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Daily transcripts
Hearing summary
25th November 1999
The Bristol Royal Infirmary Inquiry oral hearings this week centre on
the evidence of Dr Stephen Bolsin, former Consultant Anaesthetist, United Bristol
Healthcare NHS Trust (UBHT) and currently Director of Anaesthesia, Geelong Hospital,
Geelong, Victoria, Australia.
The oral hearings continued today with evidence from Diana Hill, mother
of Jessica who died in 1989 following surgery performed by Mr Janardan Dhasmana,
consultant cardiothoracic surgeon. She recounted her experiences and commented on her
impression of the paediatric cardiac service in Bristol.
Dr Stephen Bolsin continued his evidence today by discussing the
collection of audit data he undertook with Dr Andy Black from Bristol University. He told
the Inquiry about his attempt to bring the data to the attention of the hospital
management via Janet Maher, General Manager of the Directorate of Surgery. He then went on
to discuss a letter sent by the cardiac anaesthetists to their Clinical Director Chris
Monk in 1994, which expressed the groups concerns about the arterial switch programme. Dr
Bolsin went on to comment on audit data collected by himself and presented in October 1984
relating specifically to Mr James Wisheart’s (consultant cardiothoracic surgeon) AV
canal mortality; he said he subsequently discovered that Mr Wisheart had ceased to perform
the procedure earlier the same year. Next he discussed the professional relationships
between the cardiac surgeons and the differences in management style of Mr Wisheart and Mr
Dhasmana. Dr Bolsin then told the Inquiry about his meeting with Dr Peter Doyle, Senior
Medical Officer, Department of Health, in 1994. He described their discussion of the
options for taking forward Dr Bolsin’s concerns. He explained his position at the
meeting held on January 11 1995 to consider the case of Joshua Loveday. He explained his
opposition to the operation taking place and commented on the clinical data presented to
the meeting. He concluded by talking about the subsequent events which led to his
departure to Australia later in 1995.
|
FULL TRANSCRIPT
1 Day 83, Thursday, 25th November 1999
2 (9.40 am)
3 THE CHAIRMAN: Good morning, everyone. Good morning
4 Miss Grey. Do forgive me for keeping you waiting for
5 a few minutes, there were a number of things we were
6 having to deal with. Miss Grey?
7 MISS GREY: Sir, our first witness this morning is the
8 mother of Jessica Hill.
9 MRS DIANA PARKER (FORMERLY HILL), SWORN:
10 Examined by MISS GREY:
11 MISS GREY: You have come here today to tell us of the
12 events surrounding the birth, the life and the death of
13 your daughter, Jessica Hill?
14 A. Yes.
15 Q. You have given us a statement on that matter, have you
16 not?
17 A. Yes.
18 Q. If we look, please, at WIT 263/2, we can see there the
19 first page of your statement; is that right?
20 A. Yes, that is correct.
21 Q. I think at the time of Jessica's life you gave us the
22 statement in the name of Diana Hill because that was
23 your name at that time; is that correct?
24 A. That is correct.
25 Q. Since then you have married Mr Parker?
0001
1 A. Yes.
2 Q. So you are now it follows Mrs Parker but would like to
3 be known this morning as Diana; is that right?
4 A. That is correct.
5 Q. If we turn, please, to the last page of that statement,
6 page 17; is that your signature we see there?
7 A. That is my signature, yes.
8 Q. Are the contents of your statement true to the best of
9 your knowledge and belief?
10 A. They are.
11 Q. You have come here today represented by Mr Trusted; is
12 that right?
13 A. That is right.
14 Q. If we can go back, please, to the first page of your
15 statement, page 1. You talk there, paragraph 2, about
16 the fact that Jessica was born on 10th November 1988?
17 A. That is correct.
18 Q. She was born at the maternity hospital in Exeter?
19 A. Yes.
20 Q. It is right, is it not, that most of the events we are
21 concerned about today took place in late 1988 or the
22 first part, up to August 1989?
23 A. That is correct.
24 Q. It is a little while ago. I think since then you have
25 had the benefit of reading through the medical records;
0002
1 is that right?
2 A. That is correct.
3 Q. In fact as we look through your statement we will find
4 the dates in it are very exact.
5 A. Yes.
6 Q. That is partly because you had the medical records to
7 help you remember things like dates; is that right?
8 A. Yes.
9 Q. How is your memory about these events other than that?
10 A. Because it was 10 years ago I cannot obviously remember
11 everything everybody said to me, but I can remember very
12 specifically certain things because they have just
13 stayed in my mind like it was yesterday. I can remember
14 quite a lot of things that have happened.
15 Q. The things that were particularly important to you at
16 the time, no doubt?
17 A. Particularly important, they have just stayed in my
18 mind, I can just remember them.
19 Q. We can see from your statement that Jessica was quite
20 small at her birth but it took a little while but during
21 the first five days of her life she was diagnosed as
22 having a heart murmur?
23 A. That is correct.
24 Q. You tell us at paragraph 3 that X-rays were taken of her
25 chest but at that stage you were not too worried because
0003
1 you yourself had had a heart murmur when you were
2 a small child?
3 A. Yes.
4 Q. That had closed, had it?
5 A. Yes.
6 Q. That was reassuring, was it, that there could be such
7 things as heart murmurs that closed, healed, without the
8 need for any medical treatment or need to be concerned?
9 A. Yes.
10 Q. Initially anyway Jessica seemed to be a healthy baby; is
11 that right?
12 A. She was, she was a very healthy baby. It was a normal
13 delivery, she had a lovely colour, she was drinking, she
14 was taking liquids, it was never a problem, she slept
15 properly, she was a very happy baby.
16 Q. It took a little while before you first saw Dr Joffe,
17 the first specialist I think concerned with heart
18 defects; is that right?
19 A. I think it was nearly two and a half months later we saw
20 him at the end of January and in between that time I did
21 not think there was anything wrong with Jessica, I did
22 not have any problems with her. She was quite small,
23 but there was no concern, I was not concerned about
24 anything. The health visitor, the midwife never gave me
25 any concern.
0004
1 Q. She seemed to be feeding well, did she, without being
2 breathless at the end of any feeds, for instance?
3 A. She was, she was feeding well. She did become a bit
4 breathless at times which some of my family were
5 recognising, but she was thriving very slowly.
6 Q. If we turn over the page we can see that by the end of
7 January you say she began to look a little bit more blue
8 around the mouth and was slightly more breathless?
9 A. Yes.
10 Q. It was at that stage that you first saw Dr Joffe?
11 A. Yes.
12 Q. He explained to you, did he, that she had a VSD,
13 a ventricular septal defect?
14 A. He did, he explained to me she had a VSD. He said what
15 it was, he said basically it was a hole in the heart but
16 it seemed to be that there was no concern from him about
17 this.
18 Q. If we look briefly at MR 1761/54, just pause it for
19 a moment --?
20 THE CHAIRMAN: We may have to take an address out.
21 MISS GREY: Yes.
22 THE CHAIRMAN: Mrs Hill is familiar with our ways, I do not
23 need to explain what I am doing.
24 MISS GREY: This is a letter which I think is written to the
25 Paediatric Registrar at the hospital where Jessica was
0005
1 born; is that right?
2 A. That is right.
3 Q. We would see over the page that it is Dr Joffe who wrote
4 the letter.
5 A. Yes.
6 Q. Did he see her at the Royal Devon & Exeter?
7 A. He did, yes.
8 Q. He was coming to an outpatient clinic?
9 A. He was.
10 Q. If we scroll down a little we can see the diagnosis at
11 the bottom of the letter, "Signs of a VSD with moderate
12 pulmonary hypertension and a considerable left to right
13 shunt".
14 Were those sorts of terms explained to you at the
15 time?
16 A. I do not remember him saying the pulmonary hypertension,
17 but I do remember him saying the VSD. The one thing
18 I do remember is that he did not relay any concern, it
19 just seemed that it was a VSD, a hole he hoped would
20 close up and that is all it seemed like. I mean
21 I cannot remember him saying anything about pulmonary
22 hypertension to me.
23 Q. We can see again at the bottom of the letter that he
24 says "She may run into further trouble [Jessica] as her
25 pulmonary vascular resistance falls" and then it says he
0006
1 thinks "we should start her on Lasik 4 milligrams per
2 day.
3 Can you remember anyone explaining to you that as
4 Jessica's pulmonary resistance fell over the next few
5 weeks there might be further trouble to be expected?
6 A. It was never mentioned to me.
7 Q. There is then a mention of starting Jessica on Lasik
8 4 milligrams per day; can you remember such medication?
9 A. I remember she was put on Frusemide.
10 Q. Was that possibly at a later stage in March?
11 A. I thought it was at a later stage. I know she was
12 definitely given Frusemide because I remember having to
13 give it to her at that time.
14 Q. I think you say in your statement at this stage that
15 Dr Joffe did not provide you with any medication.
16 Looking at that letter, does that prompt any further
17 recollection?
18 A. I cannot remember. I do remember giving her Frusemide,
19 whether it was in January, February, March, I do not
20 know.
21 Q. If we go back to your witness statement, please,
22 page 3. You have told us about meeting Dr Joffe and
23 then further than that Jessica's state of health
24 remained basically unchanged although she had an episode
25 of diarrhoea and sickness and she had to go into the
0007
1 hospital as a result of that?
2 A. Yes.
3 Q. But nobody linked that to any heart defect?
4 A. No, they just said she had a bad bug and nothing else
5 was thought of it, that is what I thought she had, but
6 she had to be admitted because it just was not going.
7 Q. Fortunately she recovered and she came home again after
8 five days?
9 A. Yes she did.
10 Q. The next time you saw Dr Joffe was in March, was it not?
11 A. It was at the beginning of March I saw him again.
12 I think he did an echocardiogram. He wanted to do an
13 echocardiogram to find out about the VSD. I remember it
14 very vaguely, I remember him doing it but at the time
15 I do not remember him saying anything was really wrong
16 with Jessica, it was just a VSD.
17 Q. Again you were getting reassuring signals, is that
18 correct, or ones that did not cause you any alarm at
19 that stage?
20 A. No alarm at all, I just thought she had a hole in the
21 heart and she was going to be all right. There were no
22 alarm signals at all.
23 Q. Let us look again at Dr Joffe's letter after this
24 appointment. It is at page 53 of MR 1761: a letter
25 9th March; do you have that?
0008
1 A. Yes.
2 Q. Again, it is to Dr Vulliamy, the Paediatric Registrar,
3 and he is talking about Jessica's attendance with you on
4 3rd March for echocardiography and he talks there in the
5 first paragraph about the appearance of the pulmonary
6 artery and turbulent flow. In keeping with excess
7 pulmonary blood flow: was anything said to you about the
8 problems of blood flow to the lungs and the fact there
9 might be difficulties associated with that in the
10 future?
11 A. Nothing was said to me at all. The only thing I can
12 remember was Dr Joffe saying to me that he wanted to
13 wait for the hole to close.
14 Q. And possibly that he wanted her to grow in the meantime?
15 A. He said he wanted her to grow and he was waiting for her
16 lungs to develop.
17 Q. We can see at the bottom of the letter that he was
18 ensuring that Jessica came back for review in two months
19 time and at that point he would decide whether or not
20 there had to be a catheter assessment.
21 A. That is right.
22 Q. Can you remember that discussion?
23 A. I can. He said he wanted to do a catheter just to see
24 how bad I think the VSD was. I remember him going over
25 the catheter procedure because he said to me "There is
0009
1 always a chance that a baby can die having this
2 procedure". That is what put me off having the whole
3 thing done because I thought "Gosh, I am going to lose
4 my baby having this done". It seemed quite a big thing
5 compared to the reasons. I thought there was nothing
6 wrong with her, it seemed like there was nothing wrong
7 with her and they were doing this catheter and she could
8 die having this catheter. That is what he explained.
9 Q. There was a risk attached to the catheter procedure?
10 A. Yes.
11 Q. That was explained to you and which worried you?
12 A. It worried me.
13 Q. Perhaps we might see that because if we look at the next
14 letter from Dr Joffe, page 52, please, we can see that
15 you attended again for review. This I think is
16 26th May; would that be right?
17 A. That is right.
18 Q. Jessica seemed to be going well at that stage?
19 A. She was, she seemed very well. I mean she was a bit
20 blue around the mouth, she was sometimes a bit
21 breathless but generally she was well.
22 Q. What Dr Joffe says at the bottom of the letter is that
23 "It would be advisable to proceed with cardiac
24 catheterisation"; that must have been discussed with you
25 at that meeting?
0010
1 A. Yes.
2 Q. He mentions "some reluctance on the part of mother".
3 Would that be a reflection of the concern that you
4 were having, that the catheterisation itself carried
5 a risk?
6 A. That is right. I was worried that she was going to die
7 having that catheter because he did tell me sometimes
8 that can happen, yes, it made me worried.
9 Q. In any event you agreed to it and the procedure was
10 fixed I think for the 16th June?
11 A. That is right.
12 Q. So they made arrangements to fit in, or at least to not
13 be inconsistent with your holiday a month later?
14 A. I told him we were going on holiday in July. So he made
15 the appointment for 16th June to fit it in before we
16 went.
17 Q. Jessica was taken then to the Children's Hospital for
18 that procedure. That was the first time you had been to
19 the Children's Hospital?
20 A. It was, it was the first time.
21 Q. What were your impressions of it?
22 A. The ward itself seemed very narrow and quite sort of
23 dingy. We were in a room, I cannot remember whether
24 there was another child, but we were just in a little
25 small room with windows. It just seemed quite dark and
0011
1 small and --
2 Q. It is quite an old building; would that be what is
3 reflected in your comments?
4 A. Probably.
5 Q. If we go back to your statement, page 5, please, you
6 set out there your impressions of the BCH and you also
7 mention meeting Mrs Helen Vegoda, a cardiac counsellor?
8 A. That is right.
9 Q. I think in your statement both there and later when you
10 went for Jessica's operation at the BRI you had further
11 dealings with her?
12 A. Yes.
13 Q. The overall impression from your statement was that you
14 personally did not find your dealings with Helen Vegoda
15 particularly helpful to you?
16 A. No, I did not.
17 Q. Would you accept that Mrs Vegoda was probably trying to
18 sense whether or not a parent found her presence helpful
19 or unhelpful?
20 A. I think she was trying to help me but I am surprised she
21 did not feel that I did not want her there because I did
22 -- I was saying it in a way, I did not just tell her to
23 go away because I thought that was not the nice thing to
24 do, but she must have known I just did not want her
25 there, I did not. She would say things that were
0012
1 helpful that were making me worse. I just remember at
2 the time in the hospital I really wished she had not
3 been there. After the hospital, when I saw her after
4 she was helpful.
5 Q. You had I think your aunt with you at least some of the
6 time at the BRI. Is it possible Mrs Vegoda was picking
7 up different signals from your aunt than you, possibly?
8 A. I think that is true.
9 Q. That might have been one reason perhaps why this
10 situation arose?
11 A. Yes.
12 Q. Jessica had her catheterisation and fortunately the risk
13 that you mentioned did not materialise from that?
14 A. No.
15 Q. After that procedure had taken place, did anyone tell
16 you anything about the results immediately before you
17 left the Children's Hospital?
18 A. No, I remember them putting on some X-rays on a screen
19 in the room. Nobody ever said to me she had a bad
20 condition of pulmonary hypertension, nobody ever
21 explained to me because if they had I would have then
22 been prepared for it, they had not, it was just still
23 the same as what I knew before, she had a VSD and that
24 seemed to be what she had and that was it.
25 Q. Diana, you did know of course your child had a heart
0013
1 defect?
2 A. Yes.
3 Q. Did you understand that heart defects can never be
4 described as simple or routine?
5 A. No, I just assumed from what Dr Joffe had said that
6 he was waiting for her hole to close and was waiting for
7 her lungs to develop. If this did not happen, he said
8 possibly she may need an operation in the future. The
9 future -- I came to the conclusion she would probably
10 have an operation when she was 1, 2, but he did not say
11 anything was really wrong with her, he never said she
12 was going to die or anything. I actually thought I had
13 a well baby, although she might need an operation later.
14 Q. So at that stage when you went home from after the
15 cardiac catheterisation you had not yet been told
16 anything further about Jessica's condition?
17 A. No.
18 Q. From your statement it seems the next time you heard
19 anything further was when you saw Mr Dhasmana for the
20 first time?
21 A. That is right, that is the first time I heard the bad
22 news which just left me in total shock and I knew at
23 this point something had gone really wrong.
24 Q. If we scroll down the page, you tell us there in your
25 statement that Mr Dhasmana's first words were, after
0014
1 a brief introduction -- what was the brief introduction?
2 A. He introduced himself, said "Hello", we sat down, I sat
3 down with my mother and he just said to us, he said
4 "There is nothing I can do for her" and he said it
5 quite matter-of-fact and it just was something I was not
6 expecting to hear at all. I thought I was going there
7 to hear him say she would have an operation in a year's
8 time but he just said "There is nothing I can do for
9 her", he said she was inoperable.
10 Q. If we look at the medical records again, going back to
11 1761/47, please, we can see there the account of the
12 joint cardiac surgical and radiological meeting that was
13 obviously held after the cardiac catheterisation.
14 If we skip towards the bottom of the second
15 paragraph we can see that the opinion is there being
16 expressed that the haemodynamic data that has been
17 summarised shows this could be inoperable, but in view
18 of Jessica's age, only 7 months, it was felt she should
19 be given a chance by offering her surgery and therefore
20 she was going to be put on the priority list for repair
21 of VSD, hopefully in August?
22 A. Yes.
23 Q. So by the time you saw Mr Dhasmana, he had put her on
24 the priority list for surgery and appeared to have
25 reached the conclusion in discussion with his colleagues
0015
1 that an operation would be offered given the fact that
2 Jessica should have a chance because she was only
3 7 months old; was that not the impression you got at the
4 meeting then?
5 A. When I saw Mr Dhasmana, after he said there was nothing
6 he could do for her, she is inoperable, and he said --
7 then he just saw how shocked we were. He was shocked at
8 the fact we did not know. It was written all over his
9 face.
10 He then said "Because of her age, 7 months" --
11 which at this time she was not 7 months, she was about
12 8 and a half months, but he kept saying she was 7 months
13 -- he felt he had to give her the chance of operating.
14 He said as time was going on her pulmonary hypertension
15 -- he was the first person to tell me about her
16 pulmonary hypertension, I had never heard about it
17 before. He drew diagrams and he explained to me what
18 was happening and as time was going on he would not be
19 able to perform the surgery. He said to me if another
20 month elapsed he would not be able to do the surgery.
21 So he told me to come in on 16th August and he would
22 perform the operation on the 18th.
23 There was no choice. He then proceeded to say
24 that he was going on holiday that day and Wisheart would
25 be doing the post-operative care. As soon as he said
0016
1 this I thought "No, she is not going to have proper
2 continuity of care". I told him this. I said "I do not
3 want Mr Wisheart doing the post-operative care, I want
4 to have the same surgeon". Everything was telling me,
5 signs were telling me I did not want her to have it done
6 now here. All of a sudden I had this well baby and then
7 suddenly she was going to die, it was like she was just
8 going to die.
9 Q. Because one thing that stood out, is this right from
10 what you have just been saying, was that Mr Dhasmana did
11 not know that you did not realise that Jessica's
12 condition was very serious?
13 A. He did not know and he said, and I remember these words
14 like yesterday: "The surgeons get the worst job of
15 telling the patients".
16 Q. If we look, please, at MR 1761/20. If we scroll down
17 a little to show the date, please. That I think is
18 a record of seeing Mr Dhasmana. It says there "Listed
19 for operation, repair", this is for August. "High risk
20 explained. Mother broke down."
21 That is an indication, is it, of how this news
22 came to you as a shock?
23 A. It was a shock. I just wanted the floor to open and
24 take me away. I had a well baby crawling around on the
25 floor at this time.
0017
1 He then had to test her heart, he had to check her
2 chest, check her heart and do all those things. I could
3 not cope. I was in terrible state, my mother was in
4 a terrible state, we were all in a terrible state, none
5 of us knew, none of us knew that she was this bad.
6 Q. You had seen Mr Dhasmana on 26th. I think your mother
7 had a further discussion with him the next day to find
8 out more?
9 A. She did, because Mr Dhasmana wanted us to make
10 a decision there and then to have the operation. I felt
11 I could not make that decision because part of me was
12 telling me I wanted to take her to America to have this
13 operation because she was the most precious thing,
14 I would have done anything for her. It just did not
15 feel right for her to be having it done there. I cannot
16 explain what it was, I think it was just the shock that
17 I had not been told before, that is what made me feel
18 like that and I thought "No, I am not going to decide
19 today, I want to think about what else I can do".
20 So my mother rang him the next day because she was
21 quite upset how Dhasmana -- he was quite arrogant and
22 blunt, his whole manner, his body language you know was
23 quite blunt and arrogant. So she rang him up the next
24 day asking if there was anywhere else we could take
25 him. He said "No, Bristol in the best place" and then
0018
1 he said "I do not have to operate, you know".
2 Q. When you say Mr Dhasmana was blunt and you say he was
3 arrogant, what do you mean by "arrogant"? Is it perhaps
4 the bluntness that comes across as arrogance?
5 A. I think so. He was very matter-of-fact with
6 everything. He did not relay any sort of compassion.
7 I mean I was in shock, my mother was in shock. It is
8 like, there was no sort of compassion from him at all,
9 it was just very matter-of-fact, "This is what I am
10 doing" -- it almost felt you were lucky to be having
11 this operation, I was lucky to be having this operation
12 on that day.
13 Q. But he appreciated this news was coming as a shock to
14 you because you did not know it before; did he not
15 modify his behaviour or how he was discussing it with
16 you in order to take account of that?
17 A. He did not.
18 Q. Because of the concerns you were feeling and perhaps the
19 difficulty adjusting to this news; would that be fair?
20 A. Yes.
21 Q. You also had a further discussion with Dr Joffe?
22 A. I had a discussion with Joffe about two days later and
23 I remember it because I remember feeling really, really
24 anxious about the whole thing and he then gave me
25 70/80 per cent chance that Jessica would be okay. This
0019
1 was a different statistic to what I had from
2 Mr Dhasmana. Mr Dhasmana had given me 50/50 per cent
3 that she would live so I knew it was like she could
4 die. But Dr Joffe was giving me a 70/80 per cent chance
5 she would live. Even then when I spoke to him it was as
6 if she was going to live with this operation. It seemed
7 like he was not concerned at all.
8 Q. Perhaps we can look at page 37 of the MR. Again if we
9 could redact, please? We can see there that here you
10 are attending to discuss Jessica's operation and he says
11 first that they saw Mr Dhasmana a week ago, I think it
12 must actually have been two days ago, who painted
13 a realistic picture of the risks involved in the
14 procedure.
15 You are said now to have a good idea that the
16 procedure is a high risk one. I think that had come
17 across to you by that time; is that right?
18 A. Yes.
19 Q. Then he goes on to say that "It is likely to be
20 successful in 7 or 8 cases out of 10 but not in the
21 other 2". Does that accord with what you remember about
22 his discussions of the risks?
23 A. Yes, I remember him painting a picture to me that it was
24 going to be quite -- that it was like she was not going
25 to die. I remember him saying to me there was
0020
1 a 70/80 per cent chance she was going to be okay because
2 automatically I thought -- it made me feel better
3 actually when he said that because I thought perhaps she
4 is going to be alive. I wanted somebody to tell me she
5 was going to live and he was doing that.
6 Q. So one person had said "virtually inoperable" but the
7 next person was saying at least that there was a chance?
8 A. There was a chance.
9 Q. That perhaps at least in 7 or 8 cases a child would
10 live?
11 A. Yes.
12 Q. He goes on to say though that you were "aware that
13 denying Jessica this operation would result in Jessica
14 having a markedly shortened life-span due to pulmonary
15 vascular obstructive disease". That was the other side
16 of the coin that had been explained to you by now, was
17 it?
18 A. Yes.
19 Q. On the basis of that you decided to have the operation?
20 A. I did. Things worried me like, I know she was getting
21 older, it was getting worse and I just remember fixing
22 this month in my head, Dhasmana saying she was 7 months
23 and in actual fact she was not 7 months, she was 8 and
24 a half, so by that time she was getting older anyway and
25 then it was another month later she had the operation,
0021
1 so by the time she had the operation she was 9 and
2 a half months. Surely if she is inoperable she is not
3 going to live because "inoperable" means she cannot
4 live.
5 Q. If we went back to the earlier medical records I think
6 what was being said was there might be a chance but that
7 the outcome was always uncertain.
8 In any event, Jessica was admitted to the BRI on
9 16th August?
10 A. Yes.
11 Q. You had I think from your statement a number of
12 discussions with people who again emphasised that this
13 was a risky procedure, you did not necessarily have to
14 go through with it?
15 A. That is right. Several people -- I mean I cannot
16 specifically remember how many people said it but I know
17 a couple of times that was said. That is another thing
18 I can remember like yesterday that was said to me.
19 I did not actually want -- really something was telling
20 me I did not want her to have it done here but the fact
21 is I did not have much time to take her anywhere else
22 although I wanted to. It was like I was given that date
23 for three weeks later. She was going to have it --
24 Dhasmana was going to do it, Wisheart was going to do
25 the post-operative care and there was no other date
0022
1 given to her.
2 Q. By that time presumably you were aware that the
3 operation had to be carried out as a matter of urgency?
4 A. Yes.
5 Q. You describe in your statement a conversation with
6 a house officer and a nurse and also Dr Bolsin making
7 this same point; is that right?
8 A. Yes, my aunt who was with me remembers it as well.
9 Q. Ultimately, however, you signed the consent form and
10 the operation went ahead?
11 A. Yes. A Dr Parry got me to sign the consent form and
12 I signed it.
13 Q. He again explained the nature of the operation to you?
14 A. He did. People were explaining to me what was going to
15 happen, you know, there is no doubt about that. But you
16 could just tell from some people, some of the medical
17 staff were telling me "You could pull out if you want
18 to". It almost felt as if she was not going to live.
19 I do not know --
20 Q. Could that be a reflection of the fact if they knew it
21 was a difficult operation they were worried about the
22 outcome?
23 A. It could well have been, it could well have been.
24 Q. But for you that perhaps made it more difficult because
25 your concern was what choice did you have for Jessica?
0023
1 A. It was very difficult because I had a baby who was very
2 well. She was by this time -- well, she was standing
3 up, she was babbling, she was crawling. I did not have
4 an ill baby on my hands so it was very hard to watch
5 this well baby that they were saying was inoperable who
6 was going to die, who was ill. I could not believe it.
7 Q. Jessica had the operation and initially things seemed to
8 go reasonably well, that was the news you had after the
9 operation?
10 A. Yes, I think they took longer than they expected because
11 we were told to ring back at a certain time, I think it
12 was 2.00 and she still was not back. So about 4.00 me
13 and my aunt went back anyway because I just wanted to be
14 as close as I could to be near her.
15 Q. If we go on to your statement, please, page 12, we can
16 see, if we go down, please, to paragraph 32 that not
17 surprisingly the four days after the operation were very
18 difficult for you?
19 A. They were. They were dreadful. You just lived second
20 by second, watching your child, just hoping that they
21 will live. It was just awful. I felt alone. All
22 I could do was pray, that is the only hope I had left,
23 just to pray because I just -- it seemed like my baby
24 was taken from me. There was nothing I could do.
25 Q. You say there in the statement that you do not believe
0024
1 Mr Wisheart ever visited Jessica?
2 A. I never met him, although I cannot ever remember him --
3 this is what worried me initially. I just knew --
4 I just wanted the same surgeon to be there to have the
5 continuity of care for Jessica and I can never ever
6 remember -- I was never introduced to Mr Wisheart,
7 I know that.
8 Q. He might have visited Jessica at times you were not
9 there?
10 A. He might have done but I can never ever remember
11 seeing him.
12 Q. Sadly on 22nd August Jessica suffered a cardiac arrest?
13 A. She did.
14 Q. I think her lung collapsed; is that right?
15 A. She did, it was a dreadful night. They tried to
16 resuscitate her and they could not. I always had this
17 feeling that they never had the right drugs for her
18 because I always remember Dhasmana saying to me that she
19 was a very -- when we went to see him on that day of the
20 28th I always remember him saying to me she was a very
21 rare case -- she was a very rare case, which shocked me
22 because all I knew she had a VSD, she was not a rare
23 case to me, to what I had thought. He was now saying
24 that.
25 Q. You saw Mr Dhasmana then after Jessica had died in order
0025
1 to find out a little bit more about what had happened?
2 A. No, Mr Dhasmana was not there when she died, he was on
3 holiday, he had been on holiday --
4 Q. I meant in a subsequent appointment; it is my fault for
5 not putting that properly.
6 A. When he came back from holiday my sister and I went to
7 see him because I felt nothing had been done correct for
8 her, I had this feeling nothing had been done properly
9 for her. We went to see him and he said "You know the
10 critical bit was going to be after the operation" and he
11 was even then very matter-of-fact, very blunt. It was
12 as if he was watching the clock to get me out of the
13 room.
14 Q. If we look at your statement, page 13, you describe
15 there the meeting with Mr Dhasmana. Mr Dhasmana tells
16 us about the operation. You say there that he remained
17 arrogant. In talking to us, again you have used the
18 words "blunt" and "matter of fact". Is that what you
19 were finding distressing from him?
20 A. That is what I found. He was always very blunt. There
21 was not a compassion to him, it was a very blunt man.
22 He appeared a very sort of blunt, matter-of-fact man
23 which I found uneasy because I was trying to get
24 questions out but I felt I should not be asking those
25 questions. It just felt like that I mean --
0026
1 Q. Because you were feeling rushed; is that right?
2 A. I was feeling rushed and, yes, and it was just his
3 bodily manner, everything, I just felt I should not be
4 asking these questions.
5 Q. Mr Dhasmana explained your daughter's death by saying
6 that her lungs gave up?
7 A. He did. It was not the heart, it was the lungs.
8 Q. So it was related to the problem of pulmonary vascular
9 disease; did you understand that?
10 A. Yes.
11 Q. You just told us he said Jessica was a rare case?
12 A. He did, he said it was a very rare case, which confused
13 me because I was told she had a VSD.
14 Q. Did he explain why she was rare?
15 A. No. I mean he drew diagrams, when we saw him he went
16 into depth about the pulmonary hypertension, but he was
17 saying she was a very rare case which I could not quite
18 understand.
19 Q. Did he not perhaps link it to the speed with which the
20 pulmonary vascular disease had developed?
21 A. He may have done but it did not come across like that.
22 It came across that she had a very rare thing that no
23 other baby had.
24 Q. Which is why you talked about drugs, is that right, or
25 whether they had had the drugs to manage it?
0027
1 A. This is right. I then thought "They are not going to
2 have the right drugs then" and it came across that they
3 would not have done. I do not know, it seemed very --
4 not quite right. I mean at the time when Jessica was on
5 ITU two other babies died as well and I remember that to
6 this day, two other babies died and I remember thinking
7 "Why are these babies dying?" and I asked a nurse and
8 she just said it was a bad patch and that is something
9 I can remember.
10 Q. Did you feel your concerns had been answered then by the
11 meeting with Mr Dhasmana?
12 A. Not really, not really, no. I mean when me and my
13 sister left him we felt really uneasy, we felt we did
14 not really know anything more than we knew. I wanted
15 really to see somebody to tell me something proper.
16 Because Mr Wisheart had never seen us after Jessica
17 died, I think we saw a Registrar who just went over
18 things. I wanted to see somebody who I thought knew
19 what they were talking about. That is why we went back,
20 we were just uneasy with what happened to Jessica.
21 Q. I think you say in your statement you wondered if
22 perhaps it was Mr Wisheart you should have seen because
23 he had been concerned with the post-operative period?
24 A. Yes, and I never saw him.
25 Q. You did not try and make another appointment?
0028
1 A. To see Mr Wisheart?
2 Q. Yes.
3 A. No.
4 Q. By then you did not want to see him. Why not?
5 A. Because when Jessica died it was like we were told to
6 get our bits, it was all a bit of a rush because she
7 died at 3.00. We were then at 6.00 told to get -- I was
8 trying to keep alive basically because I did not want to
9 be here in this world any more -- at 6.00 we were told
10 to get our stuff, we were told to get Jessica's stuff
11 and so we collected our stuff from the room, we
12 collected Jessica's stuff from the room. The thought of
13 going to see Mr Wisheart or somebody just did not cross
14 my mind. Helen Vegoda came to see us.
15 Q. I think the fault is mine, Diana, for putting the
16 question badly: you had gone to see Mr Dhasmana and you
17 had not really been helped by that, you were still
18 uncertain you say about why this had happened and you
19 wondered, you say in your statement, whether you should
20 have seen Mr Wisheart; but you did not make another
21 appointment to go back and see Mr Wisheart?
22 A. No, I did not.
23 Q. Because you could not face going back and seeing another
24 person, or why?
25 A. I think it is because I never met him. I never met
0029
1 Mr Wisheart, therefore I thought Mr Dhasmana would be
2 the one to explain and tell me what happened. But
3 really when I think of it, Mr Dhasmana was not there
4 either, so who would be the best person to tell me.
5 Q. Looking on again events in time, you say in your
6 statement that on 1st March 1994 you gave birth to
7 a little boy?
8 A. That is right.
9 Q. I think this time you heard concerns that he had a heart
10 murmur?
11 A. Yes, that is right, yes.
12 Q. You were concerned now about continuing treatment at the
13 Royal Infirmary or in Bristol?
14 A. Yes, I just thought: "No, do not let me have another
15 baby with a heart problem", that is all I kept thinking,
16 but he looked well as well, he was --
17 Q. Initially I think you were again put under the care of
18 Dr Joffe?
19 A. That is right.
20 Q. And the Children's Hospital?
21 A. That is right.
22 Q. And you were referred to Dr Martin?
23 A. When James was 1 year old we went to see Dr Joffe
24 first. Dr Joffe did an echocardiogram and said that
25 James had pulmonary stenosis but he said there was
0030
1 nothing really to worry about -- this view again that
2 nothing was wrong with James came across. My husband
3 was with me at the time and we both felt there was no
4 concern about James, but he did say "at 15 we will check
5 him again and he may need an operation" but at that time
6 he just had pulmonary stenosis, there was nothing wrong
7 with James, he was fine, he would be able to run around
8 and play football and everything.
9 Q. If we go on, please, to page 15 of your statement we can
10 see that you were eventually referred to Dr Martin --
11 A. That is right.
12 Q. -- this is the three-year check, whose initial reaction
13 was again that there was not anything to worry about?
14 A. When we arrived in the room and we sat down, he had no
15 notes or any details of James whatsoever in front of
16 him. He did not even know why we were there. He
17 actually asked us why we were there. With that we
18 explained that our GP had sent James up because he had
19 quite a loud heart murmur and the GP was insistent that
20 James went.
21 James had just had an ECG done and we asked
22 Dr Martin to look at it. We had to actually ask him to
23 look at it. He looked at it and he said: "It is a bit
24 irregular" -- this was only last year, so I can remember
25 very well -- and he said "there is nothing really wrong
0031
1 with this ECG". With that I just then had to explain
2 about Jessica because I thought "no, I am not going to
3 have another child go through the same thing and let it
4 go too long". I do not know, instincts were telling me
5 this.
6 So I then had to explain about Jessica, I could
7 not see the walls, I was in a dreadful dreadful state.
8 With that his attitude changed. He then said: "We
9 better do an echocardiogram". Half an hour later he did
10 the echocardiogram and he said "yes, James has pulmonary
11 stenosis which is quite severe, he will need an
12 operation soon". I thought "what if we had not been
13 insistent, what would he have done, sent us home?"
14 After that I was asking him constant questions
15 because I could not believe it and I remember saying to
16 him "what were the risks of this operation" and he said
17 "James has more of a risk of falling off that chair
18 than this operation" and I thought with that that I just
19 cannot let them touch him.
20 Q. I think at that stage you insisted that James should be
21 referred to Birmingham?
22 A. After that I just -- we both wanted to refer him
23 somewhere where we had confidence.
24 Q. And you did succeed after some correspondence in getting
25 that referral made?
0032
1 A. We had trouble. My husband wrote a letter to the GP.
2 The GP wrote to Dr Martin. Dr Martin said there was no
3 reason why we should be going to Birmingham, he could do
4 the operation fine. Both of us still did not want James
5 to have this operation there, signals were telling us
6 not to have it done. We then in the end had to get
7 Hugh Ross to get us the referral.
8 Q. If we turn over the page we can see your impressions of
9 Birmingham when James was sent there. You obviously
10 formed a very favourable impression of Birmingham, is
11 that right?
12 A. It was just a well organised hospital.
13 Q. It is also a brand new Children's Hospital, is it not?
14 A. Yes, it is; it is brand new.
15 Q. That must have made quite a big difference in the
16 impression you got of the environment there?
17 A. It did. The thing that came across as well was that
18 nurses, there seemed to be qualified paediatric nurses
19 about everywhere asking you questions, helping you.
20 When I was with Jessica in the BRI there was not that,
21 it did not seem there was that. But in the children's
22 hospital there were, there were lots of nurses round
23 willing to help, explaining -- it just seemed a very
24 well organised hospital and I know it is a new hospital,
25 but it just seemed very well organised and I just think
0033
1 "thank God I sent James there".
2 Q. It is also fair to say, is it not, that your main
3 experience of the Children's Hospital and the BRI with
4 Jessica had been five years earlier?
5 A. Yes.
6 Q. Presumably you might expect there to be something of
7 a change --
8 A. Yes.
9 Q. -- in five years between the two hospitals?
10 A. Yes, another point I wanted to say was that when we did
11 get our referral eventually to Birmingham we did see
12 a cardiologist there and he was the one who actually
13 said to us: "James needs this operation now" -- this is
14 the first person to tell us this -- he said "if James
15 does not have the operation very soon he will die in his
16 early 20s". This was the first person to tell me. He
17 was concerned. He said "we need to put James on the
18 waiting list now", and he did so. Had nobody told me
19 that at Bristol, had it been left, I would probably have
20 lost my son, I do not know.
21 Q. Just to press you for a moment: Dr Martin when he did
22 perform the echo did tell you that James's condition was
23 so severe that he needed an operation quite soon?
24 A. He did, I agree, Dr Martin did say that. It is just the
25 fact that he did not know why we were there initially,
0034
1 he could not see the reason with the ECG why there was
2 anything wrong and I think that is what made us
3 concerned, that is what actually made us go to
4 Birmingham.
5 Q. You say that, happily, this part of your story has
6 turned out well and James is well and continuing to
7 thrive; is that right?
8 A. That is right.
9 Q. If we scroll down a little further on this page of the
10 statement you learned recently about the issue of organ
11 retention?
12 A. That is right.
13 Q. And that sadly the BRI had retained Jessica's heart and
14 parts of it?
15 A. That is right, yes.
16 Q. I think now you have buried Jessica's heart; you have
17 reclaimed it and buried it, is that right?
18 A. Yes, we have buried it. It was just horrible news to
19 learn because you then have to go through another
20 burial, you know -- basically they did not tell you they
21 had her organs.
22 Q. I think you knew at the time of Jessica's death that
23 a postmortem would have to be carried out?
24 A. I can never remember them saying that, that is me,
25 I just cannot remember them saying that. All I can
0035
1 remember, they asked me if I wanted to give her organs
2 for organ donation, I remember that very well and
3 I remember saying "no" because she was in such a mess
4 anyway I did not want them to do anything else; I just
5 wanted to put her at rest, I remember that. The
6 postmortem bit I cannot remember.
7 Q. I think you say in your statement that you had no idea
8 that a postmortem would take place. Did the discussion
9 about organ donation not include any discussion about
10 the need for a postmortem?
11 A. I cannot remember. The word "postmortem", I just cannot
12 remember.
13 Q. You describe a process of leaving the hospital obviously
14 in a very short space of time and in very considerable
15 distress obviously. If anyone had mentioned the need
16 for a postmortem, is it possible that it might have
17 slipped your mind?
18 A. I do not think so because at the time my aunt was there
19 with me, my aunt was there with me and she was pretty
20 much together about it all and she cannot remember
21 either.
22 Q. Or the word 'autopsy' perhaps, do you remember that
23 being used?
24 A. No.
25 Q. Eventually at any rate when the news about retention
0036
1 came, it came as a considerable shock?
2 A. It did. I actually believed they would never have her
3 heart. I thought, "no, they cannot possibly have kept
4 her heart", so it was a shock because I had thought they
5 could never have done that.
6 Q. Diana, I have asked you a number of questions dealing
7 with the whole series of events of Jessica's life and
8 also that of James; is there anything else that you
9 would like to add in telling this to the Inquiry?
10 A. I have something I would like to add that were written
11 down in my own words, I thought if I did not write it
12 down I might forget what I had to say.
13 The loss of my daughter has changed me and my life
14 forever. When your child dies a part of you dies too.
15 When I learned there were problems with the Bristol
16 hospital and subsequently discovered that my child need
17 not have died I was devastated. I have campaigned with
18 other families for the Inquiry we have today for nearly
19 four years and I hope to find the answers to why my
20 daughter died, for those responsible to answer for their
21 actions.
22 I hope the Inquiry will ask the questions on
23 behalf of my daughter of Mr Joffe and Mr Dhasmana as she
24 cannot ask them herself. For all the families of the
25 children who died or who were injured this Inquiry is
0037
1 their last chance of getting answers to those
2 questions. I beg you to allow them not to go
3 unanswered.
4 This Inquiry has to recommend changes that will
5 never allow tragedies like Bristol to happen again. The
6 principles of self regulation upon which, even now, many
7 doctors cling to as if they were a God given right have
8 failed and the Bristol story is about that failure.
9 We have been hearing this week from Dr Bolsin and
10 about how over a number of years he tried the mechanisms
11 of self regulation to prevent further deaths and, as we
12 have heard, it was over 5 years before effective action
13 was taken and the high toll in terms of children's
14 deaths and injury were stopped. Without Dr Bolsin
15 speaking out, the deaths would have continued much much
16 longer and many more families would have suffered as
17 I and others have done.
18 The thing that concerns me most now is that many
19 of the clinicians involved in this story are still
20 working at the Bristol hospital. Some of them have even
21 refused to make statements to the Inquiry and one of the
22 cardiologists has even been forced to give evidence
23 despite the UBHT's assurances that it would fully
24 cooperate with the Inquiry.
25 If these people have the interests of patients at
0038
1 heart and not their own privileged positions, why are
2 they so reluctant to get to the bottom of the problems;
3 why did it take so long before anyone was willing to
4 act? If they have done nothing wrong and have nothing
5 to hide, why are they reluctant for the truth to come
6 out now?
7 I wanted to thank you Professor Kennedy for
8 allowing me to tell my daughter's story, and also for
9 the hope that those interested in family health will
10 reflect on Bristol and learn about what it takes to be
11 a good clinician and to practice medicine in an
12 honourable and safe way for the benefit of all our
13 patients.
14 THE CHAIRMAN: Mrs Hill, I think it is we who should thank
15 you for coming and telling Jessica's story. Again we
16 are much helped by what you were able to tell us.
17 It is important for me just to say one thing: to
18 remind you of what the Inquiry can and what it cannot
19 do. As regards what it can do, what its terms of
20 reference are, I will give you the assurance it will do
21 its very best to meet its terms of reference.
22 Mr Trusted?
23 MR TRUSTED: I have no questions, sir.
24 THE CHAIRMAN: Mrs Hill, thank you very much indeed again.
25 MISS GREY: Sir, may I suggest we break now for 10 or 15
0039
1 minutes until resuming with the evidence of Dr Bolsin?
2 THE CHAIRMAN: Shall we say 10 minutes then until 10.50.
3 Thank you.
4 (10.40 am)
5 (Adjourned until 10.50 am)
6 (10.55 am)
7 DR STEPHEN BOLSIN (RECALLED):
8 EXAMINED BY MR LANGSTAFF (CONTINUED):
9 THE CHAIRMAN: Good morning, Dr Bolsin.
10 DR BOLSIN: Good morning.
11 MR LANGSTAFF: Good morning, Dr Bolsin.
12 DR BOLSIN: Good morning.
13 MR LANGSTAFF: Can I tidy up one or two loose ends from the
14 last couple of days before we move forward and talk
15 about what was happening in the middle of 1994?
16 A. Yes.
17 Q. The first matter was, you remember we discussed words
18 such as "rocking the boat", "troublesome" and whether
19 they were ever said, whether you had ever mentioned
20 those before?
21 A. Yes.
22 Q. Is this the position: that you had never actually used
23 those words before; you had not heard them said of
24 yourself, but that was how you perhaps saw yourself?
25 A. Yes, I think that is a correct summary.
0040
1 Q. Can I tidy up, again, questions of timing and events?
2 You have been happy to concede, if "concession" is the
3 right word, on a number of occasions that your dating
4 and sequencing is not all that it might be?
5 A. Yes, I apologise for that.
6 Q. We have to take it as we find it, and what I want is
7 your best help, really, to sort one or two details out.
8 A. Yes.
9 Q. Do I also have a correct impression that the process of
10 data collection was not a process of your simply saying,
11 "Well, let us go and do this, get the data, analyse it
12 and then present the results", but that along the way,
13 sometimes, some of the workings became known to others
14 and you discussed them with others?
15 A. Yes.
16 Q. So that when the Inquiry has to look at the evidence of
17 others, we may see, as it were, snapshots of something
18 which is actually a moving and developing process?
19 A. Very much so. It was a continuous process.
20 Q. So although, yesterday, you and I identified the data
21 which you produced in the not very well tabulated and
22 the better tabulated form, in fact there may have been
23 drafts or workings which people became aware of before
24 the final cleaned-up, well-presented product was
25 produced?
0041
1 A. Yes. That is certainly possible.
2 Q. One of the matters which I want to see clarified, if
3 I can, are the timings of meetings that there were with
4 Professor Prys Roberts. You say, or he indicates, that
5 there had been a meeting between you and he sometime in
6 1989 when you had expressed generalised concerns?
7 A. Yes.
8 Q. And later on, when you were going to, or thinking of
9 going to Oxford, you spoke to him again?
10 A. Yes.
11 Q. Had there been anything between those two, any contact,
12 when you talked to him about concerns?
13 A. It is possible, but I do not think I could confirm it to
14 you.
15 Q. What I particularly want to tie down in time, if I can,
16 is when his meeting with Dr Roylance took place -- this
17 is the meeting at which you remember he gave evidence at
18 the GMC?
19 A. Yes.
20 Q. And one of the charges in respect of Dr Roylance was
21 that there had been meetings in February and March of
22 1992, at which Dr Prys Roberts had expressed various
23 concerns to him?
24 A. Yes.
25 Q. If it had been early 1992, can we agree that
0042
1 Professor Prys Roberts would not, by then, have seen any
2 finished product of your data collection?
3 A. No. No, he would not.
4 Q. Because again -- if I can see if I can tidy this up --
5 we are told by Dr Black in his statement that his
6 daughter worked during the summer vacation of 1992,
7 producing or collating the data.
8 A. Yes.
9 Q. While I deal with that, one of the disputes of which
10 you have been aware from reading the rebuttal statements
11 to your statement is a query by Mr Wisheart over the
12 accuracy of the cross-clamp times and circulatory arrest
13 times that you ultimately reported?
14 A. Yes.
15 Q. His case is that the times that you end up with are
16 double, roughly -- that is my own word, not his -- but
17 double roughly the figures that he would accept.
18 A. Yes.
19 Q. I am not going to spend time arguing about particular
20 figures here and now, because it is not the appropriate
21 forum and the appropriate way for the Inquiry to
22 investigate that discrepancy, but what I think I can ask
23 is really the reliability of information transfer from
24 basic records into the data that you had, and this is no
25 reflection upon you, it is simply asking about the
0043
1 process.
2 A. Yes.
3 Q. Do you know whether Dr Black's daughter had any
4 particular training or expertise in the process of data
5 collection?
6 A. I would not be able to answer that. No, I do not know,
7 I am afraid.
8 Q. Did you, or Dr Black, as you recall it, carry out any
9 check to ensure that the data transfer had been properly
10 done?
11 A. No. As I remember it, the cross-clamp and bypass times
12 would have been data that was already tabulated by the
13 perfusionists and would have come straight from the
14 perfusion computer from the period -- I think their
15 computer started to collect data in October 1990.
16 Q. That was the sheet we looked at?
17 A. It would be a sheet at that time, yes.
18 Q. So as far as you recollect, that is where the times came
19 from. If they have got it wrong, it is wrong. If they
20 have got it right, that basic data will be right,
21 whatever the analysis might be?
22 A. Yes. I am sorry to take you back, you were asking about
23 Professor Prys Roberts and meetings, and I think it is
24 likely that I had more than one meeting with Professor
25 Prys Roberts in terms of expressing concerns, because at
0044
1 the time in May when I asked for the reference, one of
2 his phrases, which still rings in my minds, was "And
3 then you will have the data and you will just have to
4 shut up or put up", implying I had repeatedly expressed
5 concerns and if the data did not support my concerns, he
6 would not have to have me whingeing in his office, as it
7 were.
8 Q. What Professor Prys Roberts says -- we saw his statement
9 and the dates that he has put on meetings appear; this
10 is a comment you can accept or reject -- is that there
11 were a number of meetings fitting in with the number of,
12 or recollection of meetings generally as you describe in
13 your statement, only the dates are actually earlier than
14 you would have them?
15 A. Yes. I think that the --
16 Q. Is there a dating issue here?
17 A. I think that Professor Prys Roberts when he talks about
18 the meetings in March 1992, may be talking about my
19 expression of unofficial concerns, unofficially
20 documented concerns. There was also another meeting in
21 1993 which was the meeting at which Andy Black and
22 I presented our data formally to Professor Prys Roberts,
23 so there is a discrepancy in dates, but it may well have
24 been March 1993. One meeting was unofficial concerns;
25 the other one was formally documented concerns.
0045
1 Q. Can we just have a look at Professor Prys Roberts'
2 statement, please, at WIT 382/2?
3 Can we scroll down? He is talking about
4 discussions that he had with you, you show him
5 preliminary data. This would have been before you got
6 to the stage of having anything like the finished
7 product, as I call it?
8 A. Yes, this would be logbook data and whatever else was
9 available.
10 Q. Then we scroll down to N4. Can we scroll down, please:
11 "Early in 1992, Dr Bolsin again expressed ...
12 continuing concern", especially as his written approach
13 to Dr John Roylance had been rebuffed, the 1992 letter,
14 I think. "I told Dr Bolsin that I would speak
15 informally to Dr Roylance."
16 He describes meeting with Dr Roylance on two
17 occasions in 1992 and he has dated them.
18 A. Yes.
19 Q. So if he has gone through the process one would expect
20 of picking up those dates from diaries or logs, those
21 dates are probably right?
22 A. Yes.
23 Q. He deals with those occasions, explained Dr Bolsin had
24 been collecting data and expressed concerns and he has
25 talked about his meeting with Dr Roylance. You were not
0046
1 there and you cannot comment. We have to rely upon his
2 evidence and that of Dr Roylance to resolve that?
3 A. Yes.
4 Q. But if he is right about that date in early 1992, the
5 data he would have seen corresponds with your
6 recollection?
7 A. Yes.
8 Q. This is preliminary data?
9 A. Yes.
10 Q. That would fit with the fact that it was not until the
11 summer that Susannah Black -- Dr Black's daughter's
12 name -- began to work on the data and collect it?
13 A. Yes.
14 Q. In terms of the analysis that took place of that data,
15 there had to be a classification, an input, in order to
16 understand how you were going to classify the
17 operations?
18 A. Yes.
19 Q. Did that come from Dr Hayes?
20 A. No. I think that was me looking at the operative record
21 from the theatre book and the perfusion record.
22 Q. What Dr Black says -- can we look at WIT 326/15 --
23 paragraph 4.3.5:
24 "There were 69 different descriptive titles for
25 the operations ... They needed to be classified ...
0047
1 into the categories used by the paediatric cardiac
2 surgical registry."
3 That would be for comparison purposes?
4 A. Yes.
5 Q. "Finding a suitably qualified independent person to do
6 this took Dr Bolsin some time".
7 A. Yes.
8 Q. He says the classification was not undertaken until
9 1993 and was carried out by Dr Alison Hayes?
10 A. Yes.
11 Q. He describes her as someone relatively recently
12 appointed in the UBHT?
13 A. Yes.
14 Q. So is what he says there correct, as you recall it?
15 A. Yes, I think so.
16 Q. What we have been told by Dr Hayes -- we understand
17 from Dr Hayes' evidence to the General Medical Council,
18 GMC 14/113, is in her statement, she was appointed in
19 the summer of 1993 and commenced in post on 1st October
20 1993, so if your recollection and Dr Black's is right
21 that she helped to categorise the operations, the 69
22 operations so they fitted with the register, that must
23 have taken place after appointment in the summer of
24 1993.
25 A. Yes.
0048
1 Q. And her recollection, when she was asked about it --
2 I do not have a transcript to show you but I will just
3 read out what my record is of what she said to the GMC.
4 Asked by Mr Henderson, she said:
5 "I was actually asked by Dr Bolsin, because
6 Dr Bolsin and Dr Black were working together on the
7 categorisation.
8 Question: Can you help us, please, as to what you
9 did then? Let us start with when you did it. Can you
10 remember the time-frame involved?
11 Answer: I do not really remember.
12 Question: Had you taken up your position as
13 a consultant at that stage?
14 Answer: Yes. I think it probably was within the
15 first month or two of my consultancy, but I could not
16 give you an actual date.
17 Question: That would put it as being at late
18 1993?
19 Answer: Yes."
20 1st October 1993 is probably a date that she would
21 remember as anyone who is appointed to a post tends to
22 remember the date they started?
23 A. Yes.
24 Q. So is she probably right that it was round about October
25 1993, that she did or completed the work of
0049
1 categorisation for your -- what I have called the
2 "finished product" analysis?
3 A. Yes, I am sure that would be right.
4 Q. Can I take you back to your own statement? It is
5 WIT 80/113, line 15:
6 "When the data was initially produced, Dr Black
7 and I presented the results to Professor Prys Roberts."
8 I think his recollection is that Dr Black showed
9 him the data.
10 A. Yes.
11 Q. May that be right?
12 A. I thought I was in the room, but I certainly was not
13 there for the whole of the conversation.
14 Q. If we go down to line 36, there is a recollection there
15 of something that Dr Black told you about a meeting
16 which other people had had. If you just read it to
17 yourself.
18 A. Yes.
19 Q. You cannot, of course, give evidence about what was said
20 in conversations that you were not party to.
21 A. No.
22 Q. This was something reported to you, and you had to rely
23 upon what Dr Black was telling you?
24 A. Yes, absolutely.
25 Q. Essentially really for the wider audience, what we have
0050
1 in the Inquiry is, we are told by Professor Prys Roberts
2 that he did raise concerns with Dr Roylance, as you have
3 seen in 1992, with that data?
4 A. Yes.
5 Q. He does not tell us that he had any later raising of
6 concerns as might be suggested by this statement here?
7 A. Yes.
8 Q. And we do not have any evidence from Dr Black that he
9 was told by Professor Prys Roberts that he had done it
10 and reported it to you?
11 A. Yes.
12 Q. So might it be the case -- again, it is purely
13 a question of timing -- that what you and Dr Black may
14 have been talking about in the conversation was
15 something that was reported to you as having happened in
16 March 1992, when Professor Prys Roberts first raised the
17 concerns with Dr Roylance?
18 A. I do not think so. It was a much more immediate thing
19 than that. Andy and I had gone into see Professor Prys
20 Roberts with the data. I had to leave, I think to do
21 a list or something, and I left Andy and Cedric looking
22 at the data. When I came back and spoke to Andy, I said
23 "What did he think? What did he do?" and he said he
24 now believed that there was firm evidence, and he picked
25 up the phone and spoke to John Roylance immediately.
0051
1 That was at the end of that meeting, but that is what
2 Andy told me, and --
3 Q. And that is all you can say?
4 A. Yes.
5 Q. If we want to take that any further, we will have to
6 take that up, I think, with others.
7 A. Yes.
8 Q. Can I then come back to the chronology? I think
9 helpfully, this morning, we have established that
10 probably the finished product would have been available
11 sometime in the autumn of 1993?
12 A. Yes.
13 Q. So certainly that would fit in with what I was
14 suggesting to you yesterday that Professor Angelini told
15 us that he saw it round about November 1993?
16 A. Yes, and Dr Monk as well, in corroboration.
17 Q. Let us move forward to the April of 1994. We have
18 dealt, I think, with the Bistro 21 dinner.
19 A. Could I add one other thing about the Bistro 21 dinner
20 which perhaps did not emerge yesterday? The other
21 possibility and I think this was a very real
22 possibility, was that this was a sort of "bonding"
23 exercise in the Trust, and I think that given the sort
24 of management culture that was overtaking the NHS at
25 this time, those kinds of exercises were seen as quite
0052
1 useful, and I think it is quite possible that
2 I believed that I was going to a bonding, you know,
3 touchy-feely-fuzzy-warm meeting at which we were going
4 to get together, rather than necessarily a meeting at
5 which we were going to address a specific issue of
6 paediatric cardiac surgical mortality. I do not know if
7 that helps?
8 Q. I am not sure it does. For what reason do you think,
9 looking back on it, the Bistro 21 meeting may have been
10 a touchy-feely-fuzzy-warm bonding session, as opposed to
11 a dinner intended to sort out differences, if there were
12 differences, as to the performance of cardiac surgery
13 and the interpretation of any figures there were?
14 A. I think firstly the venue, holding a meeting in
15 a restaurant, is not a venue for where you will sort
16 something out; it is more a venue where you will have
17 a warm convivial meeting, and I think if we were going
18 to sort out paediatric cardiac surgery, it would have
19 been better to have done it in an office in the
20 University department, or something.
21 Q. Yesterday you were telling us that -- these are your
22 words "I think Chris Monk invited me to attend the
23 meeting. I think it was at relatively short notice"?
24 A. Yes.
25 Q. "My understanding was that we were going to address
0053
1 some of the issues of cardiac surgery, and probably
2 paediatric cardiac surgery".
3 A. Yes, but I think it could have been in a "How can we
4 move this forward together?" kind of atmosphere.
5 Q. Again, to try and get what you are saying right, are you
6 saying that you go along to address the issues, not with
7 the object of being confrontational, but with the object
8 of producing a resolution?
9 A. Yes.
10 Q. So what you would have been looking to achieve from your
11 own point of view from the meeting, was a consensus that
12 matters needed to be moved forward and a plan of action?
13 A. That kind of thing, yes.
14 Q. And as it happened, as we know, nothing transpired?
15 A. I think if we had been intending to do that in
16 a Bistro 21 atmosphere, it would have been formal and
17 not informal, and the formality was not there.
18 Q. About either 5 or 13 days later, depending on where one
19 dates the Bistro 21 meeting, did you speak to Janet
20 Maher?
21 A. Yes.
22 Q. She was, then, General Manager of the Division of
23 Surgery. What did you seek her out for?
24 A. I was still concerned about paediatric cardiac surgery
25 and a lack of an open review in a service that I was
0054
1 concerned about the results of.
2 Q. Why speak to the Manager?
3 A. Because I was having very little success with the
4 clinicians involved. I know that Gianni was also
5 expressing frustration in dealing with the clinicians
6 involved, and I was looking for any avenue to achieve an
7 open review of this service which I believed may have
8 been exposing children to risk.
9 Q. So what did you ask Miss Maher to do, and on what
10 basis?
11 A. I wanted the management structure within the Trust to
12 know that I believed that there was a problem.
13 Q. And what were you hoping to achieve by that?
14 A. I was hoping we would get to the destination we talked
15 about yesterday, which was the open and thorough
16 review.
17 Q. Two questions arise. The first is that since less than
18 two weeks before you had had a meeting with the Medical
19 Director, the Chairman of the Consultant Hospital
20 Medical Committee, and one of the two paediatric cardiac
21 surgeons, and the Professor of Cardiac Surgery and the
22 Director of Anaesthesia, at which you could have
23 explored concerns but as it happens did not, do you see
24 any inconsistency, possibly, in saying, "Well, the
25 reason I went to Miss Maher was because I was so
0055
1 concerned I needed to express and make sure they were
2 aware of them"?
3 A. Yes, I think the consistency I would identify in my
4 actions is that I did not want to approach the surgeons
5 directly, because of the preceding history of doing
6 that.
7 Q. Did you think, as a result of going to Mrs Maher, she
8 would probably tell the surgeons you had done so?
9 A. I was happy for her to tell the surgeons in the same way
10 as I was happy for my Director of Anaesthesia to tell
11 the surgeons, I was happy for Brian Williams to tell the
12 surgeons. I was not willing to tell the surgeons myself
13 because I was fearful of that route.
14 Q. You were fearful of saying something directly to the
15 surgeons?
16 A. Yes.
17 Q. But happy that somebody else should say to the surgeons,
18 "Dr Bolsin has these concerns"?
19 A. Yes. I was happy for them to do that.
20 Q. Would not the effect on you and your career and the
21 regard in which you were held, be exactly the same in
22 each case?
23 A. If we got an open and thorough review, I would have been
24 a contributor to that. What I wanted Janet Maher to set
25 up was the process of an open and thorough review.
0056
1 I would then be able to contribute to that review and
2 I would then be able to possibly explain, this was my
3 contribution. That would have been fine as far as I was
4 concerned.
5 Q. Are you saying that if you had expressed your concerns
6 face-to-face with a cardiac surgeon, that you thought
7 you would get nowhere?
8 A. I had already expressed my concerns face-to-face with
9 the senior paediatric cardiac surgeon, and been
10 threatened with my career from Bristol. I was not
11 prepared to do that again and I think the subsequent
12 actions or the subsequent events had demonstrated I was
13 right probably not to do that.
14 Q. What I am trying to disentangle, Dr Bolsin, is what you
15 are hoping to achieve, which you tell us was the open,
16 thorough, complete review?
17 A. Yes.
18 Q. The process about which you go about it, which I think
19 you acknowledge would probably be more effective if the
20 anaesthetists as a group had planned it and put it
21 forward as a group?
22 A. Yes.
23 Q. That did not happen, and it was --
24 A. Well, it did happen later.
25 Q. We will come to the switch in a moment. I want to ask
0057
1 you about that and the contrast is, as you rightly point
2 out, between the approach there and the approach here.
3 But you are saying, "I was frightened for my own career
4 to raise it individually with a surgeon"?
5 A. Yes.
6 Q. Directly?
7 A. Yes.
8 Q. "But not frightened for my own career to raise it,
9 identifiably but indirectly"?
10 A. Yes.
11 Q. Might it perhaps have been worse as a matter of
12 perception for those looking at your actions, saying
13 "This is a man who is prepared to whisper around the
14 back, go behind my back and say things and not say it to
15 my face"?
16 A. I think what I wanted was corroboration of my concerns,
17 so that people would say, if anything happened,
18 Dr Bolsin had been expressing his concerns, and he had
19 expressed them to a lot of people.
20 Q. One way of having corroboration might have been to
21 express it openly in a meeting, with others present,
22 might it not?
23 A. It is certainly possible that that would have been one
24 way of doing it, yes.
25 Q. In any event, you speak to Mrs Maher, and a couple of
0058
1 days later --
2 A. The next day.
3 Q. -- I am sorry, the next day, Dr Monk speaks to you?
4 A. Yes.
5 Q. And your recollection of what is said?
6 A. My recollection was that this is not the way to go about
7 this problem of paediatric cardiac surgical mortality;
8 I think it was probably, "We have to keep it within the
9 profession", that kind of thing.
10 Q. So he was echoing there, was he, the view of a number of
11 people -- if you want chapter and verse I will go
12 through it in a moment -- who have told us they
13 expressed similar views to you?
14 A. Yes.
15 Q. That concerns like this should in the first place have
16 the ownership of the individual and then the
17 individual's group, and director and so on: very much
18 the blueprint that you set out in your Melbourne
19 lecture?
20 A. In 1999.
21 Q. I appreciate, with hindsight, but that was the point
22 being made, was it: "If you have got concerns like this,
23 come on Steve, you do it this way and not that way"?
24 A. No, I think it was more negative than that. It was
25 "Don't go to the management. That is not something we
0059
1 do."
2 Q. He tells us that he had asked you on a number of
3 occasions to explain, present, your data. Had he?
4 A. I had presented the data to him and I think I had gone
5 through the data with him, as I went through it with
6 a lot of my other colleagues -- well, with my other
7 paediatric cardiac anaesthetic colleagues. I cannot
8 remember being specifically asked to present the data to
9 them. I think there is a difference in emphasis there.
10 Q. Let me move on from 18th April to the letter that we
11 anticipated a moment or two ago in respect of the switch
12 operation.
13 Can we look at UBHT --
14 A. I am sorry, can I just go back and talk about the
15 presentation? If I had been asked to present the data,
16 I do not think I would have shrunk from that task.
17 I was very prepared and used to presenting data of this
18 nature around the country, and also within the UBHT, so
19 it is not something I would have shrunk from.
20 Q. Before we come to the switch operation, picking up on
21 that last point about the sharing and ownership of data,
22 what Professor Farndon told us -- the reference is
23 Day 69, page 96, so others can track it -- is that the
24 thrust of his reply to you, having had a conversation
25 with you about your data in late 1993, was that the data
0060
1 had to be owned and shared.
2 Is that your recollection of something that he
3 said to you?
4 A. I cannot remember those particular words. What I was
5 hoping to get out of that consultation with Professor
6 Farndon was that he would take the data and address the
7 issues with the people involved.
8 Q. I am not concerned with what you wanted him to do. What
9 I am asking about is whether you recollect that he gave
10 you this advice. You appreciate that the question will
11 follow, if he did give you that advice, why did you not
12 take it?
13 But the next thing which he told us he said to you
14 by way of advice -- the reference is page 100 the same
15 day -- was that his response was that this was the route
16 to go; that any audit has to be carried out with the
17 knowledge of all participants looking after the care of
18 those particular patients, with clearly defined
19 objectives and with a mechanism for closing the loop, so
20 he would have to go to the Directorate of Cardiac
21 Surgery to report those findings and say, "Is there
22 a problem? How do these results benchmark? Do you have
23 any data on the risks of each particular child? These
24 are all high risk patients/average risk/low risk, with
25 other contributory factors, anaesthesia and cardiology,
0061
1 that led to these outcomes."
2 That is what he says he said to you. As you
3 recollect it, is he right? Might he be right? Is he
4 wrong?
5 A. I do not think we had that kind of detailed discussion
6 about the figures. If he had been talking about risk
7 factors, I would have engaged in and remembered that,
8 because I was developing factors in my own adult work,
9 so I cannot remember a conversation of that amount of
10 detail.
11 If I can go back to what I was expecting from the
12 meeting, which helps me to remember what I remember of
13 the outcome of the meeting, I was expecting him to say,
14 "I will deal with this and take it on" and that was the
15 impression I got from the meeting, not that there was
16 a discussion of risk factors and other things that could
17 be muddying the waters; the impression I got from the
18 meeting was that Professor Farndon was prepared to take
19 this data on face value, and deal with it with the
20 people involved.
21 Q. So is this the case as you recollect it: if he said to
22 you that you should take the matter up with the cardiac
23 surgeons and cardiologists, that, if he said that,
24 nonetheless the main message you picked up from your
25 meeting with him was that rather than you having to do
0062
1 something yourself, he would take it forward?
2 A. Yes. Just a brief point. The ownership issue I would
3 have considered addressed by the fact I had already
4 shared the data with my paediatric cardiac anaesthetic
5 colleagues at that stage.
6 THE CHAIRMAN: You spoke a moment ago about Professor
7 Farndon talking about risk factors and other matters,
8 "muddying the waters". What did you mean by "muddying
9 the waters"?
10 A. I think that in explaining, as we know, outcomes, there
11 are a number of factors that can be invoked. We have
12 already established that pre-operative care, surgical
13 technique, post-operative care, anatomy, all of these
14 things can impact on adverse outcomes. I think if he
15 had raised these issues with me, I would have engaged in
16 a discussion about that and we would have talked about
17 cross-clamp times, bypass times and perceived technical
18 proficiency, but I do not remember doing that at all.
19 Q. It is just that that is an intriguing expression,
20 "muddying the waters", as if an otherwise clear
21 picture -- perhaps your perception of what was the
22 problem -- would in some way be distorted by reference
23 to something else.
24 A. I think I was relatively happy in my own mind that there
25 was a clear picture of a problem that needed to be
0063
1 reviewed.
2 Q. But this is a recurring theme which -- perhaps I can put
3 it to you this way: if there is a question to be asked,
4 is the right way of answering that question to assume
5 the answer before you have explored the question
6 adequately?
7 A. I was not assuming the answer; I was assuming that we
8 had an indication. The signpost that Mr Langstaff
9 mentioned yesterday was pointing towards an open review
10 which would then have brought out all these other
11 factors. But what we were not getting was the open
12 review out of which would have fallen all of the other
13 risk factors that are supposed to have been discussed in
14 that meeting.
15 MR LANGSTAFF: So you are saying, as I understand it,
16 that your data was not the review?
17 A. No.
18 Q. That you therefore had no basis to prejudge whether the
19 surgeon, the cardiologist, the anaesthetist, anyone, was
20 at fault; that was something for the review if a review
21 could be achieved?
22 A. Absolutely, and in fact, if I could just add to that, if
23 you remember the tabulated data, I never tabulated the
24 data comparing one surgeon with the other, because I did
25 not feel that that was an important part of the
0064
1 signposting; I felt that the signposting was towards an
2 open review from which might fall these other
3 comparisons. I did not want to personalise this issue.
4 Q. I took you a little bit out of step in the light of some
5 of the answers you have given, but can we look at
6 UBHT 61/6?
7 21st June 1994. To review where we had got to at
8 this stage, you have produced what I have called the
9 well-presented, better presented data at the tail-end of
10 1993, whenever it was?
11 A. Yes.
12 Q. September/October, thereabouts?
13 A. I suspect it would have been after Alison Hayes had
14 reviewed the classification.
15 Q. So it would have been after her appointment sometime?
16 A. Yes, I think so.
17 Q. She fixes it at the first two months being
18 October/November 1993.
19 A. Yes.
20 Q. You have taken advice from Dr Ashwell; we have seen
21 the correspondence. There has been the meeting of
22 21st January 1994, the dinner at Bistro 21.
23 A. Yes.
24 Q. You are raising concerns with Janet Maher and Dr Monk
25 having a word with you about that?
0065
1 A. Yes.
2 Q. Your data had not focused at all on the switch
3 operation, for reasons that we went into yesterday I am
4 not going to repeat.
5 A. Yes.
6 Q. This letter, which we see -- if we just take a long view
7 of it, please -- it is signed by four anaesthetists?
8 A. Yes.
9 Q. If we go back to the text so you can see it more
10 clearly, it deals only, does it, with the arterial
11 switch?
12 A. Yes.
13 Q. How did it come about that this letter was written?
14 First of all, is it your draft?
15 A. Yes.
16 Q. If we go up to the top, above "Private and
17 Confidential", if we can enlarge the SNB/JEW", that is
18 your reference, is it?
19 A. Yes, I am sure that is my reference.
20 Q. Who is JEW?
21 A. She must have been one of the secretaries, I think.
22 Q. So you have this letter typed up for you in the
23 department?
24 A. Yes, I think I actually had several. I do not know how
25 many versions of this document you have, but there was
0066
1 an initial much more critical document which was
2 produced.
3 Q. I think this is it. But we will ask -- I beg your
4 pardon. This is not it. We will come to it in
5 a moment.
6 You are saying there are several versions?
7 A. Yes.
8 Q. Tell us about how the letter first of all came to be
9 written in any of its versions?
10 A. After the completion of the Bolsin/Black data
11 collection, we were still concerned about other
12 operations. I think you have to bear in mind the
13 background that I did not think that everything we did
14 was bad, but I thought there were some operations which
15 were exposing children to excess risk.
16 I wanted to identify which those operations were
17 and to get the unit to either not do them, transfer the
18 children out, or put them in the hands of somebody who
19 might be doing them more safely and the precedent for
20 that --
21 Q. Can I stop you there? Did you also have in mind you
22 might identify a particular reason why they were so bad
23 and correct it or improve it?
24 A. Certainly, yes, that would have been part of the
25 process. That would have fallen out of an examination
0067
1 of the results.
2 Q. I stopped you mid-flow.
3 A. I did not think that the unit would be hostile to that,
4 because there was a precedent for that. Mr Wisheart,
5 with switch operation, had decided it was beyond his
6 technical capability or he did not want to do it and had
7 left it to Mr Dhasmana, so there was a precedent within
8 the unit for people to pick up certain operations
9 because they were better at them.
10 I started to collect data on the arterial switch
11 programme, and again, it was a continuous moving target,
12 and we saw a table yesterday with switch data, and that
13 would have been updated as I obtained records on it.
14 Q. Just to remind you of that, we find that, I think, at
15 page 61/46. That is your report which is dated after
16 this letter, 13th July?
17 A. Yes.
18 Q. Then, if we go overleaf, turn it round, 61/47, this is
19 the sort of data that you were collecting?
20 A. Yes, and I would have been adding cases as I was
21 identifying their operation date and their outcomes from
22 the records.
23 Q. The last date I can tell you, on that sheet, because we
24 have blanked out the day and the month, is a date in
25 June, which precedes the date of the letter.
0068
1 A. Yes.
2 Q. Can we go back to the letter? In fact, let us go back
3 to the version we have at GMC 4/64: the same date. The
4 reference at the top is a bit clearer,
5 SNB/JEW.monk.21.doc.
6 Is this produced from one of Mr Monk's files on
7 the computer?
8 A. I have no idea, I am afraid, I cannot help you.
9 Q. Does that indicate that the letter was prepared or
10 drafted with some assistance from him?
11 A. I think the sequence of events was that we were
12 beginning to get a picture of an arterial switch
13 programme that had a high mortality rate, and we had had
14 two of the anaesthetists -- I think possibly three, but
15 certainly Dr Masey and Dr Underwood had been to
16 Birmingham, and we had had some initial successes, but
17 viewed overall, there was a problem with this operation.
18 I remember, in the coffee room in cardiac theatre,
19 sitting with Ian Davies, Chris Monk and myself and
20 possibly one or two of the other cardiac anaesthetists,
21 and saying "We have a problem here and we have
22 a responsibility to do something about this problem",
23 and I think that this was possibly part of that change
24 of tactics that you had been talking about.
25 It may have been a maturation in my consultant
0069
1 career that I wanted to be on board with my colleagues
2 in raising concerns, and the upshot of this meeting was
3 that Chris Monk, myself and Ian Davies said that we
4 would not undertake any anaesthesia for arterial switch
5 procedures, but Chris, being aware of the data, which
6 I may have produced at this meeting -- I may not, I am
7 not sure -- said, "Send me a letter". I think the
8 initial suggestion was that we should all sign the
9 letter and then he would take it to whomever he thought
10 appropriate. As the letter was produced, he then said,
11 "Send it to me and then I will be able to take it on".
12 He did not want to be a signatory, because he thought
13 that may in some way prejudice what he did with the
14 letter. That may explain the reference to "Monk" on
15 this early draft.
16 Q. That is very helpful. What we have here -- because we
17 are looking at a slightly different version of the same
18 letter?
19 A. Yes.
20 Q. And it coincides with your recollection that there were
21 several versions?
22 A. Yes.
23 Q. The words that we have here in the first line:
24 "We wish to express our increasing concern ..."
25 A. Yes.
0070
1 Q. And the second line: "The mortality of this operation is
2 apparently unacceptably high ..."
3 A. Yes.
4 Q. Just pausing there for a moment, what you had, as you
5 have shown us, is a list of operations with outcomes?
6 A. Yes.
7 Q. What you had not, in that table at any rate, was a point
8 of comparison between Bristol's performance and
9 performance elsewhere.
10 Was it a matter of importance, as you saw it at
11 the time, that there should be some valid comparison?
12 A. Yes. I think I mentioned earlier on that at some point
13 in this process I was contacting other units, and I had
14 spoken to Cardiff, where I am sure Francesco Musomecci
15 was now operating, and I spoke to one of their
16 anaesthetists and asked what their success rate was, and
17 I think that even if the Marc de Leval seminal Cusum
18 article had not been published at this stage, certainly
19 an abstract had been published in the Journal of
20 Thoracic and Cardiovascular Surgery.
21 So there were some contemporary comparators for
22 the outcome of switch programmes.
23 Q. What happened to change that draft with the "increasing
24 concern" and "apparently unacceptably high" into the
25 draft which we first saw -- we can go back to that,
0071
1 UBHT 61/7.
2 A. I went round and asked the signatories if they would be
3 prepared to sign the letter. I got the signatures of
4 some of the anaesthetists, Ian Davies, Dr Baskett and
5 myself, to sign the original shall we say harsher
6 version, but Dr Masey, when I showed it to her, wanted
7 a less harsh version. In fact there is a version of
8 this document -- I am not sure I have it -- in which
9 I have written down what her concerns with the original
10 harsh version were, and I have put them in brackets
11 underneath her name and we then modified the document in
12 order to be able to all sign it and carry it forward,
13 with shared ownership.
14 Q. So you had changed tack. You had learned the lessons,
15 had you?
16 A. I think I was maturing as a consultant.
17 Q. So if you had not learned, at least you were learning?
18 A. I was certainly learning. I learned a lot at Bristol.
19 Q. If we go down to the bottom of this one, there are four
20 signatures?
21 A. Yes.
22 Q. You will notice in the bottom right-hand corner, that of
23 Dr Peter Baskett?
24 A. Yes.
25 Q. On this version, neither Dr Underwood nor Dr Masey
0072
1 appear to have signed. If we go over to UBHT 61/7, this
2 version has signatures from Dr Underwood and Dr Masey,
3 but none from Dr Baskett?
4 A. Yes.
5 Q. What was happening?
6 A. It was summer time and I got Dr Baskett just before he
7 went on leave, and then spoke to Dr Masey and she wanted
8 the changes, so I then had to get the secretary to do
9 the changes and then Peter had gone on leave and then
10 I think Su Underwood remembers that she had pneumonia,
11 so I had to go and get her signature from her house
12 because she was off sick. That explains why Peter is
13 not on there.
14 Q. Not entirely, because I think, unless I am mistaken,
15 that UBHT 61/7 and 61/6 -- go back to 61/6 for
16 a moment -- the wording of the text appears to be
17 identical. This is the less strong version. So
18 although I understand that the stronger version was not
19 signed by Drs Underwood and Masey, this less strong
20 version was, ultimately, signed by all six
21 anaesthetists?
22 A. Yes.
23 Q. But we do not have a copy of this particular letter with
24 all six signatures on it. Was there one?
25 A. My recollection was that the final version that I sent
0073
1 was with Dr Baskett's signature off, but I do know that
2 Dr Baskett was prepared to sign either version of the
3 letter. I think I may have explained that to Chris when
4 I handed it to him.
5 Q. Having handed it to Chris, what was it your
6 understanding that he was going to do with it?
7 A. I believed that he was going to take it to Mr Wisheart,
8 because he was the Director or Associate Director of
9 paediatric cardiac surgery, and arrange this review,
10 confidential, you know, involving everybody review.
11 Q. Can I just test the basis for your thinking that? The
12 reason why I do this, you have on a number of occasions,
13 I think, assumed that a meeting or conversation had
14 taken place when we have had evidence or been told by
15 others that, as it happened, it did not.
16 Is this your assumption of what Dr Monk was going
17 to do with it? Or does it rest on more than just your
18 assumption of what he was going to do with it?
19 A. The initial letter was going to be with Dr Monk's
20 signature on it, and it was going to be sent to,
21 I think, Mr Wisheart. I think that was the Plan A that
22 we talked about in the coffee room.
23 Q. So "it was going to be" comes from what?
24 A. I think that was the view of the group, that we as
25 a group would sign a letter, as all the paediatric
0074
1 cardiac anaesthetists, and we would send it to someone.
2 Q. Send it to someone?
3 A. Yes. I think that Mr Wisheart was the person that we
4 thought was most appropriate. He was the Medical
5 Director; he was responsible for clinical standards in
6 the Trust; he was a paediatric cardiac surgeon; he was
7 an appropriate person to send a letter of this nature
8 to.
9 Q. So when Dr Monk changed his approach a little and said
10 "It would be more helpful to me, representing us, to
11 have a letter addressed to me so that I can take it
12 forward", upon what did you base your understanding that
13 he was going to take it forward to Mr Wisheart, as
14 opposed to anyone else?
15 A. On the basis that we were originally planning to address
16 it to Mr Wisheart, I would have assumed that he was
17 going to take it to that person, but it is an assumption
18 and I have no firm evidence that that is what he planned
19 to do with it.
20 Q. A letter like this is quite extraordinary, is it not, in
21 clinical practice, particularly in the middle of the
22 1990s?
23 A. It certainly was in Bristol. I am --
24 Q. That will do for the next question. So all of you knew
25 you were doing something which was out of the ordinary,
0075
1 and effectively, you would have expected some form of
2 reaction from those to whom the letter eventually went?
3 A. Yes. We would have expected feedback, yes, certainly.
4 Q. The feedback would come because of the way in which the
5 letter was going to be handled, from Dr Monk?
6 A. Yes.
7 Q. Did you get any feedback?
8 A. Nothing much direct, I do not think, no. I just assumed
9 that it had been put into the system and that it was
10 going to produce a review. I hoped that this was going
11 to be another way of getting to that destination.
12 Q. Did you ask Dr Monk what had happened to it?
13 A. Again, I cannot remember specific instances of me having
14 asked, but I suspect I would have mentioned it casually
15 to him, how are we going with the review of the switch,
16 or whatever.
17 Q. Were you present when any of the other anaesthetists, in
18 the coffee room or whatever, asked Dr Monk -- I am not
19 interested in the reply, just the fact of asking -- what
20 he had done with the letter and what happened to it?
21 A. I cannot remember being present, no.
22 Q. You knew because anaesthetists had been involved, you
23 knew anyway because you worked with Mr Dhasmana that he
24 had on two occasions gone to Birmingham for further
25 training?
0076
1 A. Yes.
2 Q. We can date those as December 1992 and July 1993.
3 A. Yes.
4 Q. That was with specific reference, was it, to the
5 arterial switch in neonates?
6 A. Yes. If you are telling me that, the answer is "Yes".
7 Q. It was a question.
8 A. I think that in Birmingham, most of their arterial
9 switch work was in neonates. I am not sure exactly
10 which bit of the programme Mr Dhasmana went to
11 Birmingham to learn about.
12 Q. Because the operation, as we discussed briefly earlier
13 this week, in the non-neonates and the neonates, may
14 have some technical similarities?
15 A. Yes.
16 Q. But we have been told that it is, in many respects,
17 a different condition?
18 A. Yes.
19 Q. Because the operation in the non-neonates has
20 complications of the VSD which is present, and so on?
21 A. Yes.
22 Q. The operations on neonates, the last operation that took
23 place on a neonate was, we understand, I think October
24 1993?
25 A. Yes.
0077
1 Q. Everyone, I suspect, must have been hoping for the best
2 when Mr Dhasmana had gone to Birmingham the second time?
3 A. Yes.
4 Q. In the hope that he might improve technique or discover
5 methods of management at Birmingham that might not have
6 been applied but in some way helped to secure the best
7 possible results for the children. That was perhaps his
8 object?
9 A. Yes.
10 Q. Was there talk about what had actually happened after he
11 came back?
12 A. Yes. I remember having a conversation with Dr Masey
13 about the away-day she had had with him.
14 Q. When, sadly, there was no significant sustained
15 improvement in the results of neonatal operations after
16 that, was it your understanding that Mr Dhasmana had
17 withdrawn from operating on neonates?
18 A. I do not think that was ever made clear to any of the
19 paediatric cardiac anaesthetists; it certainly was not
20 made clear to me.
21 Q. Did no-one comment on the fact, "We have not done
22 a neonate", at the time of this letter, "for 9 months"?
23 A. I cannot remember that being raised at the time of the
24 letter being produced. The letter specifically did not
25 deal with any age group for the arterial switch.
0078
1 Q. Can you help us, perhaps, by giving us an added
2 perspective to our view of the unit as a whole and how
3 communications worked within it?
4 If it is the case that cardiologists and cardiac
5 surgeons had together agreed that there should be no
6 more operations for anatomical correction of
7 transposition of the great arteries in neonates, and if
8 they had agreed that in round about October 1993, why do
9 you think it should be that the paediatric cardiac
10 anaesthetists did not know of it?
11 A. I do not know. If you want me to comment on the
12 communication within the unit, then I think it may well
13 be that as we have seen from the audit meetings, the
14 paediatric cardiac anaesthetists were not always
15 involved in the meetings between the paediatric
16 cardiologists and the paediatric cardiac surgeons.
17 Q. One of the problems, perhaps, was, was it, that they had
18 their audit meetings on a Friday afternoon; you had your
19 meetings on a Friday afternoon?
20 A. That is certainly one of them. I think the other thing
21 was that some of those early audit meetings that we saw
22 the minutes of recently were actually on a Monday
23 morning and they were at the Children's Hospital, and
24 the paediatric cardiac anaesthetists had all their
25 commitments at the Bristol Royal Infirmary, so it would
0079
1 have been procedurally quite difficult to get from
2 a meeting in the Children's Hospital down to a list in
3 the BRI.
4 So there were all sorts of barriers to that kind
5 of communication occurring.
6 I must say, I was very surprised when I first
7 heard that the neonatal arterial switch programme had
8 been suspended in October 1993, because as far as I was
9 aware, none of us in the paediatric cardiac anaesthetic
10 department knew that.
11 THE CHAIRMAN: Mr Langstaff, just remind me -- I may be
12 wrong -- but I thought I remembered seeing that both
13 Mr Wisheart and Mr Dhasmana were at the audit meeting
14 which Dr Bolsin is telling us was at the Children's
15 Hospital. Is that not the case?
16 MR LANGSTAFF: Yes.
17 THE CHAIRMAN: So your Monday morning commitment to
18 paediatric cardiac anaesthesia would have taken account
19 of that, would it not, or am I wrong?
20 A. No, the situation would have been that the anaesthetic
21 would have started at 8 o'clock down at the Bristol
22 Royal Infirmary. We would then have put the child to
23 sleep, put the arterial and central venous lines in,
24 taken the patient into theatre. The junior registrar
25 would have prep'd and scrubbed the patient, and then
0080
1 Mr Wisheart would have arrived from the audit meeting at
2 the Children's Hospital.
3 THE CHAIRMAN: Thank you, that is helpful.
4 MR LANGSTAFF: Sir, if the Panel need the evidence set out
5 on a schedule, it can be done, but it is not the case
6 that at every meeting there were the same personnel, so
7 there may have been occasions when Mr Wisheart or
8 Mr Dhasmana was not at one of the Monday morning
9 meetings, but that is something which can be identified
10 from looking at the records. We need not waste time on
11 it now. I think it right to correct any impression that
12 they were always necessarily there.
13 Does it follow -- suppose they had taken
14 a decision like this at the meeting, and you or Dr Masey
15 or Dr Underwood had been working away in the Royal
16 Infirmary, giving the answers then, they come hotfoot
17 from the meeting -- that there was no discussion over
18 the table and in the course of the operation as to what
19 had happened?
20 A. No, I do not remember that happening, and I am not sure
21 that I have ever seen a minute of one of those audit
22 meetings where it was said, "We will now suspend
23 neonatal arterial switch operations". I think that the
24 way in which the decision was made and communicated may
25 in fact reflect the sensitivity of the surgeons for
0081
1 adverse outcomes in the unit: they did not want to
2 broadcast them.
3 Q. So I am right in thinking that the wording of this
4 letter supposed that all the anaesthetists, including
5 those who had concern over the exact wording of the
6 letter, thought that the programme was the arterial
7 switch programme, without reference to whether it was
8 neonates or non-neonates?
9 A. Yes. While we have the letter on the screen, may
10 I bring in the last sentence, which says that there were
11 already criticisms by June 1994 in the institution,
12 possibly reasonably widely held?
13 Q. The "publicly" may be a reference to Private Eye
14 earlier, perhaps?
15 A. Possibly, yes.
16 Q. And "privately", there had plainly been concern which
17 had driven Mr Dhasmana to Birmingham, together with an
18 anaesthetist, possibly with a perfusionist?
19 A. Yes, I think it also confirms the impression of people
20 like Professor Vann Jones, that it was easier to talk
21 about this issue than not to talk about it, in the
22 corridors of the institution.
23 Q. Can we go to BMA 1/18? Again, your report, I think?
24 A. Yes.
25 Q. 18th July 1994. Why then, when you put forward a letter
0082
1 in June of that year, seeking a thorough review which
2 you thought was in the system somewhere and was going to
3 happen?
4 A. I think this was data that I was continuing to collect.
5 I think that the data that I may have discussed or
6 presented at the meeting in the coffee room in theatre,
7 would have had -- I mean, it was rough data. It was
8 that table that you have seen with crossings-out and
9 deletions on it. I was now producing a summary document
10 that I hoped everybody would be prepared to accept.
11 Q. You there are looking at not only the neonates but the
12 non-neonates.
13 A. Yes. I have now divided them up into neonatal and
14 non-neonatal groups.
15 Q. To whom did you show that particular report?
16 A. I think it was circulated amongst the paediatric cardiac
17 anaesthetists.
18 Q. For joint discussion and taking forward if need be?
19 A. Yes, we had had a joint discussion. We had produced
20 a joint letter. This was joint data.
21 Q. UBHT 54/3. This is the third bit of data which you told
22 us you produced, the third collection?
23 A. Yes.
24 Q. This time again, there is no analysis of the data as
25 such; it is a list with outcomes?
0083
1 A. Yes. What I was doing at this stage, having done the
2 original data collection and analysis, having seen
3 a problem continuing to develop, and having identified
4 the switch operation, I was now looking at other
5 operations that I thought may be high risk procedures
6 that we should be not doing or sending to safer
7 institutions or concentrating in safer hands in this
8 institution.
9 Q. How many surgeons were performing AV canal repairs?
10 A. There were only two surgeons, and I believe that they
11 were both performing AV canal repairs.
12 Q. Is this the only report, particular report, that you
13 produced dealing with AV canal repairs?
14 A. Yes. I think it is.
15 Q. You focus here only on one surgeon?
16 A. I was very concerned about the mortality rate for
17 this series of operations in this surgeon's hands.
18 Q. Can we look at the text? From where did the data as
19 to date of operation and outcome come?
20 A. I think that I would have originally gone back to the
21 perfusionist's log. I would have cross-checked with the
22 operating theatre books and I can certainly remember
23 going to ward clerks and opening cupboards to get old
24 operating theatre books for cross-checking, and then
25 I would have had to go to the medical records department
0084
1 to confirm the status of the patient, having identified
2 the notes and the numbers.
3 Q. Is this work that you did on your own?
4 A. Yes. I think it probably is, yes.
5 Q. Having learned the lessons, as you have told us you were
6 beginning to do?
7 A. Yes.
8 Q. Hence the collective, the collaborative approach to
9 seeking a detailed review of the arterial switch
10 procedure --
11 A. Yes.
12 Q. -- that is what you were asking: for a detailed review,
13 you were not asking at that stage to stop to procedure?
14 A. No, I think what I wanted was a detailed review of the
15 total activity of the unit.
16 Q. There you had had the collaborative approach. What
17 approach did you take with this particular piece of data
18 reported in this way?
19 A. I think that the goal with this data would have been,
20 again, in the same way as we had done with the switch,
21 to alert the paediatric cardiac anaesthetists to
22 a potential problem in the practice of this unit.
23 I would have hoped after this -- and I think we were
24 somewhat taken over by the events of December 1994 and
25 then January 1995 -- to then have produced a similar
0085
1 letter asking for a review of the AV canal in the same
2 way we asked for a review of the arterial switch
3 procedure, and then on the basis of that, we would
4 perhaps have been able to widen any initial review we
5 had been able to achieve.
6 Q. So to whom was this report shown?
7 A. This report, I think, went again to the paediatric
8 cardiac anaesthetists. I think I may well have sent it
9 to Gianni Angelini as well. This, to me, was a flashing
10 red light. This was a serious problem and this was
11 potentially life-threatening.
12 Q. Can we look at the wording of it?
13 "A previous analysis undertaken in this unit has
14 demonstrated ..."
15 A. Yes.
16 Q. To which previous analysis was that a reference?
17 A. I think this was the Bolsin/Black data collection.
18 Q. You report on that almost in the language you would use
19 when writing a summary of an article for a professional
20 journal, "The data also demonstrated that ..."
21 It is very much objective third person speech, is
22 it not?
23 A. I am writing in the language of professionals to
24 professionals. I am a professional. I was writing for
25 professionals.
0086
1 Q. Did you know that Mr Wisheart had stopped doing AV canal
2 operations in August 1994?
3 A. No, I did not know that.
4 Q. Again, if he you had known that, this whole exercise,
5 which must have taken you some time and effort --
6 A. Yes.
7 Q. -- and discussion with colleagues who would be troubled
8 by it, would have been unnecessary?
9 A. Absolutely. I think what it also reflects, just to
10 extend on that a little bit, is that the people I showed
11 this to, the paediatric cardiac anaesthetists and
12 Professor Angelini, also did not know that Mr Wisheart
13 had given up AV canal operations at this time.
14 Q. Again, if you had to attribute the failure of
15 communication of that fact to the anaesthetists, to what
16 particular factors would you ascribe that failure?
17 A. I think, without wishing to harp on about it, I think it
18 may be this sensitivity and prickliness of talking about
19 paediatric cardiac surgical mortality.
20 Q. It is something which is pretty obvious, is it not?
21 If a surgeon simply stops doing a particular operation,
22 it is apparent, is it not?
23 A. No. It is not apparent to the people providing the
24 service.
25 Q. The cardiologists would have to know of it because they
0087
1 are doing the referrals.
2 A. I would assume that they may well have been told, but
3 again, I am not sure that there is any documentation to
4 support that.
5 Q. Again, may the split site have had an impact, do you
6 think, upon the failure of communication in the respect?
7 A. Certainly, yes. I think it may have been that, along
8 with the sensitivity of the issue.
9 Q. Were there problems of relationship within the surgical
10 department, amongst the surgeons themselves, as you saw
11 it at this time?
12 A. I was not aware of any particular problems. I am not
13 quite sure what you are alluding to there.
14 Q. For instance, did you know how well Professor Angelini
15 got on with Mr Hutter?
16 A. I am sorry, right, you mean the adult surgeons as well
17 as the paediatric surgeons?
18 Q. The surgeons?
19 A. I am not sure if at this point Gianni Angelini was not
20 proposing the Cardiac Surgical Institute, and I know
21 that the proposal of the Cardiac Surgical Institute had
22 caused some fairly heated discussion amongst the adult
23 and paediatric cardiac surgeons.
24 Q. So were there particular personal difficulties, as you
25 saw it, amongst and between the cardiac surgeons?
0088
1 A. I am not sure about "personal". I think there may have
2 been -- I am trying to think back now, actually. Yes,
3 there may have been professional rivalries or people
4 thinking one person was overstepping their remit, or
5 this should not be being done, that they were changing
6 status quo, upsetting the balance of things, you know,
7 moving forward perhaps when people did not want to.
8 Q. Was there rumour, leave aside whether it was well or
9 ill-founded, that two of the surgeons kept a door in the
10 corridor between their offices locked?
11 A. I have no idea. No, I cannot confirm that to you at
12 all. That is bizarre.
13 Q. That is why I asked, to see whether you had heard of
14 such a story.
15 A. They must have felt very threatened, if they did do
16 that.
17 Q. Mr Dhasmana was the Associate Director, was he, at this
18 stage?
19 A. I think he probably was, yes. I am not sure about
20 the --
21 Q. He began in January 1993, I can tell you.
22 A. Okay, I am sure he was, then.
23 Q. Is it the case that he produced less paper than
24 Mr Wisheart, his predecessor, had done?
25 A. In terms of documentation and what was happening in the
0089
1 unit?
2 Q. Yes.
3 A. I would not be able to comment authoritatively on that.
4 Q. Were you able to form any view of the relative
5 approaches of the two of them, Mr Dhasmana on the one
6 hand and Mr Wisheart on the other, to the job of being
7 Associate Director?
8 A. I think Mr Wisheart had a lot of experience within the
9 Health Service, was very good at managing meetings and
10 was a very good manager. Mr Dhasmana did not have so
11 much experience and I do not think had quite the
12 interpersonal skills that Mr Wisheart had.
13 Q. Was Mr Dhasmana the sort of person to send memos round
14 if an important decision had been reached that others
15 might know about, or should know about?
16 A. Possibly. I do not remember receiving very many memos
17 from Mr Wisheart or Mr Dhasmana.
18 Q. I think I am asking for your impression of style of
19 management. Was it then not part of Mr Dhasmana's style
20 to do that?
21 A. I do not think I noticed a change in the number of memos
22 coming out of the department or the unit when
23 Mr Dhasmana took over from Mr Wisheart.
24 Q. One of the approaches that it might be thought was
25 a response to the split site and problems of timings of
0090
1 meetings and so on would be circulation by minute or
2 note of important decisions that might affect several
3 people?
4 A. Certainly.
5 Q. And you would add to that, surgical sensitivity as to
6 outcomes as a reason why not?
7 A. Yes.
8 Q. But if that were a reasonable response, it did not
9 happen? Is that what your recollection is, generally
10 speaking?
11 A. Yes. There was no dramatic change, it would be my
12 recollection.
13 Q. Looking on down this document:
14 "The data demonstrated one surgeon (JDW) was
15 statistically worse than the other (JPD). The Associate
16 Directorate of Cardiac Surgery explained the results as
17 representing an evolving and improving practice and that
18 subsequent results are and would be better. This
19 analysis cannot be supported by these results and
20 serious attention must now be paid ..."
21 A. Yes.
22 Q. So what you are recording there is that there had been
23 discussions, and you knew it, in the directorate of the
24 results of the AV canal operation?
25 A. Possibly, yes.
0091
1 Q. There would have to have been, for the results to be
2 explained?
3 A. It may not have been a discussion; it may have been
4 a piece of information that had been put out. I must
5 say, looking at that now, I am again racking my brains
6 to try and think of the provenance of that comment, that
7 sentence.
8 Q. Your words are what I am trying to probe into, to see if
9 you can help us with why you said that.
10 A. Are there any references at the bottom of this
11 document?
12 Q. Yes. We have looked at those before. The first you
13 think is in your handwriting.
14 A. Yes. I am not sure whether this might not have been
15 something that I remember having been said at the
16 20th January meeting when no data were produced to
17 support it. It may have been a phrase that I have taken
18 home from that meeting.
19 Q. That probably helps with your recollection of the 20th
20 January meeting. Remember, yesterday you thought it was
21 limited to the Fontan operation and you could not
22 recollect discussing wider results?
23 A. Yes.
24 Q. It would follow, from what this has prompted you to
25 think, that probably there was a wider discussion, even
0092
1 although it came to this conclusion which you are here
2 showing that the data does not support any further.
3 A. Yes. I think that this conclusion may have been the
4 conclusion about the results of the unit as a whole,
5 rather than specifically about the AV canal data,
6 because I certainly do not remember seeing any AV canal
7 data at that meeting. I am sure, if we look at the
8 dates of the deaths in the AV canal meeting, that they
9 would have given rise to discussion or comment, had they
10 been presented at that meeting.
11 So I think that the representing and evolving and
12 improving practice was an overall take-home message from
13 Mr Wisheart about the overall service, not about any
14 specific operation.
15 Q. Is that right? I appreciate you are thinking on your
16 feet, but if you just concentrate on the language here,
17 the language you have used:
18 "The Associate Directorate of Cardiac Surgery
19 explained the results".
20 "The results" appears as a matter of grammar to
21 relate back to the VSD repair, AV canal repair and
22 tetralogy of Fallot correction. "This unit had results
23 that were ..."
24 So the "results" appear as a matter of language to
25 be referring to ...
0093
1 A. If it is referring to the VSD repair, AV canal repair
2 and tetralogy of Fallot correction; it is referring to
3 the global activity of the unit.
4 Q. It is referring to those three operations?
5 A. Yes, but we know that there was no particular reason
6 then for the surgeons to refer to those three operations
7 because they did not know anything about the
8 Bolsin/Black data. I think that that comment refers to
9 the global activity of the unit rather than to either
10 specifically the AV canal data or the
11 VSD/AV canal/tetralogy of Fallot data.
12 Q. I do not want to get drawn into detailed semantic
13 discussion with you, it may not be helpful, but perhaps
14 you would accept the point that, as a matter of
15 presentation, anyone coming to this document for the
16 first time would probably read the results as referring
17 to the results of those three operations, and would not
18 necessarily appreciate that what you had in mind as
19 prompting the comment was an overall review of results
20 in January of that year.
21 A. Yes. I take that point exactly, but I think if we then
22 come on to the next sentence, what do we mean by "these
23 results"? Where does "these results" take us to?
24 Q. That goes back to the very first paragraph , under the
25 list of operations, the 30 per cent mortality on the
0094
1 table, 70 per cent mortality in the AV canal series?
2 A. What I am saying there is these specific AV canal
3 results, which I have above my computer at the top of
4 the document, are mentioned in this last sentence here
5 but are not what I am referring to in the sentence
6 before, which is the global activity of the unit which
7 we were told was an evolving and improving practice, and
8 does not represent the activity of the VSD/AV canal and
9 tetralogy of Fallot, which people did not know they
10 needed to address, if you see what I mean.
11 Q. You appreciate that if that is right -- again, I would
12 not wish you to think on your feet and give an answer
13 which was not right, but if that is right, then the word
14 "results" in the paragraph beginning "a previous
15 analysis" has been used in three entirely different
16 senses: "results" in the third line, referring to three
17 operations; "results" in the sentence beginning "The
18 Associate Directorate..." as meaning all the results of
19 the unit in every operation; and "results" in the third
20 from last line as meaning the results of the AV canal
21 data series alone?
22 A. Yes, I think the "results" refers to whatever is
23 preceding it in the sentence, rather than necessarily
24 a uniform use of the word "results" in the document.
25 MR LANGSTAFF: Anyway, I am going to move on. Sir, I am
0095
1 going to come to a discrete topic. Is this an
2 appropriate time for a break?
3 THE CHAIRMAN: I take my guidance as ever from you,
4 Mr Langstaff. Shall we break then for a period of time
5 for lunch and reconvene at about 10 past 1?
6 (12.25 pm)
7 (Adjourned until 1.10 pm)
8 (1.10 pm)
9 MR LANGSTAFF: Dr Bolsin, can we then move away from this
10 report, October as it was. Again a slight gap in
11 chronology. Go back to the meeting that you had with
12 Dr Peter Doyle.
13 A. Yes.
14 Q. This you deal with in your statement at page 119. You
15 rightly date it 19th July, bottom of the page, please,
16 19th July 1994.
17 A. Thanks for pointing that out.
18 Q. Credit where credit is due, Dr Bolsin.
19 A. Thank you.
20 Q. He came along to the Bristol Royal Infirmary in
21 connection, amongst other things I think, with your
22 activities in auditing of adult cardiac surgery?
23 A. Yes, that is right.
24 Q. At some stage were you in receipt of funds from the
25 Government in order to carry out research?
0096
1 A. Yes, that had initially started with --
2 Q. I do not think we need to go into details.
3 A. Okay.
4 Q. Had you met Dr Doyle before this?
5 A. Yes, we had met at committee meetings in the Department
6 of Health in London.
7 Q. Again as a matter of recollection and going back to it:
8 there came a time when you and he were in a taxi going
9 to Temple Meads station?
10 A. Yes.
11 Q. You in fact had asked to accompany him or were
12 accompanying him down to the station?
13 A. Yes.
14 Q. Before that his recollection is that neither you nor
15 Professor Angelini had had any conversation with him
16 about any particular concern regarding paediatric
17 cardiac surgery; may he be right on that?
18 A. Yes, I think he could be right.
19 Q. In the back of the taxi did you give him something?
20 A. Yes, I gave him a brown envelope which contained the
21 Bolsin/Black data and the results I had up until then of
22 adverse outcomes or the high risk operations in the
23 paediatric cardiac surgery unit.
24 Q. What we call the "Bolsin/Black data"?
25 A. Yes.
0097
1 Q. Which was the well presented tables we have seen before,
2 was it?
3 A. Yes.
4 Q. Did you also have, given the date, the report on
5 arterial switch operations?
6 A. I think I would have done, yes.
7 Q. You think you would have done; you cannot remember?
8 A. I cannot to be quite honest with you remember the date
9 on the provisional switch report.
10 Q. 13th July?
11 A. Yes, I suspect I would have had that data. I may even
12 have been trying to prepare it in time for that meeting.
13 Q. You had the figures in an envelope?
14 A. Yes.
15 Q. What was your purpose in handing the envelope to
16 Dr Doyle?
17 A. As you know, I had already been to Dr Ashwell at the
18 Department of Health and been referred to the GMC
19 guidelines which had been deemed inappropriate and I was
20 still concerned about the continued activity in some
21 paediatric cardiac surgical operations in Bristol which
22 I believed were exposing children to risk and I thought
23 that I was now justified in involving another senior
24 medical officer at the Department of Health to try and
25 find out if there was a problem and whether we should be
0098
1 doing something about it.
2 Q. Again, so I have it clear, were you looking to him to
3 give you advice about how you should deal with it or
4 were you looking to him to take action himself about it?
5 A. I think I wanted to raise the subject with him in order
6 to try and find out what actions were open to us locally
7 and possibly to him centrally to try and get some action
8 in the Trust.
9 Q. It is a request from you to him to identify the best way
10 forward for you?
11 A. Yes. It actually turned out to be a discussion of what
12 possible routes were or what possible courses of action
13 were open to us.
14 Q. Dr Doyle tells us that he did not in fact open the
15 envelope and look at the data, but there was
16 a conversation and you were expressing concern to him
17 about the matter in Bristol?
18 A. Yes.
19 Q. Did he give you advice?
20 A. Yes. We discussed, to my memory, three options: one was
21 that we go direct to the Secretary of State and the
22 conclusion briefly was that it did not seem to be that
23 important in that what we were looking for at that stage
24 was still the open review and to go to the Secretary of
25 State for an open review was an unnecessarily severe or
0099
1 serious action to take.
2 The next possibility was that we went to either
3 the Royal College of Surgeons or to someone like
4 John Parker. John Parker was sitting on the committee
5 that Peter and I sat on and was President of the British
6 Cardiac Society and was a cardiac surgeon and was
7 somebody who could take that kind of issue on and the
8 conclusion was that he would probably involve the Royal
9 College of Surgeons and again there may be a suspension
10 of operating good or dangerous in the Infirmary and that
11 probably was not what we wanted to do.
12 Q. Because that would involve stopping operations which
13 were beneficial?
14 A. Yes, yes, absolutely.
15 Q. And the third course of action?
16 A. The third course of action was that Mr Doyle would write
17 to Professor Angelini who was aware of the problems and
18 I had reported to Mr Doyle that Gianni was aware of the
19 problems and he would then report back to Peter Doyle
20 with the authority of having been contacted by the
21 Department of Health about a perceived problem. It was
22 the third course of action we agreed upon because that
23 preserved operating within the unit, it would lead to
24 the open review, it would reduce the high risk
25 operations and the solution would be found, we hoped.
0100
1 Q. Again, so we have consistency of account: you have said
2 on a number of occasions that you thought Gianni
3 Angelini had actually spoken to Mr Doyle at the
4 meeting. Peter Doyle tells us that did not happen, but
5 I think what you are saying is your best recollection
6 thinking about it is that you said "Professor Angelini
7 knows about the problem"?
8 A. Yes.
9 Q. You were getting Peter Doyle, were you, to essentially
10 give him an element of outside authority to do whatever
11 it was that he wished to do?
12 A. Yes, yes.
13 Q. We move then, 19th July. I took that slightly out of
14 sync' because we had looked at the data which we know
15 went on to October.
16 In your statement can I look at page 120, where we
17 have anaesthetists' concerns, line 14, where you say "In
18 August 1994 ..." you were talking about the letter we
19 have seen of June 1994 when first drafted?
20 A. Yes.
21 Q. The Nottingham City Hospital application you deal with.
22 I am not I think concerned about that.
23 A. Yes.
24 Q. Page 121 -- let me take you back, WIT 80/118, bottom of
25 the page "Meetings with MPs". You date that 1993. Is
0101
1 it in fact right that those meetings or the contacts
2 took place after the operation on Joshua Loveday in
3 1995?
4 A. Yes.
5 Q. Again we have to adjust the chronology as you tell it
6 in your statement?
7 A. Yes, I am sorry about that.
8 Q. Similarly if we go back to 121, where we have
9 Dr Roylance issuing threats.
10 A. Yes.
11 Q. I will come back to the conversation in some detail.
12 For timing purposes this again was after the
13 Joshua Loveday operation, was it not?
14 A. Yes, I think so. I must say I am slightly puzzled that
15 I had presumably in my Filofax, because my only
16 contemporaneous record was my 1994 Filofax which I have
17 submitted to the Inquiry which presumably had an
18 appointment for Friday, 25th November in Trust
19 Headquarters with Dr Roylance.
20 Q. Let me show you. If you go to WIT 80/16, bottom of the
21 page, Dr Roylance's recollection: "1995 not 1994 that
22 I asked to see Dr Bolsin" and then sets out the
23 circumstances?
24 A. Yes.
25 Q. If we can have UBHT 52/170. This is your account of
0102
1 events written in October 1995?
2 A. Yes.
3 Q. If we go to page 182, please. You see Dr Roylance and
4 a manslaughter investigation which describes the subject
5 matter, or part of it, at any rate, of the conversation
6 you are having with Dr Roylance. Can we scroll down?
7 "The early part of the meeting had been spent
8 discussing the background to the documentary programme
9 and dealing with the Trust's position regarding
10 authorised speakers for the programme. I had put
11 forward the view that I would like to speak on the
12 programme as my name was mentioned in the
13 Hunter/de Leval report."
14 That report did not come out until February 1995?
15 A. That is quite right.
16 Q. Thinking about it, I wanted to show you that so you are
17 happy about conceding, if that is the right word --
18 A. I am very happy with that. I agree it was a 1995
19 meeting. I am wondering what I was doing at Trust
20 Headquarters at 10.00 am on Friday, 25th November 1994
21 and whether that is a correct reference in my Filofax or
22 not.
23 Q. I cannot, I am afraid, help you on that.
24 A. Sorry about that.
25 Q. That has to remain a secret between you and your
0103
1 Filofax.
2 A. You have my Filofax.
3 Q. Have a look at it, it is WIT 80/192. That is where you
4 picked it from I think?
5 A. Yes, okay. I am sorry, that must have been about
6 something else.
7 Q. Again so we get the chronology right, just to complete
8 this topic of the dating of that particular meeting, you
9 were asked about the meeting at the GMC?
10 A. (Witness nodding).
11 Q. You also said at the GMC that the last time -- the only
12 time you met Dr Roylance personally face to face was
13 after the Joshua Loveday operation?
14 A. Yes.
15 Q. That again will tie in your October 1995 recollection
16 with Dr Roylance's recollection?
17 A. Yes.
18 Q. And with the subject matter of the discussion?
19 A. Yes, except that this might tend to suggest there may
20 have been a meeting with Dr Roylance in November 1994.
21 Q. It may suggest there was a meeting planned.
22 A. Yes.
23 Q. Which might have been cancelled and did not take place?
24 A. That is perfectly true, yes, yes.
25 Q. WIT 80/122. Bottom of the page. You are describing
0104
1 here I think how it was that you became aware of the
2 intention to operate on Joshua Loveday?
3 A. Yes.
4 Q. What was your understanding about whether arterial
5 switch operations would take place by the time we had
6 reached December 1994?
7 A. As you know, as we discussed this morning, the
8 paediatric cardiac anaesthetists had sent a letter to
9 Dr Monk addressing the issue. Following that I had
10 a meeting with Dr Doyle and Dr Doyle had requested
11 Professor Angelini to provide him a report about the
12 safety of the paediatric cardiac surgery unit and the
13 plans for making it safe in the future.
14 My understanding from Professor Angelini was that
15 one of the undertakings that he had gained from the
16 paediatric cardiac surgeons was that there would be no
17 more switch operations in the BRI until Mr Pawade
18 arrived.
19 Q. Help me with this: the chain of communication that you
20 are describing appears to go from someone at the Trust
21 to Dr Doyle at the Department of Health, from Dr Doyle
22 to Professor Angelini, from Professor Angelini to you to
23 give you your understanding?
24 A. Yes.
25 Q. Thank you. You could only speak as to your
0105
1 understanding, you cannot speak for how accurate any of
2 the stages of those chains might be in reporting?
3 A. No. I mean I would say that I had kept Professor
4 Angelini informed of my communications with Dr Doyle and
5 he had kept me informed, I thought, of what his
6 impression was of what was going on as well.
7 Q. Yes. When you heard that this operation was going to
8 take place, what was your reaction?
9 A. Just to be clear: I saw that the operation was going to
10 take place because it was on an operating list that was
11 circulated. I immediately went round my colleagues
12 suggesting that I thought this operation should not go
13 ahead. We had raised our concerns as a group. There
14 were obvious problems with this operation, I did not
15 think we should proceed.
16 Q. A consequence I think of your concern and Professor
17 Angelini's concerns and the concerns of others who were
18 notified and spoken to was that a meeting was convened
19 by Mr Wisheart which took place, did it, on 11th January
20 1995?
21 A. Yes.
22 Q. Can we have a look at notes of that meeting taken by
23 Dr Martin, UBHT 61/185? First of all, does it
24 correctly, as you recall it, identify those who were
25 present?
0106
1 A. Yes.
2 Q. You appreciate what is blanked out is the name of
3 Joshua Loveday?
4 A. Yes.
5 Q. The second sentence:
6 "The results for neonatal arterial switch for
7 patients with intact ventricular septum were discussed
8 in passing. The overall mortality has been 9/13
9 (69 per cent). It has previously been decided to halt
10 the neonatal arterial switch programme for the moment
11 pending the development of the new unit."
12 That development, it was anticipated at this
13 stage, was it, that there would be a new hospital in the
14 sense that the BRI operating centre would move for
15 children to the Children's Hospital?
16 A. I know that had been proposed. I was not quite sure how
17 definite that was as a development.
18 Q. You knew a new paediatric cardiac surgeon had been
19 appointed?
20 A. Yes, and I knew who that was.
21 Q. Had that been one of the developments that had taken
22 place since he had spoken to Dr Doyle?
23 A. I think so, but I am not sure of the dates. I am not
24 sure what date --
25 Q. Appointed in September?
0107
1 A. In that case, yes.
2 Q. Again would I be right in thinking that up until you
3 heard of the intention to operate on Joshua Loveday, you
4 had seen developments taking place to improve cardiac
5 surgery in a way you had not seen before?
6 A. Yes, I think there were distinct developments in terms
7 of improving the service. I think we still had not seen
8 an open and thorough review and I still think we were
9 not sure which operations we did particularly well and
10 which operations we did particularly badly.
11 Q. Which might not have been such an important and vital
12 consideration if, on 1st May 1995, somebody else was
13 actually going to do the operations?
14 A. Yes, I think that is true except that I am not sure it
15 was intended at this stage that only one surgeon was
16 going to do paediatric cardiac surgery from May 1995.
17 Q. You did not, but you might have pointed out of course
18 the cardiologists, the anaesthetists, the nurses would
19 all remain the same and there may be practises they were
20 conducting which had an adverse influence?
21 A. Certainly, certainly.
22 Q. The third paragraph: "In total since February 1983,
23 a total of 28 patients had undergone an arterial switch
24 operation with closure of the VSD."
25 The arterial switch with closure is the
0108
1 non-neonatal switch operation, is it not?
2 A. Yes.
3 Q. Joshua Loveday was about 18 months of age, definitely
4 a non-neonate?
5 A. Yes.
6 Q. It sets out there the results?
7 A. Yes.
8 Q. Does it appear to set out those results accurately as
9 you understood them at the time with the best available
10 data?
11 A. Yes, I think so, it was the first time we had seen all
12 the data presented in this clear format and it was in
13 many ways the open and thorough review, the destination
14 we had been looking for, certainly for this particular
15 operation.
16 Q. It was Dr Pryn, was it, who conducted the essential
17 research that was presented?
18 A. Yes. The impression I got was that the surgeons had
19 gone through their records and Dr Pryn had gone through
20 his records and there was one slight modification in
21 principle to the printed sheet we looked at at the
22 meeting.
23 Q. We can find that at page 126/51. That is the revised
24 version. Let us go over to 126/52 for the original:
25 these are the figures Dr Pryn prepared, are they. We
0109
1 can see the alteration, the five JDW patients was
2 changed to four?
3 A. Yes.
4 Q. It is not very clear underneath the first group. Go
5 down to "Mortality". "17/37 and a total 88 to 94".
6 Again a consequent alteration because the numbers
7 were one out?
8 A. Yes.
9 Q. I think it is right, is it, Mr Dhasmana himself had
10 also prepared some figures?
11 A. Yes.
12 Q. Let us leave that on the board for the moment because
13 we are told these notes were made during the meeting and
14 that the revised figures were prepared as a record
15 afterwards.
16 Can I go back to the minute we had at 61/185,
17 I call it a "minute", a record? What is said, the last
18 paragraph on the screen: "In total since February
19 1983 ..." et cetera. Halfway down that paragraph: "24
20 patients operated on by Mr Dhasmana ..."
21 He was scheduled to do the operation, was he, on
22 Joshua Loveday?
23 A. Yes.
24 Q. During the period 1988 to 1994, overall mortality,
25 a third. "Mortality was higher in the first two years,
0110
1 presumably reflecting the learning curve for the
2 operation."
3 Stopping there, was that or was that not
4 a reasonable or an unreasonable view?
5 A. Of a learning curve?
6 Q. Yes. Leave aside whether there should have been
7 a learning curve, you are looking at figures and
8 interpreting figures, was it necessarily unreasonable to
9 take that view of it?
10 A. It is possible. If I can give a little bit of
11 background to my coming to the meeting, I do not know
12 whether that is important to you or not --
13 Q. I am asking you about the figures at the moment.
14 A. Yes. I had been in contact with Bill Brawn personally
15 on the telephone --
16 Q. What I am asking about -- if you follow the question, we
17 will probably get there sooner.
18 A. Okay.
19 Q. -- is whether or not it was reasonable or unreasonable
20 to say "the early results, learning curve, therefore one
21 would expect them to be worse than the later results"?
22 A. Yes.
23 Q. It goes on: "Over the period 1990 to 1994, 15 operations
24 performed, there were 3 deaths, giving an overall
25 mortality of 20 per cent. 8 of those patients were over
0111
1 1 year of age with 1 death, 12.5 per cent mortality."
2 Pausing there, Joshua Loveday in fact, if one were
3 going to put him into a category, would come within the
4 8 of the patients "over 1 year of age with 1 death"
5 group, would he not?
6 A. Yes.
7 Q. If one looked at him simply as a statistic?
8 A. Yes.
9 Q. It then reviews the figures and draws comparisons with
10 the United States, the mortality et cetera and the UK
11 Registry and sets out those figures. Perhaps we can go
12 back to Dr Pryn's data, the line that there would be for
13 those over 1 year in mortality.
14 Perhaps we can go back to page 51 because it is
15 clearer on that page. If we look at the non-neonates
16 line, the total from 1990 to 1994, we can see two
17 relevant entries: 3 out of 15, 20 per cent; 1 out of 8,
18 13 per cent, 12.5?
19 A. Yes.
20 Q. Down to the bottom of the page. The relevant comparison
21 for this operation is with TGA and VSD, is it not?
22 A. Yes.
23 Q. For 1992 that condition, that diagnosis, however it was
24 operated, had a mortality of 12 per cent?
25 A. Yes.
0112
1 Q. Could I now go back to the minute, but could I take it
2 up at UBHT 54/13, it is a better copy.
3 The paragraph we have there:
4 "There was discussion in those results and it was
5 felt that our more recent results were similar to that
6 for published data and therefore acceptable."
7 As I understand it, and correct me if I am wrong,
8 please, you were part of that discussion and you agreed
9 with that conclusion even though, as we shall go on to
10 see, you disagreed with the decision to carry on with
11 the operation?
12 A. Yes.
13 Q. The starting point in terms of looking at results was
14 that "Bristol, for children of the category to which
15 Joshua Loveday belonged or in which he was placed, was
16 not so out of step with our results that it necessarily
17 meant one should not proceed with the operation on that
18 basis alone"? I am very careful with the words I am
19 choosing.
20 A. Yes.
21 Q. It then records a further discussion. We come down to
22 the second last paragraph on the page:
23 "There was then a discussion as to whether it
24 would be appropriate to proceed with the planned
25 operation ... The general feeling expressed was that
0113
1 there was no clinical reason for deferring the surgery.
2 Dr Bolsin expressed the opinion that it would be
3 preferable to defer the surgery for a few months until
4 the new setup had been organised."
5 The discussion on the basis of the information for
6 the meeting appears to show a dispute between you on the
7 one hand and the feeling of the meeting on the other.
8 A. Yes.
9 Q. Is that right?
10 A. Yes.
11 Q. Were you expressing the view that surgery should be
12 deferred for a few months?
13 A. I think my view was that we should not be proceeding
14 with the operation the next day and that there were
15 safer alternatives for Joshua Loveday.
16 Q. What was the basis for your objection to going ahead
17 with the operation on Joshua Loveday as you expressed it
18 at the meeting?
19 A. As I expressed it at the meeting, I felt that our record
20 overall as an institution with this operation in its
21 totality, not just the over 1 year transposition with
22 VSD, was not good enough for us to guarantee a safe
23 outcome for that patient the next day.
24 Q. You agreed, did you not, that on the basis of the data
25 themselves there was no reason not to go ahead?
0114
1 A. I agreed that the difference between the two figures in
2 the categories we looked at was not big enough for me to
3 be able to say that there was a statistical difference
4 between them, but I did have other information which
5 I had at the time of that meeting.
6 Q. What other information was that that you expressed?
7 A. The information that I expressed at the meeting was that
8 Marc de Leval was looking at institutional outcomes for
9 complex procedures and that we as an institution had
10 a problem with this complex procedure.
11 Q. Did you suggest that going ahead with the operation
12 would be politically unwise, words to that effect?
13 A. I do not think I used the word "politically" that has
14 come in after the meeting, but I think I may have said
15 I thought it was unwise to proceed.
16 Q. On the basis that if it went wrong, then it would be
17 devastating to the unit, or what?
18 A. I think that would have been one consideration and I had
19 a range of considerations that it was unwise to proceed
20 with this operation at this stage. I think one would
21 have been patient safety and the other one would have
22 been that it might have an adverse effect on the unit,
23 particularly with my understanding from Professor
24 Angelini that he had given an undertaking to the
25 Department of Health that we were not going to undertake
0115
1 any more high risk procedures, in which category I think
2 he had put the arterial switch operation.
3 Q. Once one had excluded, if one excluded as a matter of
4 logic the figures as a reason for not going ahead with
5 the operation, then the decision whether to proceed or
6 not would have to be one based upon the best interests
7 of the child, would it not?
8 A. Sorry, if we have taken out the figures?
9 Q. If the figures are not a reason for not going ahead.
10 You say "The figures appear to show for this category of
11 child that we as a unit are pretty much in line with
12 results elsewhere so far as we can tell"?
13 A. I think you are using the word "figures" in a way in
14 which you perhaps implied criticism of me for using the
15 word "results" before the last break and there were
16 a whole series of figures here. The figures I would
17 have said indicated that we should not have gone ahead
18 with that operation was that overall this institution
19 had an operative mortality -- I cannot remember what it
20 was, it was big. Yes, for a small group of figures (and
21 you have taken me through them very elegantly) there was
22 no difference between the patient the next day and the
23 national average performance. But there was a whole set
24 of figures around them which indicated we had an
25 institutional problem with this operation.
0116
1 If I can bring in the information that I also had,
2 I had spoken to Bill Brawn, he had explained to me that,
3 firstly, in Birmingham they had had one death in over
4 200 switch operations.
5 Q. Did you say that at the meeting?
6 A. No, I did not, that was a personal, private conversation
7 that I had had with Bill Brawn and I did not think that
8 at this meeting was the time to bring that information
9 in.
10 Q. Was there no discussion of taking Joshua down the road
11 to Birmingham?
12 A. I believe the question was raised whether he could be
13 transferred or not.
14 Q. And?
15 A. The decision was that -- to be quite honest with you
16 I am not quite sure, it was decided that he could not be
17 transferred to Birmingham, but it was ruled out as an
18 option at that meeting.
19 Q. If there had been any significant discussion about the
20 possibility of Birmingham, presumably you would have
21 mentioned "They have actually got very good results
22 because Bill Brawn has told me", would you?
23 A. I might not have said that because the discussions that
24 I had had with Bill Brawn, he had asked me to keep
25 confidential. We were talking about another colleague,
0117
1 Janardan, in what is essentially a very small group of
2 operators, paediatric cardiac surgeons in the UK, it is
3 a very small club and if Bill Brawn had known I was
4 going to be feeding to him private conversations I was
5 having with him, expressing my concerns about the record
6 in Bristol, I do not think he would have continued to
7 advise me.
8 Q. The agreement I had understood, and obviously correct me
9 if I am wrong, that everyone at the meeting reached was
10 that the figures themselves were, as they stood, no
11 basis for not doing the operation?
12 A. Yes.
13 Q. That is not quite the same question possibly as why one
14 should do the operation?
15 A. Yes.
16 Q. Whether an operation should be performed must
17 necessarily depend upon a view, must it not, of the
18 interests of the patient and how urgently and so on an
19 operation may be required?
20 A. Yes, yes.
21 Q. What, if anything, was said about that that you
22 recollect?
23 A. The impression I got from the meeting was that the
24 operation was urgent enough to prevent transfer to
25 another centre.
0118
1 Q. That view that the operation was urgent enough to
2 prevent or militate against transfer to another centre
3 was expressed by whom?
4 A. I think it was by the paediatric cardiologists.
5 Q. Were you as an anaesthetist effectively in any position
6 to second-guess their clinical judgment?
7 A. Not at all, no.
8 Q. In terms of deciding whether there should be an
9 operation, you could not contribute on clinical grounds?
10 A. No. The only information that I would have had was that
11 Joshua would have been at home the day before and would
12 therefore not have been in need of urgent hospital
13 treatment.
14 Q. It might have been surprising to you that he had been on
15 a list first of all circulated in November and December,
16 an elective surgery and it appears that he is now
17 urgent?
18 A. Yes.
19 Q. Which of the cardiologists, because you put them in the
20 plural, do you think indicated how urgent the situation
21 of Joshua Loveday was?
22 A. I think it was Dr Martin.
23 Q. Despite the fact that the figures were not in themselves
24 a reason for not proceeding with the operation?
25 A. Yes.
0119
1 Q. Despite the view that Dr Martin had expressed, that on
2 clinical grounds the operation should go ahead and it
3 was too urgent to transfer Joshua Loveday as you
4 recollect it, you still maintained an opposition to the
5 operation, did you?
6 A. Yes.
7 Q. Everyone else, as we know, at the meeting agreed it not
8 only could, but should go ahead?
9 A. Yes.
10 Q. Upon the basis of the information they discussed?
11 A. Yes.
12 Q. Why was it, then, that you maintained an opposition?
13 A. It actually came to a vote and I asked for my opposition
14 to the operation proceeding the next day to be minuted
15 because I felt very strongly that this was not in the
16 best interests of this patient and while the small boxes
17 that we looked at were similar, all the figures, the
18 other figures around those boxes indicated that we had
19 an institutional problem, and I did use the phrase
20 "institutional problem" and it was taken directly from
21 Marc de Leval's application for a British Heart
22 Foundation grant and I felt we had an institutional
23 problem with this operation.
24 Q. "Institutional" may give one the picture of a problem
25 which is across the whole of the institution.
0120
1 A. Yes.
2 Q. Any institutional factor would therefore apply to all
3 operations, would it not?
4 A. No, what I said was: we had an institutional problem
5 with this operation.
6 Q. I appreciate you picked up the word from elsewhere and
7 used it.
8 A. Yes.
9 Q. What in particular did you think there was about the
10 institution as a whole which meant that the performance
11 of this operation as opposed to others was one which
12 should not go ahead?
13 A. I think the overall record for this operation when you
14 look back at the early learning curve and the global
15 results for the neonatal arterial switch indicated there
16 was a problem and by comparison with what I knew of
17 achievement in other centres, I believed we were not in
18 a position to expose this child to those risks.
19 I did not want to personalise the debate, I did
20 not want to say "Janardan cannot do these operations",
21 I did not want to say "The cardiologists cannot get
22 these diagnoses right", I did not want to make that kind
23 of criticism, I just wanted to say as an institution we
24 did not seem to be able to get the switch operation
25 right.
0121
1 Q. What Dr Martin has told us -- and this is his
2 recollection, it is one of a number we have of this
3 particular meeting but I shall put it to you for your
4 comment as to how accurate or inaccurate you think it
5 may be. I will read it out to you:
6 "I indicated [this is Dr Martin] his clinical
7 urgency and I do not think I would have used, I may not
8 have used the term 'deteriorating' but I would have
9 probably have indicated that with his known problem with
10 regard to the pulmonary artery bending like we have
11 already discussed, it is a condition that is only going
12 to get worse rather than better.
13 Question: Did you, as you recollect it, say that
14 the child required surgery urgently?
15 Answer: I think, as I have already indicated,
16 I indicated there was a degree of clinical urgency to
17 this case which I think we have already discussed with
18 Dr Silove and Dr Deverall. It was my opinion that
19 a delay of a few weeks would be, if there was a medical
20 reason to defer, would be acceptable but any deferment
21 of the operation, if he was going to be operated on in
22 our unit which we had agreement to, would subject him to
23 an increased and if there was a gain to him being
24 deferred then I was happy to go along with that but
25 I did not feel that was likely."
0122
1 That is what he recollects he said. Does that, do
2 you think, agree with your recollection of the way that
3 he described the urgency or lack of urgency of the
4 operation?
5 A. Certainly my impression of the meeting was that the
6 urgency of the operation prevented transfer to another
7 hospital which was also mentioned as a possibility for
8 this patient.
9 Q. Do you remember what it was about the urgency? If you
10 can; if you cannot remember please say so.
11 A. I think it would have been how blue the child was.
12 Q. Was there any feeling that the child was getting bluer?
13 A. Probably, but I cannot -- his increasingly cyanosed
14 status, his "bluerness" would have been the reason given
15 for the urgency of the operation.
16 Q. Again you are using expressions like "would have been".
17 I do not want you to say something you are not sure of,
18 of this meeting of all meetings.
19 A. I think they were given as reasons for the urgency of
20 the operation.
21 Q. During the meeting, can we go back to the minute, the
22 record, the last paragraph we see on the screen:
23 "Some discussion amongst the group regarding
24 contacts between the Department of Health and members of
25 the unit."
0123
1 When you were asked about this meeting at the GMC,
2 I think your first recollection, which you said quite
3 definitely, was that you had not mentioned at the
4 meeting anything about your contacts with the Department
5 of Health.
6 A. (Witness nodding).
7 Q. Subsequently, a day or so later at the GMC you thought
8 you might very well have done?
9 A. Yes.
10 Q. Looking at the minute here, which do you think is right?
11 A. I think the second one. I am sure the Department of
12 Health came up at the meeting.
13 Q. Was there any argument and vehement comment, discussion,
14 about it?
15 A. I think there was criticism of me for having gone to the
16 Department of Health about this issue of safety in
17 paediatric cardiac surgery.
18 Q. Who was criticising you?
19 A. I think Dr Masey criticised me. She considered that
20 this was a very disloyal act.
21 Q. Disloyal or a matter of taking matters outside the unit
22 which better belonged in the unit, or what?
23 A. I think that is the same sort of thing.
24 Q. So the flavour of what she was saying was she would have
25 expected you to do, what?
0124
1 A. I think it was not what she would have expected me to
2 do, it was she would have expected me not to have gone
3 to the Department of Health, that was the criticism.
4 Q. Can we come back to your statement, page 123? You deal
5 with the operation there. Can I ask you: did you have
6 a perception of how willing or unwilling Mr Dhasmana was
7 to perform the operation on Joshua Loveday?
8 A. No, he was one of the majority that was prepared to go
9 ahead with the operation the next day. I did not get
10 any impression of reluctance to proceed with the
11 operation.
12 Q. You deal in the next few pages with your recollection of
13 the meeting. We come to page 126.
14 A. Can I just sort of add: I do not have any recollection
15 at the meeting of Dr Monk mentioning that he had spoken
16 to Mr Wisheart that day and that they had agreed the
17 operation should not proceed and I do not remember
18 Dr Monk telling us that he had met with Mr Dhasmana and
19 that they had agreed that the operation should not
20 proceed. That information was not brought to the
21 meeting.
22 Q. Was the meeting told that Mr Wisheart in conversation in
23 a side meeting with Dr Martin and Mr Dhasmana was asking
24 whether or not the operation might not have been delayed
25 for a while?
0125
1 A. I do not remember that information being presented at
2 the meeting either.
3 Q. You deal in your statement with the consequences of the
4 operation which, as we know, went tragically wrong?
5 A. (Witness nodding).
6 Q. You deal with the Hunter/de Leval report and you gave
7 evidence to them. WIT 80/127, lines 22 to 25. You talk
8 about a "tirade of hostile questions" from Mr de Leval?
9 A. Yes.
10 Q. Was it all like that?
11 A. No, no, it was just this very early bit and when I went
12 through my explanation that the bit that seemed to have
13 got him worked up was actually not my data, that was
14 data produced within the unit by Mr Wisheart, he
15 suddenly changed, he changed his whole effect
16 completely.
17 Q. You have quoted WIT 80/128, a number of quotes from the
18 original report as you have it.
19 A. Can I say I do not have a copy of the original report.
20 Q. I think you would be the first to concede, would you,
21 that the expressions there set out, 1, 2, 3, 4 at the
22 top of the page may not be strictly and entirely
23 accurate?
24 A. They are my best recollection.
25 Q. Despite putting quotes round them?
0126
1 A. Yes, yes.
2 Q. We have had a comment from Mr Wisheart which points out
3 that each of those four payments is to an extent an
4 inaccurate reflection of the report and each of them in
5 fact casts a slightly more adverse impression upon him
6 and Mr Dhasmana than the report itself in its original
7 form did.
8 A. Yes.
9 Q. Without taking you to it in detail, you are happy to
10 accept that?
11 A. Yes, yes, and I am sorry if that impression has been
12 given.
13 Q. The only point which arises from it is: whether at this
14 stage you felt particularly aggrieved at one or other or
15 both of the surgeons?
16 A. I think what I have written down here in my statement is
17 my best recollection of a report that I think I probably
18 read once in Trust Headquarters and then saw only again
19 on overheads when Mr McKinlay the Chairman of the Trust
20 went through the original report and that was in 1995,
21 and then the original report I do not think resurfaced
22 for some considerable time and I certainly have not seen
23 another copy of that report.
24 Q. You deal at the bottom of page 128 with a meeting which
25 was chaired by Mr McKinlay.
0127
1 A. Yes.
2 Q. Your recollection was that the meeting agreed the
3 contents of the report and approved the findings of the
4 report, agreed the implementation of the conclusions?
5 A. Yes.
6 Q. What Mr McKinlay has told us is in fact the meeting did
7 not agree the report, rather it received it and felt it
8 could not approve the findings of the report because
9 that would possibly expose the Trust to legal
10 difficulties among those whom the report purported to
11 criticise.
12 A. Yes.
13 Q. Is it the case, do you think on reflection, that he may
14 be right about that?
15 A. I am not sure. Mr McKinlay certainly did not mention at
16 that meeting that the Trust was taking legal advice
17 about the report and that therefore we would not be able
18 to either quote it or approve the findings. My
19 understanding of the meeting, and it was from a short
20 preamble that Mr McKinlay went through, was that there
21 had been a meeting between the Trust senior staff and
22 the Department of Health at which it had been decided
23 that the senior clinicians should approve the findings
24 of the report and agree the implementation of the
25 recommendations of the report. That was the reason for
0128
1 having the meeting.
2 Q. It was about this time, was it, that there was a meeting
3 between yourself and Dr Roylance?
4 A. Yes.
5 Q. And if I can go back, because it is a meeting if you
6 remember we put in the wrong place so far as timing is
7 concerned --
8 A. Yes.
9 Q. -- what was it that gave rise, do you think, to that
10 meeting?
11 A. This is a meeting, the date -- we have agreed the date,
12 or?
13 Q. The date is I think in or around March/April 1995. Can
14 I remind you of the circumstances, at least part of the
15 background: you had had under your care a patient,
16 I think an adult patient, not a child; that the patient
17 had had a blood transfusion of two units of blood which
18 were not crossmatched and in consequence the patient had
19 died and the suggestion was that you might be
20 responsible for that to such an extent the police were
21 investigating whether they might bring manslaughter
22 charges?
23 A. Yes. If I could just say, you said as a consequence of
24 the blood transfusion the patient had died. In fact it
25 was established it was as a consequence of the coronary
0129
1 artery disease the patient had that the patient died and
2 that the blood transfusion had not in any way
3 contributed to the patient's death.
4 Q. We have had comments in from the Trust on this part of
5 your statement, which I will show you on the screen,
6 WIT 80/422. It picks up comments -- I do not want to
7 take too long over this -- if we look down at the third
8 paragraph:
9 "He states [that is you] during the operation the
10 patient had received two units of blood, not
11 crossmatched for them." The comment "This was not an
12 emergency where there was not time to crossmatch the
13 blood, but in fact the two units of blood given had been
14 crossmatched and labelled for another patient."
15 A. Yes.
16 Q. And you had yourself administered the incorrect blood to
17 the patient. It then says in your statement at page 3,
18 you "incorrectly stated [and it quotes] 'although
19 a recent Coronial Inquiry had exonerated my
20 involvement'" and what it says is incorrect about that
21 is the word "exonerated" I think. You said:
22 "That is not the role of a Coroner who was always
23 careful not to make any comments on culpability but to
24 examine the particular facts" and it says "you correctly
25 say the Coroner returned a verdict of death by natural
0130
1 causes".
2 That is the point you are making to me, it was not
3 your responsibility in the sense of causing death, it
4 was natural causes that caused the death?
5 A. Yes.
6 Q. The final sentence if we scroll down, please, paragraph
7 C, WIT 80/5 -- this is a completely different point but
8 I will pick it up so we have this on the screen -- it is
9 suggesting that there was managerial assistance to the
10 Department of Anaesthesia because Mrs Pat Fields
11 provided it, preceded by Mr Joe Devanny; is that right?
12 A. Yes, that is true.
13 Q. That is only to set the scene for this particular
14 meeting, no more than that and, beyond having to put
15 those comments to you, I am not concerned with that
16 particular event, please appreciate.
17 THE CHAIRMAN: We need to make that quite clear, do we not?
18 The purpose of taking Dr Bolsin to that is to set the
19 context of this meeting and no more.
20 MR LANGSTAFF: It needs to be made absolutely clear: this is
21 a regrettable incident in which, although there was
22 consideration of manslaughter charges nothing was
23 preferred and anything to the detriment of Dr Bolsin
24 must not be assumed from that fact?
25 A. Thank you for making that clear.
0131
1 Q. That needs to be made clear because it is liable to
2 misinterpretation and it is only to set the context for
3 the meeting and the questions and the issues that arise
4 that it needs to be mentioned at all. I am sorry if it
5 is --
6 A. I understand that.
7 Q. The meeting you then had with Dr Roylance was
8 essentially, was it, to discuss that issue and the
9 issues that surrounded it?
10 A. Yes, I am not sure what the reason for the meeting was,
11 but I was called to Dr Roylance's office.
12 Q. How do you recollect the meeting began?
13 A. I am trying to think now. I think we started by talking
14 fairly -- the actual beginning I cannot remember, to be
15 quite honest with you. I think we got down to the
16 business fairly quickly but there were a few
17 pleasantries early on.
18 Q. When you got down to business?
19 A. I think we were then talking about the Hunter/de Leval
20 report and the issue of paediatric cardiac surgery.
21 Q. How did that arise?
22 A. I am not quite sure to be quite honest with you. I mean
23 I would have to look at some notes of the meeting or
24 a recollection of the meeting because we also talked
25 about the issue of the manslaughter charges or the
0132
1 patient who was at issue that we have just talked about
2 and possibly more towards the end of the meeting.
3 Q. Do you recollect whether at this stage you had decided
4 to or perhaps been filmed with a view to appearing in
5 a programme called Despatches?
6 A. No, if there was any talk about filming for television
7 or appearing on television this was much more to do with
8 a BBC television programme which was -- I am trying to
9 think now -- being filmed by local television in
10 Bristol.
11 Q. There was talk about a TV programme which you -- had you
12 been filmed or were you proposing to be filmed?
13 A. I think the meeting we are talking about looked at -- we
14 talked about the Hunter/de Leval report. We talked
15 about the revised Hunter/de Leval report, the second
16 version and I was concerned that there was implied
17 criticism of me in the form of anaesthetic concerns
18 raising anxiety levels within the unit, I think that was
19 my particular concern.
20 Dr Roylance had, I think he had accepted that the
21 report was going to be made public and I think
22 I requested him to issue a statement through the Trust
23 on behalf of me just to clarify that my concerns had
24 been justified and not intended to raise the anxieties,
25 that sort of thing.
0133
1 Q. When you indicated -- which presumably you did to
2 Dr Roylance, that you were going to or thought you might
3 take part in a TV programme -- was his action one of
4 encouraging you, discouraging you, what was it?
5 A. I think what I said was "will you issue a statement on
6 behalf of me through the Trust Press Office in order to
7 disassociate me from actions which have caused -- raised
8 anxiety which is what the second Hunter/de Leval report
9 was suggesting.
10 He said he was not prepared to do that and I think
11 at that point I said "well, under those circumstances
12 what options do I have in terms of making or putting
13 across my side of the story?" and I think I probably
14 told him that I had been asked but at that point had not
15 agreed to be filmed by the BBC programme.
16 Q. You say in your statement that there was a threat made
17 to you?
18 A. Yes.
19 Q. How did the threat come to be made?
20 A. That came much later on at the end of the meeting and it
21 was a complete change of subject and we suddenly got
22 this aerospace analogy being brought up.
23 Q. Can I ask you to stop?
24 A. Yes.
25 Q. You talked about the charge that you were not going to
0134
1 face ultimately and problems arising out of that?
2 A. Actually I am not sure whether that had come up first or
3 not, it may have been we went straight to the
4 Hunter/de Leval report.
5 Q. You talked about both those issues in that case, if
6 I can put it like that, and then at the end of the
7 conversation as you recollect it there came something
8 about the aerospace industry?
9 A. Yes.
10 Q. What was the link to the aerospace industry to either of
11 the other two matters?
12 A. It was the Coronial Inquiry was the link to the
13 aerospace industry.
14 Q. What was said?
15 A. I think it was along the lines of "you have just been
16 involved in a case in which two units of the wrong blood
17 were given to a patient and the patient subsequently
18 died and there has been a Coronial investigation" and
19 then we launched into this aerospace analogy.
20 Q. Tell us it as you recollect it?
21 A. The opening phrase was I think "we now have a Chairman
22 of the Trust who is from the aerospace industry, he is
23 used" -- I have to get this right now -- "the standards
24 of the aerospace industry are such that if somebody is
25 paid to bolt the blades on helicopters and there is an
0135
1 accident where the blades fall off a helicopter then the
2 person who was paid to bolt the blades on a helicopter
3 never does that job again"; that was the gist of the
4 conversation or the gist of his dissertation.
5 Q. The link from the way that you recall it appears to be
6 with suggested lack of competence --
7 A. Yes.
8 Q. -- in the context you describe?
9 A. Yes.
10 Q. Essentially saying "if somebody cannot do the job then
11 they should not be the job", would be a way of putting
12 it?
13 A. Yes, I perceived it as a very real threat to my future
14 as a cardiac anaesthetist.
15 Q. I follow that. What I am trying to do is to link the
16 threat with something that gave rise to it?
17 A. Yes, the "something that gave rise to it" was the
18 Coronial Inquiry and the manslaughter investigation and
19 the two units of wrong blood to a cardiac patient.
20 Q. As it happens in respect of that, there was no question
21 of your being suspended from duty?
22 A. Not at all, it had never been raised.
23 Q. Is it right that Mr Wisheart had supported you in this
24 particular issue and matter?
25 A. Yes, if he was preventing me from being suspended then,
0136
1 yes, certainly, he was supporting me.
2 Q. That was, was it, as you recollect it the extent of the
3 threat?
4 A. Yes, I think it was the juxtaposition of those two
5 components, the Coronial Inquiry and the helicopter
6 blade analogy, after I had suggested that I might want
7 to put my case outside of a Trust format because he was
8 not prepared to release a statement on my behalf; it was
9 quite chilling.
10 Q. That I understand. Was there any connection in time,
11 the time that the discussion about wanting to put your
12 side of the story because of what the Hunter/de Leval
13 report had said and the threat, or can you not recall?
14 A. I think we came down to going through this
15 conversation. Dr Roylance had advised me that the press
16 do not always get things right and they can misinterpret
17 and misconstrue things and that it might not be wise for
18 me to consider taking part in the programme. What I had
19 put back to him was that he was not leaving me with many
20 alternatives if he was not prepared to issue
21 a statement. I was saying "you issue the statement,
22 I do not need to do anything else." He was saying "I am
23 not going to issue a statement" and I was saying "well,
24 what does that leave me with?" and then we cut through
25 to the aerospace analogy -- we cut through to the
0137
1 coroner's case and the aerospace analogy.
2 Q. I am conscious of the time. We are not quite going to
3 finish when I had hoped I might. It is probably
4 appropriate, sir, if we take a short break for 10
5 minutes. I do not think I am going to be very much
6 longer in asking you questions, Dr Bolsin, possibly 20
7 minutes, no more than 30 minutes, but it may be sensible
8 to have a break now rather than trying to get through it
9 in one go?
10 THE CHAIRMAN: Shall we break until just after 2.40 pm.
11 (2.25 pm)
12 (A short break)
13 (2.40 pm)
14 MR LANGSTAFF: I want to spend a few minutes before there
15 are some wrapping-up points, if I may call them that,
16 which I may take up with you, Dr Bolsin, to talk about
17 what happened after the middle of 1995.
18 A. Yes. Can I just say, before we leave the Dr Roylance
19 meeting and the helicopter blades analogy, the evening
20 of that meeting I was phoned by Dr David Coates, who was
21 one of my consultant anaesthetic colleagues. He was
22 also the place of work accredited representative for the
23 Bristol Royal Infirmary for the British Medical
24 Association. He phoned me up concerned that he had just
25 received from Dr Roylance a serious threat to my career
0138
1 and he produced for me the next day a computer record of
2 a conversation that he had had with Dr Roylance, in
3 which exactly the same analogy was used to advise
4 Dr Coates --
5 Q. A computer record?
6 A. Yes. He produced a record that he had typed up that
7 evening of the conversation he had with Dr Roylance.
8 Q. So when you say "a computer record", you mean
9 a typed-up statement by him after the event?
10 A. Yes, a contemporaneous record, yes.
11 Q. So again, this is something which we shall have to ask
12 Dr Coates about --
13 A. Yes.
14 Q. -- because you were not present at the meeting that he
15 had with Dr Roylance, and you can only speak as to what
16 he then reported to you.
17 A. No. That is right.
18 Q. Was anything published in the Daily Telegraph?
19 A. Yes, there was an article in March or April, I believe.
20 Q. I think it may have been April.
21 A. Right.
22 Q. Were you quoted in that paper?
23 A. A "Dr Bolton" was quoted in that article.
24 Q. Were you the only person who might have fitted the
25 description, do you think?
0139
1 A. I certainly fitted the description, yes.
2 Q. The doctor who was quoted in the article by the name of
3 Bolton, he was expressed, was he, to give certain views
4 as to paediatric cardiac surgery at Bristol?
5 A. I think in the article there may have been some quotes,
6 yes.
7 Q. And simply, tell us whether you actually made those
8 quotes, or did not?
9 A. No, I confirmed a telephone conversation with
10 a journalist from the Daily Telegraph.
11 Q. When you say you "confirmed" ...
12 A. What happened was, I was phoned up and I was given the
13 story of what had happened at the Bristol Royal
14 Infirmary and my error --
15 Q. And you were asked what?
16 A. "Have you got any comments to make?" My error was to
17 say, "I am not in a position to comment but you seem to
18 have got most of the story".
19 Q. The only thing I then want to ask you about is this:
20 having seen your name in print and comments attributed
21 to you which you had not given, you merely endorsed in
22 the way you described, did you write to the Daily
23 Telegraph to complain about the fact that they had
24 abused your trust in this way?
25 A. I discussed it, I think -- what I actually did, that
0140
1 morning I spoke to --
2 Q. Perhaps it is easier if you answer the question, and
3 then tell us what follows.
4 A. The answer is no, I did not.
5 Q. You were going to tell us why not. Because you
6 discussed it and you were advised not to?
7 A. I spoke to Dr Roylance and he said "It is unlikely to do
8 any good, and it is just going to make the whole thing
9 more protracted; I am happy with your explanation, do
10 not worry about it", sort of thing. "Yes, it is
11 a difficulty but we can deal with it."
12 Q. Did the fact that you were quoted in the Telegraph,
13 affect your working relationships within the unit, do
14 you think?
15 A. It think it may well have done, yes.
16 Q. In what way do you think it did so?
17 A. I think that there was probably a level of distrust of
18 me personally for having now been associated with the
19 paediatric cardiac surgical record getting into
20 a national newspaper.
21 Having said that, it was not necessarily my view,
22 because I knew that the Trust had released the
23 Hunter/de Leval report to a local television station and
24 that they had been ordered to do so by the Department of
25 Health.
0141
1 Q. But it is perceptions that I am concerned with. With
2 whom do you think it may have affected your
3 relationship?
4 A. I think that the two paediatric cardiac surgeons, it
5 would certainly have affected my relationship with them;
6 however, I knew that Mr Wisheart knew that the Trust had
7 been ordered to release the Hunter/de Leval report,
8 therefore he should not necessarily have blamed me for
9 any ensuing publicity.
10 Q. Did he blame you?
11 A. That was the perception I had, yes.
12 Q. Based on anything he said, or upon your assumption?
13 A. It was based on the assumption that we then went into
14 reconciliation with consultant psychiatrists.
15 Q. Did anything happen to your clinical commitments within
16 the Trust?
17 A. Yes. In order to reduce my exposure to Mr Dhasmana and
18 Mr Wisheart, I had to reduce my cardiac surgical
19 anaesthetising.
20 Q. That was a decision reached, we have been told by
21 Dr Monk, in discussion with him, so that he swapped your
22 list with another anaesthetist?
23 A. Yes. It was in discussion with me after it had
24 happened, because what happened was that I turned up for
25 cardiac theatre on a day I should have been there and
0142
1 Dr Masey was doing my list or in my theatre. She then
2 said, "Dr Monk told me you were doing my general
3 surgical list in another operating theatre". So I then
4 went to do the list, then went and spoke to Dr Monk, and
5 then discovered that the decision had been taken, but
6 I actually got to hear about it indirectly.
7 Q. If we can have up on the screen WIT 80/30, if you move
8 down the page, please, the bottom of the page:
9 "I decided the implications of changing
10 a consultant's working practice, however temporary,
11 required that he should have the support of colleagues.
12 Therefore I explained the situation to and requested the
13 help of Dr Thomas", and it then goes on to a meeting
14 between him, Dr Thomas, Professor Prys Roberts and
15 yourself?
16 A. Yes.
17 Q. He tells that you say the aim of the meeting was to
18 inform you of the Trust's viewpoint which he, Dr Monk,
19 had become aware of; that you could not anaesthetise
20 children for two surgeons pending resolution, the
21 possible solutions, and that he formed the impression
22 the Trust would not support him in preference to the
23 surgeons.
24 A. Yes.
25 Q. How accurate a reflection of the discussion is that, do
0143
1 you think?
2 A. The meeting with Dr Thomas and Professor Prys Roberts
3 took place after I had written a letter to Dr Monk.
4 After the informal unilateral changing of my cardiac
5 commitment on a general surgical commitment, I wrote to
6 Chris asking for some documentation, and also that it
7 should only be short-lived, and at that point, I then
8 was asked to meet Dr Monk, Professor Prys Roberts and
9 Dr Thomas, and at that meeting they explained that if
10 I did not continue to do general surgery, then the Trust
11 would have two options: one would be suspend two
12 paediatric cardiac surgeons and the other would be to
13 suspend a cardiac anaesthetist, and they would be likely
14 to take the latter view.
15 Q. The bottom of the page, there:
16 "The outcome of the meeting was that Dr Bolsin
17 agreed to move one day of his cardiac commitment on
18 a temporary basis."
19 As a matter of fact, is that correct?
20 A. I had already done that before the meeting took place.
21 I was asking to move back to my original arrangement and
22 this was when the meeting took place.
23 Q. I think there is some disagreement -- it may not be of
24 the greatest importance -- between Dr Monk and yourself,
25 on this.
0144
1 When Dr Monk gave evidence to us, he indicated
2 that you and he had agreed that you would not
3 anaesthetise with the surgeons, there had been a change
4 of rota.
5 A. Yes.
6 Q. You wrote subsequently seeking something in writing,
7 which you say you did?
8 A. Yes.
9 Q. But his recollection is that the agreement came first
10 and then the change. Your recollection is that the
11 change came first and then the agreement?
12 A. Yes.
13 Q. I think we will leave it there, if we may.
14 Only this: you were upset, were you, about the
15 change to your rota?
16 A. Yes. I did not want it to be a permanent change because
17 I, at that stage, was a national audit co-ordinator in
18 cardiac surgery, and I felt that I needed to keep up my
19 cardiac surgical commitment in order to maintain that
20 role.
21 Q. What was agreed was a temporary change?
22 A. Yes, it was not said how long "temporary" was. It could
23 have been two years, it could have been two weeks.
24 Q. As it happens, you made a point I think earlier, when
25 you described your letter of 1990 to Dr Roylance, saying
0145
1 that you were very concerned about the situation in
2 paediatric cardiac surgery?
3 A. Yes.
4 Q. You have said more than once if you thought there was
5 a serious risk from operation to a child that you would
6 no longer anaesthetise for that child?
7 A. Yes.
8 Q. Here was the situation where you thought that what was
9 required for paediatric cardiac surgery was a detailed
10 investigation of faults that might very well be
11 institutional, and putting children at risk?
12 A. Yes.
13 Q. You were being offered, as it happens by default, as you
14 recollect it, a change to general surgery where your
15 patients would not be at that risk. Why did you not
16 welcome it? Why did you reject it?
17 A. I think by this time we knew that the organisation had
18 agreed with the Department of Health that they were
19 actually not going to do any more high risk operations,
20 so I was perfectly content in my mind that high risk
21 operations were off the agenda.
22 Q. On this same point, can we look at UBHT 146/24? This is
23 the letter of 26th April 1995 to you. If we scroll
24 down:
25 "As Clinical Director I asked to you agree to
0146
1 flexibility in your work pattern in site but not in time
2 to avoid interpersonal conflict" and that is what he had
3 done?
4 A. Yes.
5 Q. The second paragraph:
6 "The reasons for this action are that the
7 report ... by the assessors raised specific concerns
8 over the lack of collaborative attitudes, the channels
9 of communication used and also summarised that the
10 personal tensions and conflicts produced by this
11 resulted in an atmosphere that impaired the efficiency
12 of the unit."
13 A. Yes.
14 Q. Is it right that in fact there was a lack of
15 collaborative attitude, leave aside whose fault it was?
16 Was that fact?
17 A. I would not have been uncollaborative. I am not an
18 uncollaborative person; I am an includer. I like people
19 to be on my side, and I think that if there was a lack
20 of collaborative attitudes, that may have been
21 a reflection of somebody else's opinion or somebody
22 else's attitude.
23 Q. I do not think I was asking whether you yourself lacked
24 collaborative attitude, but whether there was a lack of
25 collaborative attitude. What is your perception?
0147
1 A. My perception is that there may have been on the part of
2 other people, but not me. Does that answer the
3 question?
4 Q. That answers the question. To summarise:
5 "The personal tensions and conflicts ... resulted
6 in an atmosphere that impaired the efficiency of the
7 unit."
8 Were there personal tensions and conflicts as you
9 perceived them within the unit?
10 A. I think that there were from time to time various
11 personal tensions and conflicts and I think that
12 Professor Angelini has referred to them, between the
13 surgeons, and I think we also had them between surgeons
14 and anaesthetists. I think they were temporary and
15 ebbed and flowed, and I believed that they could be
16 overcome and at this stage may well have been overcome
17 by good sense.
18 Q. So does it follow that at this stage they existed?
19 A. They may have existed. I do not deny that they may have
20 existed, but my belief was that they were now resolving.
21 Q. Let us be a bit more positive about the grammar we are
22 using. If they could be overcome and may well have
23 existed, does that mean they did exist, even though they
24 might not have existed for much longer?
25 A. Yes, I think that is true.
0148
1 Q. He goes on:
2 "Great tensions remain unresolved between and your
3 colleagues... these conflicts can be viewed as an
4 avoidable risk factor."
5 It follows from what you said, there is nothing
6 contentious in that?
7 A. As a statistician and an analyser of risk factors, I am
8 not sure I have ever seen interpersonal conflicts as
9 a risk factor for whatever outcome is implied in this.
10 Q. I suppose it is probably intuitive that if you have
11 a team which is at sixes and sevens with each other
12 personally, it is less likely to function well as
13 a team, one which is harmonious. That must be
14 a sensible intuitive point?
15 A. Yes, okay.
16 Q. "This issue and many others have been discussed between
17 us on a number of occasions."
18 Is Dr Monk right about that?
19 A. I would have mentioned to him that I was unhappy about
20 the change in my cardiac work, so it would have been
21 mentioned to him before. At this stage I think I had
22 also written a letter asking for the temporary nature to
23 be defined.
24 Q. It goes on:
25 "The action to temporarily change your programme
0149
1 had your active agreement to allow the 'breathing space'
2 to correct the breakdown in relationships, communication
3 and trust."
4 A. Yes.
5 Q. Is that fair?
6 A. Yes.
7 Q. "Your happiness at working with all the cardiac surgeons
8 is not reciprocated and displays a lack of insight into
9 the personal effects of recent events."
10 Would you like to comment?
11 A. I think that the first part refers to my collaborative
12 approach and the second part, obviously the surgeons
13 were still upset.
14 Q. I think what Dr Monk is saying there, is he not, is that
15 you might have expected them to be upset by what had
16 happened?
17 A. In terms of what -- of what had happened?
18 Q. That is what he seems to be saying, and it is for you to
19 tell me because you were there, in receipt of this
20 letter, and you can tell me what, if anything, you
21 understood by that?
22 A. I think that I was doing my best to maintain my
23 professional working relationship with cardiac surgical
24 colleagues, and my expectation of my Director was that
25 he would support me in that.
0150
1 Q. You believed, from what you have been saying, that you
2 being an includer it was achievable. You went into
3 counselling with that purpose in mind?
4 A. Certainly, yes.
5 Q. You went on anaesthetising for operations?
6 A. Yes.
7 Q. And went on for quite some time, as we saw on the very
8 first day of your evidence, until you decided to go to
9 Australia?
10 A. Yes.
11 Q. And you decided to go, you did not have to go; is that
12 right?
13 A. Um ...
14 Q. Can I help you on this? You had at some stage quite
15 a significant private practice?
16 A. Yes, I was doing private cases, certainly.
17 Q. May I ask you, roughly how much in a year would you have
18 got from your private patients?
19 THE CHAIRMAN: It may help if it is put as a proportion of
20 the totality, rather than the amount.
21 MR LANGSTAFF: That is a very good suggestion. I do not
22 wish to embarrass you on this.
23 A. The embarrassing thing is that I cannot actually
24 remember very well and it varied from year to year, but,
25 yes, I suppose it was about half of my total income.
0151
1 Q. Indeed, you had been the Company Secretary of a company
2 which acted as a broker between purchaser health
3 authorities and private --
4 A. Yes, well, actually I was not Company Secretary, I was
5 Medical Director of Whitechurch Medical Securities.
6 Q. You are described on some of their letterheads as
7 Company Secretary.
8 A. Really? I thought I was Medical Director and
9 I certainly have some cards I retained as mementos of
10 a failed business venture that I was Medical Director.
11 Q. In Whitechurch, a number of those who were your fellow
12 consultants, because it was a consultant based service,
13 was it --
14 A. No, what happened --
15 Q. I do not want to take too much time on this. Did you
16 have people like Dr Monk as one of your colleagues?
17 A. He was certainly one of my colleagues. He was not one
18 of my colleagues in Whitechurch. Whitechurch was to set
19 up a brokerage in which, because of the contract
20 business of the Health Service, purchaser/providers, we
21 would bring them together on a brokerage floor like the
22 Stock Exchange and we would say "We have hips at this
23 price here. We have somebody here who wants to pay this
24 price. Can anybody do them?" That was the idea. We
25 never brokered a single contract, but it was a lovely
0152
1 idea. We actually involved the NHS waiting lists.
2 A chap called Big Mac at the NHSE said "This is
3 a fantastic idea, you must pursue it".
4 Q. So far as those private activities are concerned, some
5 of your colleagues at the hospital, the Bristol Royal
6 Infirmary, were involved. Did you get any adverse
7 comment from clinicians at the Bristol Royal Infirmary?
8 A. No. What we were trying to do was to recruit waiting
9 list cases around the country --
10 Q. You have answered the question with the "No".
11 A. I am sorry, okay.
12 Q. So can I then ask whether you noticed a reduction in
13 your income from private practice over the years, let us
14 say, beginning 1995?
15 A. Yes, I think I did.
16 Q. Was this part of the reason for your deciding to leave
17 Bristol and go to Australia?
18 A. I believed that, with what had happened in Bristol and
19 the way in which it had been responded to, my future
20 career in Bristol was going to be very limited.
21 Q. If we go to WIT 80/132, the second sentence in the first
22 paragraph, that you believed that the referrals this
23 dropped off because of your criticisms of the paediatric
24 cardiac service. What justification do you have for
25 that as evidence that we might rely upon?
0153
1 A. I think it was the reduction in the cardiac component of
2 my private practice.
3 Q. So you noticed the cardiac component dropping off?
4 A. Yes.
5 Q. If I can just deal with the last paragraph there, you
6 spoke to a surgeon?
7 A. Yes.
8 Q. The surgeon had indicated that he had been asked not to
9 refer private cases to you?
10 A. Yes.
11 Q. You put a name to him and you simply say this: that you
12 were not corrected.
13 Three questions arising on this. First of all,
14 the surgeon that you spoke to did not say it was
15 Mr Wisheart?
16 A. No.
17 Q. Secondly, are you asking us, in this statement, to
18 conclude that it was Mr Wisheart?
19 A. I am saying that I believed from what he told me that it
20 was Mr Wisheart.
21 Q. If you believed that and wished to maintain that belief,
22 then what I would ask you is that you give us his name.
23 A. This was a very confidential conversation and I have
24 undertaken not to do that. I hope you will respect me
25 for doing that.
0154
1 Q. It is in your hands, Dr Bolsin. The point is this: that
2 if this Inquiry is to approach its task with integrity,
3 then if you are seeking to maintain your allegation you
4 will have to tell us the man's name so it can be
5 checked.
6 A. Yes.
7 Q. If, on the other hand, you do not wish to reveal the
8 man's name, then the allegation, inevitably, would fall
9 because there would be no evidence of it and the Inquiry
10 could not rely upon hearsay comment like this from an
11 unattributed source?
12 A. Absolutely. Well, I would prefer the allegation to fall
13 than that I should reveal this source.
14 THE CHAIRMAN: What Mr Langstaff says is entirely
15 appropriate, but of course it would be up to you,
16 Dr Bolsin, to approach the person and ask whether he or
17 she is prepared to waive the bargain of privacy reached
18 with you and contact us. Otherwise, as we have said in
19 the past, we have to be fair to everyone and if we
20 cannot test evidence, then we will treat it accordingly.
21 A. Yes, I understand that. I do not think this person is
22 prepared for that to happen. I have approached him.
23 MR LANGSTAFF: But may we ask you to undertake to ask that
24 person?
25 A. Certainly.
0155
1 Q. At the bottom of page 131, you talk about a conversation
2 which was reported to you which Dr Andy Wolfe had with
3 Dr Monk.
4 A. Yes.
5 Q. This is a reported conversation?
6 A. Yes.
7 Q. So to know exactly what was said we would have to take
8 issue with Dr Monk, Dr Wolfe or both?
9 A. Yes. I do have a copy of the letter I drafted in
10 response to that conversation which I did not actually
11 have with me, but I will make available to the Inquiry.
12 Q. Would you please make that available to us, if you do
13 not mind?
14 A. I will do that.
15 Q. One or two matters which I have to run through with
16 you. The cardiologists -- can we look at what you say
17 at page 7? You point out the lack of availability of
18 paediatric cardiologists in the management of patients.
19 In effect, you are describing, I think, the isolation of
20 the paediatric cardiologists from the delivery of the
21 service?
22 A. Yes.
23 Q. You did not show your data to the cardiologists, or any
24 of them?
25 A. No.
0156
1 Q. If they were isolated from the service so that you had,
2 yourself, no working relationship which you might
3 significantly damage by raising concerns about the
4 service, why did you not show the data to them, or
5 discuss it with them, or, indeed, get assistance with
6 the interpretation of the data, because they may have
7 known the facts about individual cases which would have
8 helped the interpretation, may they not?
9 A. Yes.
10 Q. Why did you not then do it?
11 A. I think there were a couple of components to that
12 question. The first one was that there was not
13 a day-to-day forum for meeting the paediatric
14 cardiologists, and as you can see from the minutes of
15 the audit meetings, paediatric cardiac anaesthetists
16 were not always in a position to attend those meetings
17 and certainly did not attend as regularly as others.
18 I think the other part of the answer, which was
19 the second part of the question, which I have now
20 forgotten, I am sorry ...
21 Q. It was the fact that there were no working
22 relationships to prejudice, particularly, with them.
23 The question was, why did you not then show the data?
24 A. I think latterly, I did involve Dr Hayes, who was the
25 most recent paediatric cardiologist appointed and we did
0157
1 actually collaborate on the interpretation of some of
2 the input into the data, so she was involved in 1993
3 with the confirmation of the data.
4 Q. Sticking with the cardiologists for a moment, you told
5 us on the first day it got into some of the newspapers,
6 the analogy of the train.
7 A. Yes.
8 Q. What Dr Monk recollects that he was attempting to
9 indicate by the analogy was that there was a need to
10 keep the service going, without there being any link in
11 his mind, or in what he said, to funding.
12 A. Yes.
13 Q. May he be right about that?
14 A. Yes, it is possible. My best recollection of the
15 conversation is that funding was involved.
16 Q. But it may have not been?
17 A. It may not have been, certainly.
18 Q. Did you find difficulty with your anaesthetic colleagues
19 because of your own particular practices? You have
20 seen, I think, in some of the papers suggestions that
21 you, less than others, did pre-operative assessments;
22 that you, on occasions, went out of theatre when others
23 might not have done; and I think you were reprimanded in
24 late 1994/95 in respect of that.
25 First of all, those are suggestions which there
0158
1 are in some documents, as you appreciate?
2 A. Yes. Reprimanded in respect of which? I am sorry, you
3 said there were two possible shortfallings there, one of
4 pre-operative visits, the other of not being in
5 theatre. You say "reprimanded". Which one --
6 Q. Not being in theatre.
7 A. That was a 'Mr Wisheart being angry' comment or
8 something, was it?
9 Q. Yes.
10 A. Yes, once, possibly on one occasion he may have got
11 cross with me about it.
12 Q. Is there any force in the suggestion that you less
13 than others made pre-operative visits, or not?
14 A. No, my approach to pre-operative visits was that it was
15 part of the training programme for the junior
16 anaesthetists, as well as for the senior anaesthetists,
17 and that my position was that it was important for
18 trainees to see the continuum of care for patients
19 coming through the service, and if they were to go and
20 assess the patients and to identify the problems, then
21 it was better in terms of their training than
22 necessarily for me to go and do it. I was always very
23 happy to pick it up. If for example, they were late in
24 theatre I would come and do it. If there was a problem
25 with the patient, I would come and sort out the problem,
0159
1 but for the routine management, this was part of the
2 training exercise in a teaching hospital.
3 Q. Did your practice differ from other anaesthetists in
4 that respect?
5 A. It is possible it did, but I think we all relied on the
6 trainees to undertake a subset of some of our functions,
7 and some of them may have relied upon them in different
8 areas.
9 Q. Was there adverse comment between you and other
10 anaesthetists as to your way of handling this?
11 A. I think Chris may have mentioned this to me on one
12 occasion.
13 Q. Perhaps we might look at WIT 87/26. This was a note of
14 a discussion which he, Professor Farndon, had with
15 Mr Wisheart, as to why it was that he, Mr Wisheart, had
16 not approached you directly over the allegations that we
17 dealt with and put on one side earlier on that led to
18 the Coronial enquiry.
19 A. Yes.
20 Q. And about concerns generally. What he says --
21 A. I am sorry, could I just ask what concerns generally did
22 Mr Wisheart have that he did not approach me about?
23 Q. The meeting about paediatric cardiac surgery. We see
24 the context of the previous page. "Transcript of his
25 handwritten note which describes a meeting with
0160
1 Mr Wisheart." We will scroll down. I have taken you
2 rather too quickly to the second page.
3 A. I am sorry, Mr Wisheart is accepting adverse results
4 here, is he?
5 Q. Can we go up? It is the second or third line, "aware
6 that Steve Bolsin questions paediatric cardiac surgery
7 performance", but who questions the adults was the
8 issue. Professor Farndon's response: "Dr Bolsin did not
9 question adults, others had spoken to him about adults"?
10 A. Yes.
11 Q. If we can go down, then --
12 A. So Mr Wisheart agrees that the paediatric figures are
13 not good in November ...
14 Q. 1994.
15 A. Right, okay.
16 Q. At the very bottom of the page.
17 A. "He has been aware of problems" so presumably before
18 19 --
19 Q. It is not his awareness that I am concerned with,
20 because that is a matter for him, but it is you and what
21 it may show.
22 A. Yes.
23 Q. It is the fifth line down, " ... that he has been
24 reluctant to speak to Steve Bolsin, because as Medical
25 Director this puts him in an invidious position re
0161
1 medico-legal case of blood transfusion error of Steve
2 Bolsin."
3 So that is his line?
4 A. Yes.
5 Q. If we go overleaf, this is where we get back to where we
6 were --
7 A. Can I just go back to that previous page? Please do
8 not let me take over, but --
9 Q. You are entitled to take your time over this.
10 A. He did say he had spoken to me to advantage.
11 Q. Can we go back?
12 THE CHAIRMAN: If it will put your mind at rest,
13 Dr Bolsin, we have already seen this and gone through it
14 in some detail, so I think Mr Langstaff is now taking
15 you to a particular point. Of course, it is open to you
16 to peruse it and make whatever comment you may wish to
17 make subsequently, but at this point, I think we will
18 just go to what Mr Langstaff wants to take us to.
19 MR LANGSTAFF: So there is no confusion in your own mind,
20 we think that the "he has talked openly to advantage" is
21 Professor Farndon, and not Mr Wisheart.
22 A. Okay.
23 Q. Can we go back to where we started? It is my fault for
24 trying to rush this through. I am sorry.
25 "JW says he has not approached Bolsin because of
0162
1 the blood transfusion problem, but that it must be
2 acknowledged", and this is his expression to Dr Farndon,
3 "that Steve Bolsin is not an easy character to work
4 with, e.g., no pre-operative visits; poor tenacity with
5 patients, e.g. always making telephone calls et cetera,
6 also noted that he developed a referral agency without
7 telling people that they were named on his selling
8 document, e.g. James Wisheart, Westerby, Oxford"
9 et cetera.
10 We have heard as it happens that
11 Professor Angelini, who has been mentioned in one of the
12 documents from Whitechurh, thought that he had been
13 mentioned without his prior consent.
14 Those matters were being said about you. Did they
15 have some justification?
16 A. I would not have thought so. This is the first I have
17 seen of this kind of criticism, and I would not have
18 considered myself as a difficult person to work with.
19 The collaborative research that we had done on the unit
20 was a testament to that and the fact we developed
21 a statistical department within the department, with
22 Department of Health funding, I was working
23 collaboratively with the Association of Cardiothoracic
24 Anaesthetists, we had recruited all of the 35 units in
25 the country. This was all collaborative work, and I was
0163
1 at the centre of it.
2 Q. I am not going to take further time over it, Dr Bolsin;
3 but it was something that you had to be given the
4 opportunity to respond to.
5 A. Yes, thank you.
6 Q. Today you spoke of sharing data with your colleagues,
7 and in particular, I think, in the Anaesthetic
8 Department. The reference is at page 61, between lines
9 1 to 5, at least on the transcript we have on our
10 screen.
11 You were answering, just before the Chairman
12 interposed, you said:
13 "Just a brief point. The ownership issue I have
14 considered addressed by the fact I had already shared
15 the data with my paediatric cardiac anaesthetic
16 colleagues at that stage."
17 This is the Bolsin/Black data and you are talking
18 about 1993?
19 A. Yes.
20 Q. Does "shared the data" mean you gave the data to each
21 and every one of your anaesthetic colleagues?
22 A. I cannot say certainly that I did, but there were
23 certainly enough sheets of this information within the
24 department, and I can personally remember photocopying
25 sheets of this data which I was not going to keep for
0164
1 myself; they were for sharing around.
2 Q. You see, Dr Underwood cannot recall having had a copy of
3 the data and Dr Masey recalls being shown but not
4 retaining, not being given, therefore, a copy. May they
5 be right?
6 A. It is possible. I think for Dr Masey it was very early
7 data, and it may be that we would not have given her
8 a copy at that stage, but it is certainly very likely
9 that she would have received a copy at a later stage,
10 and possibly the clarified boxed tables.
11 Q. A completely separate matter I now want to turn to. You
12 remember that I have spoken to you about the question of
13 confidentiality and the involvement of Susannah Black in
14 the audit?
15 A. Yes.
16 Q. If it turned out to be the case that in one of the
17 television programmes in which you took a part,
18 a patient's details were displayed on a TV monitor
19 screen so that those looking at the television programme
20 might, if they looked closely, see the name and some of
21 the data, would that be, do you think, a breach of
22 patient confidentiality?
23 A. Yes, I think it probably would, yes. I mean, I am not
24 sure what the --
25 Q. The second question is, so far as you are concerned,
0165
1 if that happened in a programme with which you were
2 involved, is it something that you think would have
3 happened by accident?
4 A. I am not sure what you mean by "accident", whether by
5 accident the information got on to the screen, or
6 whether by accident the information got to the makers of
7 the programme.
8 Q. Let me simply tell you, it is a matter which I am asked
9 to put, and I think it appropriate that you should have
10 a chance to deal with it. It is suggested that in one
11 programme, when you were interviewed, as it happens the
12 camera caught a TV video or monitor which had upon it
13 patient details of somebody who, as it happens, as
14 a parent has given evidence in this Inquiry, but I do
15 not propose to name them.
16 The question is: did you, do you think, take care
17 to ensure that when you spoke about problems in general
18 terms in paediatric cardiac surgery, patient
19 confidentiality was properly respected?
20 A. I would certainly hope so, yes.
21 Q. Again, I put to you the question: did you ever supply
22 the names and addresses of those who had had, or whose
23 children had had, cardiac surgery, paediatric cardiac
24 surgery at the unit, to any outside source?
25 A. No. No. Can I say that we were governed by the Data
0166
1 Protection Act at that time, which I believe is still in
2 force, and you were not allowed to keep patient details
3 and names together, so that it would have been very
4 difficult to have done that.
5 Q. Thank you very much. There are just two or three last
6 matters which I have to pick up with you. Essentially,
7 it is this: first of all, what do you mean, looking back
8 to the screen here, by the word "ownership"?
9 A. I think you have a different screen to me,
10 Mr Langstaff.
11 Q. I beg your pardon, it is my fault.
12 THE CHAIRMAN: The question point is "define the word".
13 MR LANGSTAFF: It is my fault for reading off a screen
14 which you do not have. What do you mean by the word
15 "ownership"?
16 A. I would not like to get into argument with a lawyer
17 about this kind of word, but being more serious about
18 it, I think that people have to believe that the data
19 relates to the practice that they are involved in, and
20 that they have to feel that they are part of any process
21 that that data relates to.
22 Q. The next matter is this: just before the luncheon break,
23 I asked you about your data and you were talking about
24 the letter in which you used the phrase, "the Associate
25 Director of Cardiac Surgery explained the results", you
0167
1 remember, it was your provisional report on the AV canal
2 data.
3 A. Yes.
4 Q. I asked you what those results appear as a matter of
5 language to be referring to. We had a debate about the
6 word "results".
7 A. Yes.
8 Q. I asked you, was the word "results" referring to those
9 three operations, and you said this:
10 "Yes. But we know that there was no particular
11 reason, then, for the surgeons to refer to those three
12 operations because they did not know anything about the
13 Bolsin/Black data."
14 Do you recall saying that?
15 A. Yes.
16 Q. Do you wish to reconsider that answer at all?
17 A. Well, I think that what I am reflecting there is what
18 I have seen in the evidence that has come to the
19 Inquiry, that the surgeons maintained that they were
20 never shown the Bolsin/Black data. In fact, I believed
21 that they were being exposed to that data and subsequent
22 data through the Directorate structure of the
23 organisation, but I think what I was saying there was
24 perhaps being fair to what I have seen the surgeons have
25 said, which is that they never knew about the data until
0168
1 something like 1995, or even later, after the
2 Hunter/de Leval report.
3 Q. I am not sure that could be right. Let us go back to
4 the original document, UBHT 54/3. The bottom of the
5 page. Your words "The Associate Directorate of Cardiac
6 Surgery explained the results as representing an
7 evolving and improving practice and that subsequent
8 results are and would be better".
9 A. Yes.
10 Q. What you told us is that you used the word "results" as
11 meaning all the results and the reason you used that
12 word as meaning all the results is because you are
13 describing what the Associate Directorate of Cardiac
14 Surgery had done at its meeting of 20th January 1994.
15 A. Yes.
16 Q. At that meeting, 20th January 1994, you said that they
17 must have meant all the results --
18 A. Yes.
19 Q. -- because they did not have the Bolsin/Black data.
20 That is the context.
21 A. Right, okay.
22 Q. But you are here, on 31st October 1994, if your
23 recollection is right about how you meant the word
24 "results", using it to explain your understanding of
25 a meeting which had taken place that January?
0169
1 A. Yes.
2 Q. So it follows, does it not, that in October 1994, you
3 thought that the surgeons did not have the Bolsin/Black
4 data?
5 A. No, I think what I am saying is that I know now that
6 they tell me that they did not have the data.
7 Q. But when did you first know they did not have the data?
8 A. I think it was probably when I read their statements
9 that said that they did not get the data until after the
10 Hunter/de Leval report, because my --
11 Q. So that would be after February 1995?
12 A. Yes.
13 Q. So you did not know it at the time you wrote this?
14 A. I would have assumed at the time that I wrote this that
15 the data was being shared with them through the routes
16 that we had fed it into the system.
17 Q. If you had assumed that they all had the data, they had
18 all been shared with the data, even though now you know
19 better, you could not possibly have meant the word
20 "results" here on 31st October 1994 as meaning all the
21 results of the unit, on the basis that, at that time
22 when you wrote this, you thought they had not had the
23 Bolsin/Black data?
24 A. No. I mean, under those circumstances, it is possible
25 that the results in the third line up were referring to
0170
1 the three operations in the second paragraph, VSD
2 repair, AV canal and tetralogy of Fallot. I mean,
3 I think --
4 Q. Are you now changing what you expressed to us as
5 a fairly definite view earlier on, and I pushed you on
6 it?
7 A. I think we are reading an awful lot into a document that
8 was produced with this AV canal mortality, and I think
9 that the key thrust of this document is not the
10 interpretation of which subclause the word "results" in
11 certain sentences refers to, but that here we have an
12 operation in which we have a minimum 70 per cent
13 mortality and I think that while it is intriguing and
14 interesting to try and unpick all these different uses
15 of the word "results", I thought at this time that the
16 surgeons were aware, through various routes, of the
17 Bolsin/Black data. I do not have any evidence for that,
18 and I have seen witness statements which suggest that
19 they did not know that, but I am not sure that this
20 document actually necessarily is likely to help us in
21 concluding anything.
22 Q. It was not really so much, Dr Bolsin, -- let me be clear
23 about it -- the word "results" that I was concerned
24 about.
25 A. Okay.
0171
1 Q. As to your explanations and what they may tell us about
2 what you thought at the time the surgeons had or had not
3 got.
4 Can I simply put it this way: having looked at
5 this, thought about it again, remembered your reaction
6 to the question just before lunch, did the surgeons, as
7 you thought about it at the time, have the Bolsin/Black
8 data, or not?
9 A. I think that at the time I wrote this, I thought that
10 the surgeons had the Bolsin/Black data. When I gave an
11 explanation before lunch, I was bearing in mind what
12 they had said, which is that they did not receive the
13 Bolsin/Black data until after the Hunter/de Leval
14 Inquiry.
15 Q. The second point and it is the second last matter
16 I shall touch upon with you: you told us on the first
17 day and since, that you had started to collect data and
18 had data before Private Eye was ever published, even
19 though you had not analysed it?
20 A. Yes.
21 Q. You told the GMC, did you not, that you had not, when
22 you were asked and pressed about Private Eye and the
23 suggestion was made to you that you were the source of
24 the information, that it could not have been you because
25 you had not started collecting any data at that stage?
0172
1 A. No, I think what I said at the GMC was that it could not
2 have been me with the data on AV canals and tetralogy of
3 Fallots, because we had not started to collect that data
4 at that stage. I believe I was referring then to the
5 Bolsin/Black data collection, which did not actually
6 start until the summer of 1992.
7 Q. The third matter which I want to deal with is this: you
8 remember the discussion we had on the first day in
9 respect of constructive dismissal? In fairness to you
10 and your recollection, can we please have on the screen
11 WIT 106/123? This is a note which comes, I think, from
12 Mr Nix of a conversation or a phone call on 3rd May
13 1995. The relevant part is the second paragraph,
14 I think, which speaks for itself, that you told him the
15 cardiac surgeons had said the relationships had broken
16 down, for legal reasons you could not work together.
17 You had been asked to give up Thursday operating to do
18 another list. The rota has been changed for the next
19 3 or 4 weeks... recognise the need for the dust to
20 settle... was not happy that this should continue.
21 We have been through that.
22 "He told me he had written to Chris Monk asking
23 for an explanation of the position and was awaiting
24 a reply. He had been concerned, never spoken to the
25 BMA. Yesterday, 2nd May, he had a meeting with
0173
1 Professor Trevor Thomas, Chris Monk and himself. At
2 that meeting" -- and this is the point you may want to
3 comment on -- "they discussed hypothetical issues, one
4 of which was the possibility of constructive dismissal,
5 which he [I think it should be 'said'] represented the
6 end of the road. He reiterated he had worked with the
7 paediatric cardiac surgeons for many years and did not
8 think that anything should have changed."
9 So, so far as constructive dismissal was
10 concerned, is this when the matter first arose in
11 conversation between you and Trevor Thomas and Chris
12 Monk?
13 A. Yes, and it was raised by Trevor Thomas, I believe.
14 Q. In the context that we see?
15 A. Yes.
16 Q. And if we look at page 122 --
17 A. I mean, I think the other thing I would like to say
18 about that document is that my concern was for the
19 outcomes of patient care if I was on call when
20 a paediatric emergency came in.
21 Q. Page 122, it is the same point, I think, this appears to
22 be a handwritten note of the same meeting, does it, the
23 middle of the page, concern... speak to BMA... meeting
24 with, and discussed constructive dismissal
25 (hypothetical) represents the end of road."
0174
1 This is the same as I showed you on the first day
2 of your evidence.
3 A. Yes.
4 Q. I said this was something of a clearing up. Can we look
5 at UBHT 61/19? This is back to your letter to
6 Dr Roylance. It is on a completely different point. It
7 is the second paragraph. You have applied, you say,
8 five lines down "on numerous occasions for equipment to
9 more adequately maintain and protect cerebral function
10 during routine open-heart surgery"?
11 A. Yes.
12 Q. You were going on to say you did not get the funding and
13 you should have done.
14 A. Yes.
15 Q. What was the equipment?
16 A. The equipment was a cerebral function analysing monitor,
17 which is essentially a computerised EEG display.
18 Q. And the importance of it?
19 A. The value of it was that I had been doing research for
20 18 months at the Brompton using this machine and
21 demonstrating that by monitoring this function, you
22 could detect when cerebral blood flow was reduced and
23 when there was a possibility of brain damage occurring.
24 Q. During operation?
25 A. Yes, during cardiac pulmonary bypass operations.
0175
1 Q. Was it provided?
2 A. The machine was never provided, no.
3 Q. Or nothing of its sort?
4 A. No.
5 Q. The reason was, was it, funding?
6 A. I could not find a source of funding to purchase the
7 machine.
8 Q. And how did you find that the change of Trust status
9 might have affected funding?
10 A. I am not sure that it did either way. We eventually
11 went to --
12 Q. In that case, I need not ask you to go further on that.
13 Dr Bolsin. I have detained you longer than I had
14 intended to, as I have indicated. I have asked you an
15 enormous number of questions. It may be that in the
16 course of those I have asked you to give an answer which
17 you would now wish to change on reflection; you may wish
18 to add something, or you may wish to volunteer something
19 which we have not yet touched upon, or have not yet
20 touched upon as fully as you might have wished. This is
21 now your chance to do it. It does not of course prevent
22 you from commenting after the event in writing, should
23 you wish to do so as the Chairman will himself tell you
24 in a moment or two.
25 A. Yes. I just wanted to say something very briefly,
0176
1 really.
2 With regard to my involvement with the Bristol
3 Royal Infirmary, I hope that the Inquiry will reveal
4 that I did not shrink from my primary responsibility to
5 act in the interests of patient safety. The events of
6 the last decade have brought a severe personal and
7 professional penalty to my family and to me. It would
8 have been easier to say nothing and do nothing. For
9 various reasons, my actions have been criticised, but at
10 least I have the moral courage to act. It has been
11 said, the fact is, you see, that the strongest man in
12 the world is he who stands alone.
13 THE CHAIRMAN: Dr Bolsin, there are some questions from the
14 Panel. Mrs Maclean?
15 Examined by THE PANEL:
16 MRS MACLEAN: Yes. Thank you for your statement. I wanted
17 to go right back to the beginning. You described your
18 early days at Bristol, that you found yourself concerned
19 about the length of time which some operations were
20 taking.
21 A. Yes.
22 Q. We have heard other experts describe to us how length of
23 time can also be associated with positive aspects of
24 care, more gentle handling of the heart, and so on.
25 I just wondered whether there were other specific
0177
1 triggers for your anxiety, whether you could give us any
2 examples of specific aspects of procedure or particular
3 incidents that initially triggered your anxieties?
4 A. I think this refers to Dr Silove's point that when you
5 are interpreting the operative record all you have is
6 the surgical note and you need some clinical insights.
7 I hope that some of my evidence actually provided some
8 of those clinical insights. Certainly when I had worked
9 with Mr Lincoln at the Brompton and with Ravi Pillai,
10 now consultant at Oxford, the uniqueness of the surgical
11 technique, when they put in a VSD patch it looked as if
12 it had been machined in place. This was not the
13 experience I was seeing in Bristol, this was very much
14 a stitches everywhere, there were all sorts of --
15 patches would leak, repairs would leak, we would be
16 coming back putting tamponade around things. It was
17 surgically and technically a much less proficient job,
18 in Bristol.
19 MRS MACLEAN: Thank you.
20 THE CHAIRMAN: Mrs Howard?
21 MRS HOWARD: Dr Bolsin, we have heard a great deal of detail
22 about your approaches to sharing your concerns, your
23 methods or sharing the data which was available to you
24 at varying times. If it your approach were to be
25 described as a "scattergun" approach to achieve
0178
1 a response, would you believe that to be an accurate
2 description?
3 A. No, I do not think so. I think I went the most direct
4 route the first time around. I received a very serious
5 threat the first time around, and I think I probably
6 decided at that point not to go back down that route,
7 and there was nothing that changed my mind as the things
8 went on. In fact, that was reinforced.
9 After that I fed it through as many of the
10 clinical and managerial pathways as I could, and I think
11 I did it in a fairly systematic way. We went through
12 directorates of anaesthesia, then other directorates,
13 and then management. Only when all of those routes
14 began to fail did we actually go through to the
15 Department of Health and other areas.
16 Q. So you would not feel that it was accurate to refer to
17 it as a "scattergun" approach?
18 A. No.
19 Q. Can I just ask you a second question, which you may feel
20 is unrelated, but I feel I would like to have some
21 clarity from you.
22 In terms of achieving a response to your concerns,
23 from whom were you seeking that response? Was it the
24 Trust as the accountable organisation, or was it the
25 surgeons?
0179
1 A. I think I wanted the unit to review its results and to
2 decide what it could do well and continue doing it, and
3 to decide what it was not doing well and to stop doing
4 it badly.
5 Whether that was imposed from the top by the Trust
6 Board or whether that was agreed by the paediatric
7 cardiologists, cardiac surgeons and cardiac
8 anaesthetists as a review that we would undertake, and
9 there is evidence that people did begin to agree that
10 a review was important, I did not mind, but we had to
11 have that review in order to prevent the dangerous
12 operations from persisting.
13 Q. Can I just take you back to the word you have used.
14 You used "unit". What do you mean by "the unit"?
15 A. I think for me, the unit was the paediatric
16 cardiologists, the paediatric cardiac surgeons and the
17 paediatric cardiac anaesthetists and it was a diffuse
18 geographical unit, but I think it was a clear
19 professional unit.
20 MRS HOWARD: Thank you.
21 THE CHAIRMAN: Mr Ryan?
22 MR RYAN: Sir, there is no need for any re-examination.
23 THE CHAIRMAN: I am very obliged to you, Mr Ryan.
24 Dr Bolsin, you will forgive me, before I say thank you,
25 just to remind everyone in this hearing chamber, there
0180
1 are strong feelings that sometimes emerge, and that we
2 have all been able, during the 80-odd days that we have
3 been sitting, always to bear in mind the feelings of
4 others, and I would hope that that be the case, today,
5 as in all other days. That is not directed at anyone
6 except myself, and all of us in this room.
7 Now let me thank you for coming a long way to talk
8 to us for four days, four long days, no doubt suffering
9 from jet-lag from time to time. We are very much in
10 your debt; we are very grateful. Your evidence is
11 important for what we are doing. We are all much
12 indebted to you.
13 If I could just ask you for a second to sit there
14 while we observe the last ritual of our Thursday
15 sessions, that is to listen to Mr Langstaff say
16 something that is a necessary convention to end our
17 week.
18 MR LANGSTAFF: Sir, we leave now to meet again on Monday at
19 10.30 in the morning, when we shall have the evidence of
20 Mr Dhasmana.
21 THE CHAIRMAN: Thank you. I remind everyone, therefore,
22 10.30 rather than 9.30, because it is Monday. We
23 adjourn now, and reconvene at 10.30 on Monday. Thank
24 you.
25 (3.50 pm)
0181
1 (Adjourned until 10.30 am on Monday, 29th November 1999)
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5 I N D E X
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7
8 MRS DIANA PARKER (formerly Hill), sworn:
9 Examined by MISS GREY ................... 1
10
11 DR STEPHEN BOLSIN (recalled)
12 Examined by MR LANGSTAFF (continued) .... 40
13 Examined by THE PANEL ................... 177
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Published by the Bristol Royal Infirmary Inquiry, July 2001
© Crown Copyright 2001