little, we come, at
17 paragraph 6, to the fact that you first saw Mr Wisheart
18 when Andrew was about 18 months old?
19 A. Yes.
20 Q. He explained to you in some detail the nature of the
21 problem, what could be achieved by the surgery, using
22 diagrams; is that right?
23 A. Yes.
24 Q. You understood that the particular operation had not
25 been performed very often. Was that something that you
0094
1 got from Mr Wisheart for the first time?
2 A. Yes.
3 Q. So Dr Joffe had not explained that?
4 A. Not from our recollection, no.
5 Q. It had not been performed very often where? At Bristol
6 or nationally?
7 A. He might have meant Bristol, but we took it that it was
8 an operation that had not been performed -- they had
9 only started performing on that operation sort of five
10 years previously, and because it was quite a complicated
11 operation. He might have meant Bristol only, I do not
12 know. We were happy with the explanation he gave us at
13 the time, so we did not feel that we needed to ask
14 anything else.
15 Q. So do you think that your impression at the time was
16 that this operation had not been performed very much
17 very often nationally, or when you say that he might
18 have meant Bristol, are you expressing difficulties in
19 remembering quite what was said back in 1985?
20 A. Yes. We took it that he meant it was just an operation
21 nationally that had not been done, or had only been
22 started tackling five years previous, and he had said at
23 the time, they had only actually done about four in
24 Bristol, because this only came up about once a year.
25 Q. So you think he explained to you that they had done, he
0095
1 had done, about four or so in Bristol?
2 A. Yes.
3 Q. And that would have been at a rate of about one a year?
4 A. Yes.
5 Q. So only a very small number of these particular
6 operations had been performed in Bristol?
7 A. Yes.
8 Q. And nationally?
9 A. I did not ask.
10 Q. But you had the same impression, I think it follows on
11 from what you were saying earlier?
12 A. Yes.
13 Q. Did you ask him as to what success they had had with the
14 four operations that had been performed in Bristol?
15 A. Yes, we did, and our understanding at the time was that
16 they had all been successful.
17 Q. So your impression was that it was a new operation, only
18 been performed four times in Bristol?
19 A. Yes.
20 Q. But successfully?
21 A. Yes.
22 Q. And what conclusion did you draw from that, then?
23 A. They were pretty good at doing this particular
24 operation.
25 Q. Can you recollect whether or not you were given
0096
1 a percentage chance of success in the operation, or
2 not?
3 A. We were, and this is something that my wife and
4 I slightly differ on, from memory. I am pretty sure it
5 was an 80 per cent chance of success; my wife thinks it
6 was a little bit lower than that. But whatever, at the
7 time, I mean, we were going through that feeling of,
8 well, you know, Andrew needed an operation otherwise he
9 was not going to survive. We felt very, very confident
10 that the people that were speaking to us and giving us
11 advice -- and yes, it is a little bit of a gut feeling,
12 is it not? If you are happy with the people that are
13 looking after you and you are happy with the way they
14 explain things to you, they put you at ease and you just
15 feel, or we felt at the time, very confident with
16 Mr Wisheart and Dr Joffe.
17 Q. You think that it may have been in the region of 80 per
18 cent; you say that your wife thinks it may have been
19 rather more pessimistic than that.
20 You mentioned earlier that there were occasions
21 when your wife heard something in slightly more gloomy
22 terms than you did. Is this an example of the two of
23 you taking slightly different approaches as to whether
24 there is good news or not so good news?
25 A. Yes, definitely.
0097
1 Q. I think I took you on, in effect, to paragraph 12 of
2 your statement, which, if we look at that briefly, was
3 at page 5.
4 This is the part where you talk about the risks.
5 At that point in your statement, you are talking about
6 a discussion with Mr Wisheart immediately before the
7 operation took place?
8 A. Yes.
9 Q. Was it at that stage or in the earlier meetings that he
10 talked in percentage terms?
11 A. No, the percentage terms was at the earlier meeting.
12 Q. Did he talk about it twice, then, or only on the one
13 occasion?
14 A. So far as I can remember, it was only on the first
15 occasion, because we were quite happy with the operation
16 to go ahead and did not feel any need to ask again,
17 really.
18 Q. So the second discussion on the eve of the operation was
19 rather briefer, was it?
20 A. Yes.
21 Q. If we just turn back, then, to the earlier part of your
22 statement, back to page 3, please, you are talking there
23 as I have said, about this earlier discussion, and you
24 say that Mr Wisheart was perhaps a little blunt, "almost
25 to the point of being insensitive in explaining problems
0098
1 and risks", but you valued that because you felt it was
2 honest?
3 A. Yes. As I say, at the time when you are actually being
4 told these sort of things, you are quite emotional. But
5 shortly afterwards when you stop and you sort of think
6 about the conversation again, both my wife and I looked
7 at each other and said "No, he is just being very honest
8 with us", which is really what we wanted. He did not
9 pull any punches at all, he did not try to smooth over
10 anything. Yes, what he told us, we felt, was very
11 honest.
12 Q. You then go on to draw a contrast with an experience in
13 Bath with a consultant who was a little condescending in
14 his manner.
15 Does it follow from that contrast that you did not
16 find Mr Wisheart condescending?
17 A. No, we did not find Mr Wisheart condescending at all.
18 Q. Was he able to describe things to you in a manner which
19 you were able to understand without conveying a sense of
20 being patronising?
21 A. Yes, very much so.
22 Q. Another aspect of his care that reassured you, you say,
23 talking of Andrew, was that Andrew's Down's syndrome was
24 not treated like a difficult complication, or an issue
25 in itself.
0099
1 How was it treated in Bristol?
2 A. Just Andrew was a young boy with a heart problem and
3 they would like to do all they could to help him.
4 Q. Was there any suggestion that Andrew's Down's syndrome
5 in any way affected whether or not the operation was
6 first of all suitable for Andrew?
7 A. No, not at all.
8 Q. No discussion of whether or not it was more or less
9 desirable to have the operation, because of that?
10 A. From what we can remember, everybody we spoke to was all
11 for the operation.
12 Q. You say that this compared favourably with an experience
13 at Bath where some of the nursing staff dealt with you
14 in a rather insensitive way in relation to Down's
15 syndrome.
16 First of all, how did the nursing staff at the BCH
17 handle the Down's syndrome issue in comparison?
18 A. It did not really arise. They were lovely. It was
19 nice, coming -- I do not want this to sound wrong,
20 because Bath generally was very, very good, but we had
21 just had two experiences that were a little bit
22 unsettling.
23 Q. Can you help us a little more as to the detail of those
24 experiences?
25 A. It affected my wife more so than me, at the time. She
0100
1 was put in a private room after Andrew was born, because
2 they did not tell us straight away, because I do not
3 think they were 100 per cent sure that Andrew was
4 Down's. About three our four days after Andrew had been
5 born, a particular nurse came in one evening when my
6 wife was having her tea and was talking to her and said,
7 "You shouldn't really worry, my dear, you just take him
8 home and he is as easy to look after as a little
9 puppy". You could not imagine how she felt at the
10 time. Then she told me when I came in and we made
11 a complaint and that person was moved from looking after
12 my wife.
13 Q. That was in relation to the nursing staff?
14 A. Yes.
15 Q. What about the consultant staff?
16 A. Yes. The consultant we were under, I do not know
17 whether you can say it was his fault, but he did not
18 seem to know anything about Down's syndrome at all, but
19 in all the conversations, in the early days that we had
20 with him, he just did not show really any interest at
21 all. We just felt we were totally on our own with him,
22 and it was shortly after that, as I say, things were
23 passed over to Bristol, so we just did not feel happy
24 there.
25 Q. At Bristol it was not an issue, but was there any
0101
1 interest in it, if you felt that there had not been with
2 this particular consultant in Bath?
3 A. Yes, it was totally different when we came to Bristol.
4 Down's syndrome was not really even mentioned. We just
5 came across with a little boy, he had a heart problem,
6 "Let us see what we can do to help".
7 Q. Were there any other children with Down's syndrome being
8 treated at the Children's Hospital, the BRI, at the
9 time?
10 A. Not that we can remember at the time, no.
11 Q. Andrew had to wait, then, for his surgery and
12 eventually, however, he was admitted once but then had
13 to be discharged because of an infection in February
14 1985?
15 A. Yes.
16 Q. Then finally, readmitted for the operation on 9th May;
17 is that right?
18 A. He came in once for the operation and had an infection
19 and was sent home. Then we came in again but we believe
20 there was an urgent case came in and Andrew was sent
21 home again. Then we came back in and the operation was
22 carried out. So it was on the third attempt.
23 Q. So if we look up at page 4 of your statement, we have
24 there first of all the record of the operation being
25 carried out on 9th May. This was your first encounter
0102
1 with the Bristol Royal Infirmary; is that right?
2 A. Yes.
3 Q. So how did that strike you compared to the Children's
4 Hospital?
5 A. Totally different, really. The Children's Hospital, you
6 know, it is -- the nursing staff were looking after
7 children. A totally different atmosphere.
8 Q. Because it was more children orientated?
9 A. Yes.
10 Q. And there were more children around at the Children's
11 Hospital?
12 A. Yes, but we soon felt very, very comfy with the
13 situation at the BRI, because everybody seemed so
14 helpful and seemed to know exactly what was going on and
15 took us through everything very carefully. We were just
16 happy with the situation.
17 Q. Did you have a chance to look around the ITU and to get
18 a warning about what Andrew might look like when he came
19 back from the operation?
20 A. Yes.
21 Q. Was that helpful?
22 A. Very helpful, because it would have been a very big
23 shock otherwise.
24 Q. You mention hygiene at the Children's Hospital in your
25 statement, and you say there that sometimes you felt
0103
1 that hygiene was not of the highest standard. You say
2 that, for example, in the parents' kitchen there was
3 often food left lying around.
4 The parents' kitchen, it is obvious, is not one of
5 the wards?
6 A. No, no. That is why we made sure, we said it was the
7 parents' kitchen. Because of how things have gone over
8 the years, with parents being allowed to stay, which is
9 great, we would not have it any other way, but we just
10 felt certain parents could have been a bit more careful
11 with what they did with food, because there were a lot
12 of children in there with serious conditions.
13 Q. So was it mostly in the parents' kitchen that you
14 observed practices you did not regard as being hygienic?
15 A. Yes, because that parent was then going back and looking
16 after their child.
17 Q. But generally, the comment that might be made is that
18 arose from a praiseworthy desire on the part of the
19 hospital to provide facilities for parents.
20 Perhaps for the sake of the record I should show
21 you the Trust's comment on this. If we look, please, at
22 page 9, we can see that the Trust were unable, at this
23 point in time, 18 years after the event, to comment on
24 the standard of cleanliness observed by Mr Roberts.
25 From what you have just said, I think you would
0104
1 accept that you were not perhaps in a position to judge
2 whether the standards of cleanliness on the wards were
3 acceptable or below acceptable?
4 A. No.
5 Q. You were generally very happy at the Bristol Royal
6 Infirmary in the ward there. Were there adults on the
7 ward at the time you were there?
8 A. Andrew was in a side room with four beds and at the time
9 there were two other children in there, so -- but it was
10 on the end of an adult ward.
11 Q. So you were in a room where there were two other
12 children and Andrew. Did you have any contact with the
13 adults at all?
14 A. Myself, I did. Just wandering around talking to people,
15 you know, if Andrew was asleep and we were in there.
16 Just general conversation, yes.
17 Q. But generally the fact that there were other adults in
18 the near vicinity was not something that impacted on
19 your experience of the care that Andrew was receiving?
20 A. No.
21 Q. If we go back, please, to WIT 141/4, we see there at the
22 bottom of the page, paragraph 11, the meeting with
23 Mr Wisheart before the operation. That was shortly
24 before the operation, after Andrew had been admitted to
25 the BRI?
0105
1 A. Yes.
2 Q. Was this a shorter discussion, after the previous
3 discussions you had had?
4 A. Yes. I cannot remember how long in time, but, yes, it
5 was just a general meeting to discuss the final bits and
6 pieces.
7 Q. Looking at both meetings, can you remember what other
8 risks, apart from the risk of death, clearly a deeply
9 significant one, were discussed with you?
10 A. Only that the condition that Andrew had, if it was
11 allowed to go on over a length of time, you know,
12 i.e. four or five years, there would be damage to
13 kidneys, liver, and eventually, they would just pack it
14 in.
15 Q. What about risks associated with the operation, though?
16 What were the potential downsides for that?
17 A. I do not know whether we actually asked. They felt very
18 confident at the time that if Andrew had the operation
19 and surgery was successful, he would make a very good
20 recovery.
21 Q. Can you remember being visited by an anaesthetist before
22 the operation?
23 A. Yes.
24 Q. What did that person explain?
25 A. Basically, what he would do at the start of the
0106
1 operation and how he would look after Andrew and those
2 sort of things. As I say, it is very difficult to
3 remember exactly what he said, but we both came out of
4 the meeting feeling reasonably calm and happy with what
5 we had been told and we did not feel at the time that we
6 wished to ask any other questions.
7 Q. Again, can you remember whether there was any discussion
8 of anaesthetic risks, or is it realistically too long
9 ago to remember?
10 A. It is, really, to be honest. All we can remember is
11 that we were very happy with what was explained to us at
12 the time.
13 Q. Are you the sort of person who asks for more, if you
14 need to find out more?
15 A. Yes.
16 Q. Do you think you did, on those occasions?
17 A. I think we asked everything we wanted to ask at the
18 time. Yes, you always look back afterwards and say
19 "Perhaps I should have asked this or asked that", but,
20 no, we were more than happy with the way things were
21 explained to us.
22 Q. Turning over the page, then, surgery was conducted on
23 9th May by Mr Wisheart. Andrew remained in intensive
24 care at the BRI until the 11th.
25 Then we see that on the 21st he was taken back to
0107
1 the nursery ward at the Children's Hospital.
2 How was the transfer accomplished?
3 A. That was by ambulance.
4 Q. Were you able to go with the ambulance, or was your
5 wife?
6 A. Yes.
7 Q. He had a fluctuating temperature for a while after he
8 went back to the Children's Hospital. Was that
9 something new, or had that been the case before he was
10 sent back?
11 A. No, they said that this was, you know, quite often the
12 case, but it would be monitored and they would keep an
13 eye on it.
14 Q. Quite often the case, but caused by what?
15 A. Any operation. That is how we took it at the time:
16 anybody that undergoes surgery.
17 Q. But was the fluctuating temperature something that
18 started after he had been transferred, or had it been
19 a feature of his recovery at the BRI as well?
20 A. From what I can remember, it was a feature of his
21 recovery, but they were happy to transfer him back to
22 the Children's Hospital at the time.
23 Q. So there was no suggestion that the fluctuating
24 temperature had anything to do with the transfer?
25 A. No. It was just on the particular day that he was
0108
1 transferred, it was just a windy, blowy day, and we sort
2 of thought, "It is a shame that anybody has to be taken
3 outside and put in the ambulance and be transferred".
4 It would have been nice if it was all together. But
5 that is ...
6 Q. He was well enough to be discharged on 24th May, or
7 perhaps in retrospect he seemed well enough to be
8 discharged?
9 A. Well, he did seem well enough. He was very, very
10 perky. Everybody was happy with everything.
11 Q. I ask that question because you go on to tell us about
12 how he had to go back and was readmitted and further
13 surgery was required. Was it ever suggested that he
14 should have been kept in rather longer?
15 A. No.
16 Q. So it was just one of those things that happened after
17 he had been discharged?
18 A. Yes.
19 Q. You go on to say, looking down the page, please,
20 paragraph 14, that he was readmitted to hospital in the
21 middle of the night. Can you remember the timing of
22 this particular incident at all?
23 A. I will try to. My wife and I differ on this a little
24 bit. It was just that it was around about between 7 and
25 8 o'clock in the evening. He was crying an awful lot,
0109
1 so we called our GP who came out within an hour, anyway,
2 who examined Andrew and seemed to feel that, well, yes,
3 he did have a bit of a temperature, but there were no
4 visible signs for him to think anything different. He
5 suggested we gave him some Calpol, paracetamol, to see
6 what he was like in the morning.
7 After our GP had left, he seemed to get more
8 distressed and more distressed. So far as I can
9 recollect, it was 1 o'clockish, 1.30 in the morning. My
10 wife and I had been up all the time. I was not happy
11 and I had remembered the comment that they had said at
12 the hospital: "Look, if you are worried about anything,
13 come back to us directly", and I made the phone call.
14 I spoke to a doctor, I do not know his name, who
15 suggested that if we were unhappy, to bring Andrew
16 straight back in.
17 This is where I differ slightly with my wife.
18 I think it was in the early hours of the morning; she
19 thinks it was more towards daylight. Anyway, we took
20 Andrew back to the hospital. We had to wait a little
21 while.
22 Q. You had to wait there? Was this in the outpatients
23 clinic?
24 A. This is in the outpatients. This is where we differ
25 again. I thought Mr Wisheart was called into the
0110
1 hospital. My wife thinks that he was actually in clinic
2 in the hospital, his first clinic. We waited not very
3 long, went back to reception and spoke to somebody again
4 and said, "Look, he is obviously not very well, he is
5 crying a lot". They said "If you would like to see
6 another doctor, we will get somebody for you straight
7 away". So we said "Yes, please", and a young doctor
8 came across. He had a look at Andrew's wound. He was
9 not happy with what he saw and he called Mr Wisheart out
10 from his clinic and within 20 minutes Andrew was whisked
11 away and the wound was opened, and to be fair, the wound
12 looked very good a few days before so it was something
13 that was going on underneath the wound.
14 Q. So the difference in recollection between you and your
15 wife is that you recollect possibly Mr Wisheart having
16 to be called in in the early hours of the morning?
17 A. Yes.
18 Q. Whereas she seems to remember he was already there for
19 a clinic?
20 A. Yes.
21 Q. We have had a look through the medical notes just to
22 see whether there is anything else that can help us on
23 timing. I appreciate you will not have seen these
24 before, but if I just put up one or two documents they
25 may help you on the timing of this incident.
0111
1 If we look at MR 1207/18, I think that can go on
2 the screen, please, we can see at the top of what seems
3 to be the first relevant record for Andrew's care, it
4 says:
5 "Admitted from OPD", which would be outpatients
6 department, and then the time is 1600, so 4 o'clock in
7 the afternoon. Andrew has now been admitted under
8 Mr Wisheart.
9 If one goes down, one would see the history of
10 Andrew's readmission. The problem is set out, and then
11 the fact that he was discharged two weeks ago, do you
12 see, 2/52? He was well for a week and then over the
13 weekend he got increasingly miserable and started
14 vomiting. It goes on to discuss the clinical signs that
15 are being seen at that time.
16 If we go on to page 20, we can see the plan that
17 has been formulated. Do you see:
18 "Plan: Admit ..." then "query, an operative
19 procedure tonight. Discuss with Mr Wisheart theatre
20 tonight."
21 Can you remember the theatre taking place that
22 evening?
23 A. Obviously it did. As I did say, we were rather
24 distraught at the time, to say the least.
25 Q. Because again if we look at MR 1207, now at page 112,
0112
1 and just rotate that and look at the first three lines,
2 we can see that roughly the same timing is set out
3 there, in that at 5.30 there was an emergency admission
4 from the clinic. Then Andrew is rushed off to theatre
5 at 7 o'clock and is back on the ward at 7.30.
6 That seems to show that Andrew was admitted from
7 outpatients at about 5 o'clock/4 o'clock in the
8 afternoon. But does that help you at all on the timing
9 of when he was seen by Mr Wisheart, perhaps before that
10 admission took place?
11 A. Yes. As I said, it was a long time ago, and we were
12 extremely emotional at the time. Both my wife and I, as
13 I say, we both differ on it anyway.
14 Q. So whether it was in the early hours --
15 A. I know we did see Mr Wisheart before Andrew went to
16 theatre, that was the main thing.
17 Q. And he was able to organise immediate surgery for
18 Andrew?
19 A. Yes.
20 Q. Which was successful?
21 A. Yes.
22 Q. Because Andrew then spent not a small period of time in
23 hospital. I think he was eventually discharged on
24 12th June?
25 A. Yes.
0113
1 Q. Just moving on then, and back to your statement, please,
2 page 6, first of all you say from then onwards, that is
3 after the readmission for further operation, Andrew went
4 from strength to strength. Is he well now?
5 A. Very well, thank you.
6 Q. There may still be some need for further surgery, but at
7 the moment --
8 A. At the moment we are hoping not.
9 Q. He is continuing to be seen by Dr Joffe?
10 A. Yes.
11 Q. How regularly does he see Dr Joffe?
12 A. Once a year.
13 Q. What about Mr Wisheart? Have you had any further
14 contact with him since 1985?
15 A. Only through the first year after the operation, and
16 after that it was all under Dr Joffe.
17 Q. You mean followed up by Dr Joffe rather than
18 Mr Wisheart?
19 A. Yes.
20 Q. If we move down the page a little bit further, to see
21 your comments on the split site, you say there that the
22 fact that Andrew was moved around relatively soon after
23 the operation was not ideal, but whether it made any
24 difference to his recovery and to the problems that
25 arose was not something on which you could speculate?
0114
1 A. No.
2 Q. It is not something that anyone commented to you upon at
3 the hospital at the time?
4 A. No, not at all.
5 Q. And you then go on to talk about the fact that the BRI
6 that you knew was the old ward and in fact you were
7 invited back to see the new ward after its later
8 refurbishment?
9 A. Yes.
10 Q. How did that invitation arise?
11 A. It was just that we were coming back fairly regularly
12 with Andrew and knew a lot of the nurses and the Sisters
13 and it was just an informal -- because we happened to be
14 coming back around the time the new ward was going to
15 open, we were just asked if we would like to come and
16 have a look at it.
17 Q. You remember being very impressed with it at the time?
18 A. Yes.
19 Q. What was impressive about it, compared to the old ward?
20 A. New, modern, and it looked extremely nice.
21 Q. Any patients in it at the time?
22 A. No.
23 Q. If we turn over the page, then, you feel generally that
24 you were very well looked after by doctors and staff at
25 the Bristol hospital, and you comment on dedication.
0115
1 You also say you are very conscious that a successful
2 outcome depends on the whole team of medical staff.
3 Who do you mean by the "whole team"?
4 A. Everybody: doctors, nurses, anybody that works in the
5 hospital, really. We just found the way we were
6 treated, we just did not come across anybody that was
7 unpleasant. Whether we were lucky -- I do not think we
8 were -- yes.
9 Q. Are you praising them because they were pleasant, or
10 because of other things, or both?
11 A. Possibly because of the earlier experiences we had had,
12 with only a couple of people, true. You tend to
13 remember the people that are nice to you and the people
14 that are not very nice to you.
15 Q. You say that Mr Wisheart was very reassuring in
16 preparing you for surgery on Andrew, but also that you
17 were confident that he assessed the risks honestly?
18 A. Yes.
19 Q. Why do you say that he assessed the risks very honestly?
20 A. It is very difficult, I suppose, but he was just such
21 a nice man. He just made us feel that he was going to
22 do everything within his power to make sure that Andrew
23 was okay. That is the feeling we got. And we just felt
24 that he was in good hands.
25 Q. You also go on to give an example of a lady from
0116
1 Cornwall who was in the sad condition of being given
2 unfavourable advice on the success of an operation and
3 you went along to that meeting to give her moral
4 support; is that right?
5 A. Yes.
6 Q. Can you remember: you both were there, you both heard
7 the same words uttered by Mr Wisheart. Was there
8 a difference in what the two of you took away from that
9 meeting?
10 A. On several occasions, yes, because the lady concerned
11 was, rightly so, a very emotional Mum at the time and
12 was not handling the news very well at all; did not want
13 to handle the news. So I felt at the time that a lot of
14 the things that were said to her, she just did not want
15 to accept. So we had come out of the meeting and she
16 would say certain things to me, "Oh well, you know,
17 so-and-so is going to be okay", or "This will be okay",
18 and I would say "No, [...], that is not what they
19 said".
20 So this is where I was very lucky to have a wife
21 that I got on very well with and we were able to come
22 out of such a meeting and discuss things together.
23 I felt in [...]'s situation --
24 Q. Perhaps you could avoid mentioning her name again.
25 A. I am sorry, I beg your pardon -- in the lady's situation
0117
1 that she was just hearing what she wanted to hear.
2 Q. Does that lead you to draw any conclusions about the
3 accuracy of memories of these sorts of occasions?
4 A. To a degree. I mean, we are all different. And some
5 people can handle things better than others, I presume.
6 But, yes, I did sort of look at this lady and say to
7 myself, you know, "I wonder what I would have been like
8 if I had not had any support from my wife? Would I have
9 remembered everything that was said?" This particular
10 lady I felt was so wrapped up in the situation she was
11 in, she failed to ask a lot of questions I think she
12 should have asked.
13 Q. Do you think that written information would be helpful
14 in helping to deal with the problems of recollection?
15 A. Very helpful, to anybody.
16 Q. Did you get any from Bristol or the Children's Hospital?
17 A. No, but we were always asked, you know, were we happy
18 with the -- did we understand what was said to us.
19 Whether it was just my wife and I were lucky, we felt
20 quite happy at the time and we said yes, we were, but
21 there was a couple of occasions which we were not sure
22 and we did have to ask again, where, if that had been
23 written down, perhaps it would have been helpful.
24 Q. I have taken you through your statement and asked
25 a number of questions. Is there anything else that you
0118
1 would like to draw to the attention of the Panel about
2 how you and Andrew and your wife were treated at
3 Bristol?
4 A. Well, we have discussed this many times and neither of
5 us feel that we would have or could have been treated
6 any better anywhere. We were extremely happy with the
7 total service that we had. We could not have wished for
8 anything better. I do not know whether I am allowed to
9 say this, but when all this blew up and the media
10 coverage of this, we just could not believe the things
11 they were saying. It just enraged us, because that is
12 not the person that looked after us. This is why
13 I wanted to come today to give my statement, because
14 I cannot believe that the treatment we received, that
15 anybody would not have received the same treatment.
16 MISS GREY: Thank you very much. The Panel may have some
17 questions.
18 THE CHAIRMAN: No, Mr Roberts. We do not have any
19 questions. Mr Sharp?
20 MR SHARP: Possibly just one and a half points.
21 THE CHAIRMAN: Please come forward.
22 RE-EXAMINED BY MR SHARP:
23 Q. Really moving on from what you have just said, you say
24 in the statement, at paragraph 19, that you were
25 impressed by the fact that Mr Wisheart and the other
0119
1 doctors were obviously busy with other things, they made
2 time for you and you felt they were totally committed
3 and dedicated, and you said "this was the feeling
4 expressed to us by other parents."
5 So did you feel that your experience was in any
6 way unique?
7 A. No, not at all.
8 Q. In terms of your perception of how Mr Wisheart and the
9 other doctors were seen by staff, are you able to assist
10 the Panel on that aspect? Did you get any impression as
11 to how they were perceived within the hospital?
12 A. Everybody was thought of -- I mean, this is why we were
13 so happy with Mr Wisheart, because of comments, just
14 casual comments that were made whilst Andrew was in
15 having check-ups and this sort of thing, that, you know,
16 you have somebody looking after you who is highly
17 thought of, and everybody seemed to be so -- I do not
18 know what the word is -- I really do not know what to
19 say. I do not want to bring any names into this but,
20 yes, certain nursing staff that we got very friendly
21 with said they felt that we were very lucky to be having
22 the person doing the operation who was doing it.
23 Q. Just to remind ourselves, you were at the hospital on
24 several different occasions?
25 A. Yes.
0120
1 Q. Did you experience any different perception on the part
2 of the staff or on the part of the parents that you
3 spoke to on any different occasions?
4 A. No, not at all.
5 Q. Thank you very much. Can I move on to the matter when
6 you were sitting in with the lady who had come from
7 Cornwall? You say you were party to this advice because
8 you sat in with her when she discussed her child's
9 problems with Mr Wisheart. How did it come about that
10 you were asked to sit in with her? Or did you merely
11 offer?
12 A. I offered in the end, because I cannot honestly remember
13 the problem they had as a husband and wife, but her
14 husband, who was in Cornwall, could not be up here for
15 much of the time and the lady was staying here
16 full-time, so we just got very, very friendly.
17 Q. But was it anything that was suggested to you by anybody
18 else --
19 A. No.
20 Q. -- was it her asking you?
21 A. No, I just offered purely out of friendship.
22 Q. I want to explore the question of the perception,
23 different people's perceptions, and you have told the
24 Panel, importantly, I suspect, that the value that you
25 found in having your wife with you in meetings, but
0121
1 equally, your wife of course was someone who was also
2 emotionally wound up in the problems that you were
3 facing.
4 You, on the other hand, were not directly involved
5 in this lady's problems from Cornwall?
6 A. No.
7 Q. Would you think that there was any value in having any
8 form of a representative of a parent, a sort of
9 independent representative, on some of these occasions?
10 A. Yes. My wife and I have discussed this many times, and,
11 yes, we feel that would be very good for anybody,
12 because you are so close to it yourself that, yes,
13 sometimes I think you possibly tend to hear what you
14 want to hear. As I say, we were very lucky. I have
15 a large family and a very close family. We had many
16 people to talk to, a good health visitor. If somebody
17 else was in the situation where they were not so lucky
18 to have that support, then maybe, yes, it is possible
19 that they were told things and they did not actually
20 hear it in the way that it was said to them. It is very
21 difficult.
22 MR SHARP: Thank you very much.
23 THE CHAIRMAN: Thank you, Mr Sharp. That is very helpful.
24 Mr Roberts, thank you very much for coming this
25 afternoon. It has been very valuable for us. Miss Grey
0122
1 I am sure, was going to tell you, but I will tell you
2 instead, that if there are other things that come to
3 your mind that you think might help in addition to the
4 statement and what you have told us today, we would of
5 course be grateful to hear from you. But for today,
6 thank you very much for coming and telling us Andrew's
7 story.
8 MR ROBERTS: I was very pleased to, thank you.
9 MISS GREY: Sir, that concludes the evidence for today. As
10 Mr Langstaff announced already, we start tomorrow at
11 9.30 with the evidence of Professor Stirrat, followed by
12 the evidence of Professor Farndon.
13 THE CHAIRMAN: Miss Grey, thank you very much. Good
14 afternoon to you, and good afternoon to everyone else.
15 (3.35 pm)
16 (Adjourned until 9.30 am on Tuesday, 2nd November 1999)
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1 I N D E X
2
3
4 STATEMENT BY THE CHAIRMAN re FUTURE PROCEEDINGS .... 1
5
6 MR LANGSTAFF RE THIS WEEK'S TIMETABLE .............. 3
7
8 MRS SUSAN FRANCOMBE (Affirmed):
9 Examined by MR LANGSTAFF ....................... 5
10
11 STATEMENT BY MR LANGSTAFF re COUNSELLING SERVICE ... 31
12
13 MR ROBERT JOHN BRIGGS (Sworn)
14 Examined by MISS GREY ........................ 34
15 Examined by MR SHARP ......................... 58
16
17 MR TONY COLLINS (Sworn)
18 Examined by MR LANGSTAFF ..................... 62
19
20 MR PAUL ANTHONY ROBERTS (Sworn)
21 Examined by MISS GREY ........................ 83
22 Re-examined by MR SHARP ...................... 119
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Published by the Bristol Royal Infirmary Inquiry, July 2001
© Crown Copyright 2001