Home Page Search Final Report Interim Report Evidence - Transcripts - Witness Statements - Submissions - CCNR Report and associated documents - Statistical Reports and associated documents - Background Papers - Expert Papers Inquiry Seminars About the Inquiry Help		Daily transcripts Hearing summary 7th December 1999 The Bristol Royal Infirmary Inquiry oral hearings this week continue to hear evidence covering concerns raised about paediatric cardiac surgery at the Bristol Royal Infirmary (BRI) between 1984 and 1995 and any failure to take action promptly. Today, Dr John Roylance, former Chief Executive, United Bristol Healthcare NHS Trust (UBHT), concluded his oral evidence to the Inquiry. He began by talking about a meeting he had with Janet Maher, General Manager, Directorate of Surgery, UBHT, in mid 1994, at which she told him she had been approached by Dr Stephen Bolsin, Consultant Anaesthetist, about his concerns regarding paediatric cardiac surgery. He then spoke about the correspondence between Dr Peter Doyle, Senior Medical Officer, Department of Health and Professor Gianni Angellini, Professor of Cardiac Surgery, University of Bristol, the origins of that communication and his subsequent response to it. He then described his views on the balance between his managerial and professional responsibilities. Dr Roylance next discussed his involvement in the discussions surrounding the decision to operate on Joshua Loveday to proceed in January 1995. He told the Inquiry about the independent review of the paediatric cardiac unit carried out by Mr Stewart Hunter, Paediatric Cardiologist and Professor Marc de Leval, Consultant Paediatric Cardiothoracic Surgeon and his involvement in the publication of the report. He concluded by describing his actions to restore professional relationships within the Trust after the publication of the Hunter/deLeval report. Dr Norman Halliday, former Medical Secretary, Supra-Regional Services Advisory Group came to the Inquiry today to give further evidence about his and SRSAGs involvement in the designation of Supra-Regional Services and the responsibilities for monitoring the activity and quality of designated centres. He told the Inquiry of the occasion when concerns about the Bristol service were raised with him by the Chief Medical Officer for Wales in 1987. He concluded by commenting on the 1992 Royal College of Surgeons Working Party report on the infant and neo-natal cardiac surgical service, which recommended continuing designation of the service and described the discussions he had with the authors of the report and Sir Terrence English, former President of the Royal College of Surgeons. He explained that SRSAG agreed to de-designate the entire national service in 1992.

FULL TRANSCRIPT

   1                Day 89, Tuesday, 7th December 1999
   2   (9.40 am)
   3   THE CHAIRMAN: Good morning, everyone. Good morning,
   4     Mr Langstaff.
   5   MR LANGSTAFF: Good morning, sir.
   6           DR JOHN ROYLANCE (RECALLED):
   7         EXAMINED BY MR LANGSTAFF (CONTINUED):
   8   Q. Dr Roylance, when we finished yesterday, we were talking
   9     about the anaesthetists' letter in the middle of 1994
  10     and the suggestion, the evidence given to us by Dr Monk
  11     which conflicts with your recollection that he gave you
  12     a copy of that letter.
  13        That was the middle of 1994. Shortly before that
  14     was an incident which I have not yet canvassed with you
  15     in evidence, Janet Maher came to speak to you I think
  16     around 1994; is that right?
  17   A. Yes, I cannot give you a precise date, but, yes,
  18     somewhere about 1994.
  19   Q. Spring 1994, somewhere round then. Did she say that
  20     Dr Bolsin had been to see her and that he had figures
  21     which suggested to him that the results in paediatric
  22     cardiac surgery were not so good in Bristol as they were
  23     in other centres?
  24   A. I do not think she used quite those words but certainly
  25     we discussed what to her was a surprising conversation

   1     from somebody from a different directorate approaching
   2     her when she was General Manager of Surgery when she
   3     would have thought the normal conversation would be
   4     between him and the General Manager of Anaesthetics.
   5     So, yes, she was puzzled.
   6   Q. What was it then that she said to you as you recollect
   7     it?
   8   A. I cannot give you the precise words but something to the
   9     effect that Dr Bolsin thought that the results in
  10     Bristol were not as good as the best in other places,
  11     something I already knew.
  12   Q. Did she mention that he had figures which showed this?
  13   A. No, no.
  14   Q. Are you sure?
  15   A. Yes, and I do not think she was shown any figures.
  16     I mean by implication if somebody says "The results are
  17     not as good as in other places" one could say "Well,
  18     that must be talking about numbers, results are numbers"
  19     but she did not reveal what I subsequently discovered,
  20     and that was that he was performing a secret audit,
  21     I think that is the easiest way I can say.
  22   Q. If you had understood from her that he had figures,
  23     would you have taken any steps in consequence?
  24   A. If she had told me he had independent figures which he
  25     was generating himself, that would have concerned me.

   1     The fact he had figures did not surprise me because
   2     I knew that the results in Bristol were sent to the
   3     Cardiac Society where they were totalled up nationally
   4     in order to produce a big enough series to produce any
   5     sensible view of outcome and those figures were returned
   6     to cardiac units and were made available to people
   7     within the cardiac unit. So if I had been told that he
   8     had figures I would have been far less surprised than if
   9     I had been told he had not got any figures because
  10     I knew that was the way paediatric cardiology, and
  11     I think adult cardiology behaved. They summated their
  12     figures nationally.
  13   Q. I do not wish to be unfair to you, so let me show you
  14     what you said when you thought about this at leisure in
  15     WIT 108/127, it is paragraph 38. You deal with the
  16     conversation, second line:
  17        "I do not remember the conversation very well but
  18     I believe Mrs Maher told me that Dr Bolsin had been to
  19     see her to tell her that he had figures which he felt
  20     showed that results in [Bristol] paediatric cardiac
  21     surgery were not as good as in other centres."
  22        Your recollection a moment ago was that figures
  23     were not mentioned, plainly your recollection at leisure
  24     was that they were?
  25   A. I am sorry, I am not being clear, I was hoping to be

   1     clear. I am conscious of the fact that when Dr Bolsin
   2     is mentioned and figures are mentioned, there is
   3     a tendency to talk about his, Bolsin/Black audit. If
   4     somebody says to me that the results in Bristol are not
   5     as good as in other centres, that must be a numerical
   6     assessment, it must be figures. Do you understand what
   7     I am trying to say?
   8   Q. Perfectly.
   9   A. I knew Bolsin had access to figures, everybody in the
  10     unit had access to figures, they were national figures
  11     in which they were returned and they were anonymised so
  12     that each unit would know its own figures because they
  13     had sent them to it but nobody would know anybody else's
  14     figures, just the overall group. It is possible to look
  15     at that figure and see that ours as a contribution to it
  16     did not actually put the average up.
  17        In terms of figures, yes, results must mean
  18     figures. In terms of a personal secret audit it would
  19     never have occurred to me that that was the case.
  20   Q. Can I explore this a little further? If indeed you are
  21     right and the figures that Janet Maher was talking about
  22     were no different from the figures that were available
  23     through the returns to the Cardiothoracic Register,
  24     there would be nothing remarkable in his having those
  25     results?

   1   A. No.
   2   Q. There would have been no particular reason for her to
   3     have mentioned to you anything about him coming to her
   4     saying "I have figures which suggest that paediatric
   5     cardiac surgery is not as good as it ought to be"?
   6   A. I am sorry, that is not quite true. I have to remind
   7     you that all the directorate managers as well as the
   8     clinical directors I saw as people who I needed to
   9     assist to be successful. They referred to me sometimes
  10     just for reassurance, sometimes for help and so that
  11     I was constantly talking to them on how they should
  12     conduct their management activity, how they should make
  13     decisions, pursuing this new concept of pushing
  14     decisions to as near the bedside as possible.
  15        Janet Maher found it extraordinary that Dr Bolsin
  16     chose to share with her his anxiety that the results in
  17     Bristol were not as good as the best in other parts of
  18     the country. Now I have explained to you that I knew
  19     that. The facts of what he was saying were not odd or
  20     surprising. The fact he had chosen to have
  21     a conversation with Janet Maher, she did not
  22     understand. So she said "What do I do?" I would have
  23     said "What have you done?" and she said "I told him if
  24     he has anxieties he should go and talk to the Directors
  25     of Cardiac Surgery and of Anaesthetics, namely

   1     James Wisheart and Chris Monk", and I reassured her that
   2     that was an entirely proper response.
   3   Q. At this time I think it may have been Mr Dhasmana, might
   4     it not, the Associate Director of Cardiac Surgery?
   5   A. Yes, yes, I beg your pardon.
   6   Q. In any event you would have been surprised, do I take
   7     it, that an anaesthetist, part of the team providing
   8     cardiac surgical services who ought to have had free
   9     access and free discussion of the surgical results for
  10     the units --
  11   A. Did have; not ought to have, did have.
  12   Q. -- was going to the Manager and saying something about
  13     his concerns based upon figures which he had; that is
  14     the way you report it in paragraph 38.
  15   A. Yes.
  16   Q. If one takes the language you have used at paragraph 38
  17     the impression one may be given from it, if you will
  18     forgive me for saying so, is that the figures which
  19     Dr Bolsin had were figures personal to Dr Bolsin because
  20     otherwise there would seem to be little point in her
  21     coming to you to tell you that he had been to her with
  22     figures from which he drew a particular conclusion.
  23     Would it not follow her concern was that he had not
  24     spoken with the clinicians involved, the implication is,
  25     about the figures?

   1   A. I am sorry, if you draw that conclusion from that
   2     English, then I apologise for the English. It is not
   3     what I meant; it is not what I thought I said.
   4   Q. I am simply concerned, Dr Roylance, to have your
   5     evidence as clear as we can and what you are telling me
   6     is that to draw that implication from that paragraph
   7     would be wrong. We have that evidence and I shall move
   8     on.
   9   A. I did not wish to infer that. It is my statement. As
  10     I say, I apologise if it means that. What was bizarre
  11     about the situation is that if Dr Bolsin had an anxiety
  12     of any sort, of all the places to go and discuss it and
  13     all the people to discuss it, Janet Maher did not seem
  14     to be in any way appropriate; that was the nub of the
  15     matter. I think I remember that she actually said he
  16     ought to go and talk to Roger Baird as well who was her
  17     Director of Surgery. In other words, go and talk to the
  18     people he ought to talk to.
  19        She did not show any lack of concern, but just
  20     thought it was a funny way because this was not just
  21     a chance chat at a social meeting or some other meeting,
  22     he actually sought her out to share with her that he
  23     thought the results in Bristol did not meet the "gold
  24     standard" being achieved in some other centres.
  25   Q. Why was she mentioning this to you, do you think?

   1   A. Because I was very close to her and if something strange
   2     happened that was beyond her normal experience, she
   3     would share it with me in case I had a view,
   4     a suggestion that she might have told him something
   5     different, might have said something different, might
   6     have done something different.
   7        All the general managers constantly shared their
   8     anxieties and their enthusiasms and their successes with
   9     me. We had a very close relationship. It was the only
  10     way, I believe, to create this new concept of general
  11     management in an organisation which had a very different
  12     culture.
  13   Q. Your approach, as I follow it, is to tell her what she
  14     should then say to Dr Bolsin. You did not think it
  15     right to say anything to Dr Bolsin yourself?
  16   A. No, no, if Dr Bolsin had wanted to talk to me, I was
  17     available. He knew I was available, everybody knew
  18     I was available. This was a matter of a conversation
  19     between Dr Bolsin and Janet Maher which Janet Maher, she
  20     was a psychologist, found curious and when she found
  21     something curious she would share it with me.
  22        I said "What did you say to him?" and she said "Go
  23     and talk to --" yes, it may well have been
  24     Janardan Dhasmana, I do not know, but certainly it was
  25     Roger Baird and Chris Monk and she indicated to him that

   1     if he had that sort of anxiety, that is where he ought
   2     to discuss it.
   3        I think she gleaned from him he had not so done
   4     and that struck her as odd as well.
   5   THE CHAIRMAN: Dr Roylance, just for my understanding:
   6     looking at the paragraph that is on the screen, when it
   7     says that "Dr Bolsin had been to see her to tell her
   8     that he had figures", as I understand it you are saying
   9     that would not be particularly surprising because those
  10     figures were as it were publicly available common
  11     knowledge.
  12        It might be, therefore, that instead of saying "to
  13     tell her that he had figures", your account would be
  14     better understood as "he had seen the figures which were
  15     generally available". But you said "he had figures"
  16     which might suggest they were other than the figures
  17     generally available?
  18   A. I apologise if that is a possible conclusion. It is
  19     a matter of trying to be succinct and not be too wordy
  20     in giving you my evidence, I apologise for that if it is
  21     misleading.
  22   MR LANGSTAFF: You picked up from Mrs Maher that Dr Bolsin
  23     had not been talking to the appropriate people about
  24     concerns which he was expressing to her. Did you pick
  25     up from her, Mrs Maher, any sense that the concerns were

   1     ones which she felt were potentially very serious?
   2   A. No, I do not think so. I knew at the time and whether
   3     she did -- I suspect she did -- that we recognised that
   4     there were ways in which paediatric cardiac surgery
   5     could be improved. We were pressing very hard and by
   6     that time, April 1994, we were well advanced in seeing
   7     a way to achieve that improvement.
   8        We would not have gone to all that trouble if we
   9     thought the results in the unit met or exceeded the
  10     "gold standard". I am quite sure that while Ash Pawade
  11     who is there now, will want more resources and so on he
  12     would not base it on the fact that his results were
  13     worse than the best in the country, they happen to be
  14     better.
  15   Q. The reason why I ask about your sensitivity to the way
  16     that Mrs Maher regarded the issue arises from her own
  17     statement which I will just show you. WIT 153/20, to
  18     put it in context, if we scroll down so we have
  19     paragraph 6 at the top.
  20        We can see she is describing here a conversation
  21     you were not party to when Dr Bolsin came to her and
  22     repeatedly referred it appears to data upon which he
  23     based the concerns but did not explain what it was. She
  24     sets out her overall impression at 7. Then 8:
  25        "The potential seriousness of what Dr Bolsin was

   1     saying made me feel extremely uncomfortable. I asked
   2     Dr Bolsin if he had shared this information with
   3     paediatric cardiac surgeons, or if he had shared the
   4     information with anybody else. I could not get a clear
   5     response from Dr Bolsin on this point."
   6        You did not have the sense, then, did you, that
   7     she took it in this particular way as she describes it
   8     here?
   9   A. No, I mean that may be because I would have reassured
  10     her that the statement that we were not reaching the
  11     quality of the best in the country was something that
  12     was widely known and I knew. So having reassured her,
  13     I do not remember her by the time she talked to me being
  14     other than curious rather than extremely uncomfortable.
  15     She may have been and she may have concealed that fact
  16     from me. I mean I would not wish to challenge what she
  17     felt at the time. I would say that she did not convey
  18     any sense of extreme anxiety to me.
  19   Q. She deals with what she said to you and how you reacted
  20     at WIT 153/24, paragraph 17. She says that when she
  21     spoke to you, this is the third line down, she repeated
  22     what Dr Bolsin had said to her. Then she says this:
  23        "I got the impression that Dr Roylance may have
  24     been in a similar position to Dr Monk, that is someone
  25     who is starting to get to know there is something being

   1     raised as a concern, but the detail of that concern was
   2     still very unclear. I would not have expected
   3     Dr Roylance to indicate to me how he planned to deal
   4     with this information. Quite rightly I believe he
   5     needed time to assess the best approach. My
   6     understanding was that he intended to take time and talk
   7     to the key people involved, probably including Dr Monk
   8     and Mr Wisheart. I did not know if he would go directly
   9     to Dr Bolsin or not. I cannot remember any other
  10     details."
  11        The way she describes the meeting is as someone,
  12     a manager who has gone to you to report what Dr Bolsin
  13     has said, that you had received the information but have
  14     not indicated to her how, and she looks to you to be
  15     doing something in response to the information, that is
  16     the way she puts it.
  17        Your recollection is rather that you say to her
  18     "This is what you should tell Dr Bolsin to do"?
  19   A. When I would talk to Janet Maher, the nature of the
  20     conversation would be for me to ensure that her
  21     position, her action, her conversations were what
  22     I would have wished of her. That would be the nature of
  23     the conversation.
  24        I would not be discussing with Janet Maher and
  25     asking her for her advice on what I was going to do.

   1     That would not have been part of the conversation, which
   2     is why she says she would not have expected me to
   3     indicate what I was going to do. That was not the
   4     nature of the conversation. I did not meet general
   5     managers in order for them to make me a better Chief
   6     Executive. I hope the meetings enabled them to be
   7     better general managers.
   8   Q. The understanding she refers to there, "My understanding
   9     was that Dr Roylance intended ..." and she goes on, was
  10     that something you think you conveyed to her or not?
  11   A. No, I would not have conveyed anything to her about what
  12     I was going to do, I was concerned with what she had
  13     done. I was, at that time, and talking to Chris Monk
  14     and James Wisheart and a number of other people early in
  15     1994, pressing ahead with the recognised solution to the
  16     problem. I did not find it surprising that people
  17     thought there was a need for the solution. We were
  18     driving it forward, and I would have been talking to
  19     Chris Monk and James Wisheart. I did not see this as
  20     the surprising, you know, the difficult position that
  21     Janet Maher thought it was because I knew we were not
  22     investing all that money because we were the best in the
  23     country, but that we were in the lower regions of the
  24     band of quality that was being provided across the
  25     country.

   1   Q. I cannot properly ask you why it was she had
   2     a particular understanding because you cannot comment on
   3     other people's understandings, save to ask this: was
   4     there anything in your conversation or anything which
   5     you did, do you think, which might have given her the
   6     understanding which she sets out here?
   7   A. I cannot say. I cannot say. I can say that I was
   8     reassuring to her and in that reassurance she may well
   9     have felt "Thank you very much, he is satisfied with
  10     what I have done, it is now on his table". That may
  11     have been her understanding, I cannot say that. It was
  12     not my intention and never was to say to people "The way
  13     you manage is to come and give me your problems and
  14     I will take them away", it was never my practice to do
  15     that because I do not think that was a way to develop
  16     managers.
  17        I actually would always discuss what they had
  18     done, should do and how they should approach things.
  19     I cannot say why. I expect she trusted me and she had
  20     the degree of anxiety which she had not conveyed to me,
  21     she may well have felt my reassurance meant that I was
  22     going to deal with it.
  23   Q. Can I move on? You told us yesterday that
  24     Mr Peter Durie and you enjoyed a very close
  25     relationship?

   1   A. Yes.
   2   Q. That arose in the context of the conversations which
   3     Martin Elliott said that he had with Mr Durie as
   4     a result of which the reflection was not, it seems,
   5     given to you of any sense of danger in the way in which
   6     the paediatric cardiac services were provided.
   7        Overnight we have had -- and I will have it on the
   8     screen now, this I think is your first chance to have
   9     a look at it, and I am sorry. Can we have WIT 108/150
  10     and I will give you a moment to look at his e-mail to
  11     the Inquiry. I will read it through because it may be
  12     difficult for those watching on the screen to follow the
  13     words. It gives his address and says:
  14        "Feedback. I read with interest the transcripts
  15     of the Inquiry proceedings on 6/12/99, particularly
  16     paragraphs 88 through 97 of Mr Roylance's evidence.
  17        "I should like to comment on the semantic debate
  18     which took place over the phrase 'potentially dangerous
  19     which I used when declining formally to apply for the
  20     Chair of Cardiac Surgery in Bristol in 1991/2 [and he
  21     gives the reference to the document we saw yesterday].
  22        "I wish to make it quite clear that I considered
  23     and still consider that the separation of services on to
  24     two sites was inappropriate and actually dangerous.
  25     I was not being asked to make a formal critique of

   1     Bristol services, rather to express my personal reasons
   2     for declining the Chair. The debate over the use of the
   3     word 'potentially' is misleading, since I was of the
   4     opinion that the services were potentially dangerous for
   5     the individual child as I described in my written
   6     evidence to the Inquiry. I thought the risks were too
   7     great, that the organisational will was not there to
   8     make the necessary change at that time, hence my
   9     decision to decline the Chair."
  10        I showed you it for two reasons, one to ask if you
  11     had any sense from what you were told by Mr Durie or
  12     from what you read at the time that there was danger in
  13     the sense that Martin Elliott now tells us he intended?
  14   A. Can I first of all say that I may have been guilty in
  15     drawing inferences from a bit of "doctor's English"
  16     which was not meant to imply what I inferred.
  17        I have to say I find this very sad, this comment.
  18     I really cannot understand how somebody can come, an
  19     expert in paediatric cardiac surgery, form the judgment
  20     that practices are dangerous in Bristol, put his hat and
  21     coat on and go home. I really find it hard to
  22     understand that.
  23        I have to say if I had gone and visited
  24     a department with a view to being a Professor of
  25     Radiology and looked round the department and thought

   1     "that was dangerous" I would have called in to the
   2     College of Radiologists on my way home.
   3   Q. If it is to be suggested what he did was to tell the
   4     Chairman of the Trust and the Medical Director, what
   5     else would you suggest that he should have done?
   6   A. I think he should have told the Royal College. I am
   7     sorry, I think he should have -- if he felt that, he
   8     should have ensured that the proper medical professional
   9     machinery was activated to put it right. I find that
  10     quite an astonishing thing. Peter Durie did not tell me
  11     "I have just seen a chap who says we have a dangerous
  12     service in paediatric cardiac surgery". I knew him
  13     extremely well. It would have been quite out of
  14     character for him to have received that information and
  15     sat on it. I find that, I must say, I find that very
  16     sad. I really am very disappointed in that remark,
  17     those remarks there, I am extremely sad.
  18   Q. It would appear Mr Wisheart had a document in his hand
  19     which used the words "potentially dangerous".
  20   A. Yes.
  21   Q. Did he, in your words, "sit on it"?
  22   A. No, I think his understanding was the same as my
  23     understanding, that there was a potential for danger to
  24     occur and by that I mean that if you take the necessary
  25     steps you avoid that potential arising. I am sorry,

   1     I really have to defend -- you will be able to ask
   2     James Wisheart yourself, but I have to defend his
   3     interpretation that something he says is potentially
   4     dangerous actually means is dangerous.
   5        I do not know why you put the extra word in. The
   6     extra word must -- I am not being semantic, I am
   7     actually explaining what inference was drawn. If you
   8     say to me I should have formed the judgment that
   9     somebody, some time after he had been, wrote a letter to
  10     say why he did not want to come in the unit and what he
  11     meant to say was "Please, that service is dangerous" and
  12     that is all he did, then I do not think I should express
  13     further my view, but I think you can infer what my
  14     feeling is.
  15   Q. I think you have made your feelings very clear on that.
  16     Can I go forward to UBHT 61/246? 12th May 1994. It is
  17     a letter to Mr Durie. Shall we have a look at what it
  18     says?
  19        "As you know, Gianni Angelini has been to see
  20     me ..." This is a letter as you can see from the bottom
  21     of the page, 247, it is from Professor Vann Jones and it
  22     has a second signatory of Professor Angelini.
  23        Can we go back to 246?
  24   A. The middle of 1994, was it? I beg your pardon, I am
  25     trying to put this thing in perspective.

   1   Q. This is 12th May 1994. It is, as the initials at the
   2     top suggest, from Professor Vann Jones and it is to the
   3     Chairman.
   4        "As you know, Gianni Angelini has been to see me
   5     at your behest to discuss the problems that we have with
   6     paediatric cardiac surgery."
   7        Stopping there, what that sentence suggests is
   8     that Professor Angelini had spoken to Mr Durie or
   9     Mr Durie to him and that Mr Durie had directed
  10     Professor Angelini to go and talk to Professor Vann
  11     Jones.
  12        Did you know that any of that had gone on?
  13   A. This is at a time when we were -- sorry, I have to give
  14     a slightly long answer. This was at a time when we were
  15     actively initiating two things: the move up the hill and
  16     the appointment of a paediatric cardiac surgeon, we were
  17     actually looking for ways of doing it and so on and
  18     I was looking at the date to see if I could actually fit
  19     it into where we were at that time. I do not think
  20     I ever saw this letter because if they said "We accept
  21     the reality of the position, it is unlikely that
  22     paediatric cardiac surgeons will move to the Children's
  23     Hospital" I would have said I do not understand why they
  24     are of that view because Gianni Angelini was actually on
  25     the Working Party planning the move.

   1        I think this is a letter -- you must correct me if
   2     I am wrong -- about which there is some doubt about
   3     because I think Peter Durie is of the view he never
   4     actually received this letter. But the content of it,
   5     the subject matter of it I was aware of but not through
   6     this letter.
   7   Q. Can I go further then to the subject matter of this? It
   8     reads on, he talks about the history of -- that is the
   9     problems with paediatric cardiac surgery, "It has run
  10     along in a rather half-baked fashion". It deals with
  11     the move to the Children's Hospital which it says is
  12     unlikely. Then the line beginning:
  13        "However our present problem is that we have good
  14     units on our doorstep, namely, in Southampton and in
  15     Cardiff and if paediatric cardiac surgery is to survive
  16     in Bristol, the surgical side certainly needs a very
  17     major shake-up. As you know at present it is run by two
  18     part-time adult/part-time paediatric surgeons, but it is
  19     now such a highly specialised completely different
  20     speciality from adult cardiac surgery that the option is
  21     a very poor second to what is required."
  22        Then it deals with the idea which
  23     Professor Angelini was putting forward of appointing a
  24     senior lecturer.
  25        Did you know that there was a perception at least

   1     on paper that there was a problem relating to having
   2     good units on the doorstep and needing as it were to
   3     compete if paediatric cardiac surgery was to survive in
   4     Bristol?
   5   A. I knew there were other -- I am not sure about the unit
   6     in Cardiff, whether they had a paediatric cardiac
   7     surgical unit then?
   8   Q. I think in 1994 they did have one.
   9   A. They were just beginning it, were they not?
  10   Q. I think so.
  11   A. I think they needed to say it was a unit that was going
  12     to be a good unit in Cardiff. I knew there was a good
  13     unit in Southampton, I visited it twice and possibly
  14     three times and talked to the senior cardiac surgeon
  15     down there.
  16        So I knew there were places, and that is no
  17     different from the argument that when the radiologists
  18     wanted an MRI scanner, they said "the units in the US
  19     have MRI scanners and we have not", it is the sort of
  20     argument that is presented and I believe if we had
  21     stayed behind in this evolution of cardiac surgery when
  22     other places were appointing specialist paediatric
  23     cardiac surgeons, it is quite reasonable to say in the
  24     fullness of time we would have fallen out of the band of
  25     results and been left behind; I do not find that

   1     a strange reflection of the thinking at the time.
   2        We were actually moving very hard to improve the
   3     unit. But the purpose of this letter was not to achieve
   4     the change, it was to suggest that funding a consultant
   5     senior lecturer on soft money for a couple of years
   6     would solve our problem because this is addressing how
   7     to solve the problem. Provided I was (a) able to
   8     promise in advance that that consultant senior lecturer
   9     would be appointed an NHS consultant in two years time
  10     and (b) that I could promise to take responsibility for
  11     his salary from that point on.
  12        The truth of the matter is that if the only
  13     problem of getting a paediatric cardiac surgeon was two
  14     years of non-recurring money, I could have found that;
  15     the problem was the recurring money and I could not
  16     promise that I could appoint him to a consultant post
  17     that at that time did not exist because of the
  18     regulations, the legal requirement was that NHS
  19     consultant posts are appointed in competition, open
  20     competition at a selection committee which I could not
  21     control.
  22   Q. Do you know what had prompted Mr Durie to go to
  23     Professor Angelini and ask him to go to Professor Vann
  24     Jones to discuss the problems with paediatric cardiac
  25     surgery?

   1   A. Not with certainty now. Peter Durie was very useful in
   2     the Trust and certainly very useful to me because one of
   3     the functions he liked to fulfil was to go, as he called
   4     "walkabout". Often if there was any area that I had
   5     the slightest anxiety about I would ask him would he
   6     mind picking that particular area for his next
   7     walkabout, just go and talk to everybody. I would even
   8     forewarn him sometimes what I thought the problem was so
   9     that he could evaluate it as an outside caring Chairman,
  10     and because he was non-managerial and a Chairman and
  11     I was managerial, it was at times very much more
  12     effective for me to ask him to go.
  13        So I cannot tell you whether I asked him to go or
  14     whether this unit was in the rota, I cannot tell you now
  15     whether I asked him to change his rota but I have to
  16     tell you that I did from time to time say "there is
  17     a problem in radiotherapy" I might say to him, "would
  18     you mind changing your programme, go and stroll round
  19     there, this is what I think it might be, go and find out
  20     for me". And he would come back and type me a file
  21     note, dictate a file note for me.
  22   Q. This letter to him obviously as Chairman, is this the
  23     sort of letter you would expect to find its way into
  24     your files?
  25   A. Yes, if Peter Durie had received that he would have

   1     given it to me. I cannot now tell you whether we would
   2     have saved filing space by leaving it in his file to
   3     which my personal assistant had access or whether we
   4     would have duplicated it or whether we would have filed
   5     it in my file. We were in the same suite of offices, it
   6     would have been filed in Headquarters and I would have
   7     seen it.
   8   Q. So the system would be that if it came to Peter Durie
   9     then you would have had a copy of it and it would have
  10     been filed?
  11   A. Yes, and we would have discussed it, it would have been
  12     on his list of points for discussion the next time we
  13     had what he used to call his "one-to-one".
  14   Q. You did not in fact see this letter?
  15   A. No, he tells me he did not see it. I do not know, he
  16     told me, but he has given evidence that he did not see
  17     this letter either and I cannot explain that.
  18   Q. It is of complete curiosity that a letter of this length
  19     in particular by busy people should be written and not
  20     sent, if it was not?
  21   A. I said it was curious. I cannot offer any explanation
  22     I could accept as to why he did not receive it, but he
  23     did not and he did not show it to me. What I am saying
  24     is the fact I did not see the letter does not mean I did
  25     not know the thinking of those two and this scheme which

   1     of course I remember because it solved the problem
   2     I could solve and left me with the problem that I could
   3     not solve and ...
   4   Q. You tell us that perhaps the inspiration for Peter Durie
   5     going to see Professor Angelini may well have been at
   6     your own instinct that there were problems and concerns
   7     that he might like to go and talk to Professor Angelini
   8     about?
   9   A. I have no memory of asking him to, I was merely saying
  10     as a matter of honesty that not all Peter Durie's visits
  11     were as spontaneous as they appeared to others to be.
  12   Q. Do you have any recollection of having then been aware
  13     of something moving and some problems, some concerns
  14     that you asked Peter Durie to have a walkabout and have
  15     a look at?
  16   A. Not particularly then. I knew problems arose with this
  17     move and with staff anxiety which moves always produce
  18     and so I do not think we got that far to have disturbed
  19     the staff, so you used the words "I may well have asked
  20     him to go". That is true and I may well not have asked
  21     him to go.
  22   Q. Can we have a look at WIT 86/38? Can we scroll down,
  23     please? This is Mr Durie's statement to us.
  24     Paragraph 11:
  25        "Despite there being many routes for someone who

   1     wished to voice concerns approaching me about paediatric
   2     cardiac surgery, I can only recall one person doing so.
   3     That was Professor Angelini in May 1994 who voiced his
   4     concern about the clinical outcomes in paediatric
   5     cardiac surgery", and he goes on to describe the
   6     concerns about what you then call "walkabout".
   7        "12: When informed about any issue --
   8   A. That does suggest to me that his memory is that I did
   9     not ask him to go, is it not?
  10   Q. It suggests that.
  11        "When informed about any issue there were
  12     a number of options open to me as Chairman. If
  13     I considered a problem to be acute and clear-cut I would
  14     instruct the Chief Executive to take action, otherwise
  15     I would request the Chief Executive to look into the
  16     issue.
  17        "13. As the concern about paediatric cardiac
  18     surgery outcomes, voiced by Professor Angelini was the
  19     first I had heard, I chose the latter option" that is
  20     requesting you to look into the matter.
  21        "At my next meeting with Dr Roylance, I told him
  22     about the Professor's concern and I asked him to look
  23     into it."
  24        Is that right, did that happen?
  25   A. I am sure it would. I have no reason to doubt that,

   1     no. That is what he regularly did. He also -- I mean,
   2     to show how close it was, he said if ever he slipped and
   3     made a management decision then he left me with full
   4     authority to cancel it if I did not agree with it.
   5     There was a time when we tended to overlap a little
   6     bit.
   7        So he would go and have a visit and it seems this
   8     was part of a group of visits in which he went to talk
   9     to all the professors and then having done so, if there
  10     was anything that arose he would actually type what he
  11     called the file note, quite an informal note and we
  12     would discuss it the next time we met.
  13   Q. What he is saying there is that some time, I would
  14     imagine shortly after speaking to Professor Angelini in
  15     May 1994, he says to you "I have had concerns expressed
  16     to me about outcomes in paediatric cardiac surgery,
  17     would you look into it"; did you do so?
  18   A. Yes, yes.
  19   Q. How did you look into it?
  20   A. Well I talked to him. At that time I was talking to
  21     Angelini very frequently and I remember quite clearly
  22     his view was the solution was to appoint a paediatric
  23     cardiac surgeon; that is what we needed, banging on the
  24     table "we need a paediatric cardiac surgeon", and I said
  25     "yes, that is what we are trying to do". He said "the

   1     first thing you need to do is to decide whether there is
   2     a need to appoint a paediatric cardiac surgeon" and
   3     I would say "no, no we have gone past that stage, the
   4     Board has agreed, everybody has agreed, we are actually
   5     going to do it" and he seemed to think that if we could
   6     strengthen the argument, the case for appointing
   7     a paediatric cardiac surgeon that in itself would
   8     generate the money. It is a sad fact about the Health
   9     Service that certainly that does not happen, you have to
  10     identify the money.
  11   Q. At this stage, in May 1994, the decision in principle
  12     had been taken you say to appoint a paediatric cardiac
  13     surgeon, does that mean the funds had then been found?
  14   A. Yes, we would not have got that far. Looking back, I am
  15     sorry, Ash Pawade was appointed some time towards the
  16     end of 1994 -- the Appointments Committee, was it, just
  17     remind me?
  18   Q. 20th September 1994 was the Interviewing Committee. He
  19     did not take up office until May 1995 as you know?
  20   A. No, but he was appointed by the Interviewing Committee.
  21     There is then always a delay when they give notice,
  22     finish what they are doing and so on and we hope they
  23     come. So he was appointed. The selection committee
  24     happened you say in September.
  25   Q. Yes.

   1   A. The shortlisting would have happened almost certainly in
   2     July because after the shortlisting references would
   3     have to be taken up and appointments made to interview
   4     the candidates, so that that is when the shortlist would
   5     be.
   6        Now we have to say before that there is an advert
   7     with enough time for applications to be in in time for
   8     the shortlist, and I am trying to work backwards, and
   9     I think this was quite a period before we formed the
  10     decision.
  11        So that I am trying to convince myself and work it
  12     out that by May 1994 we must have had identified where
  13     the money was coming from, we must have been through the
  14     process, the Medical Committee approval of the job
  15     description and all the rest of it. So that by that
  16     time we must have been well on our way to appointing
  17     a paediatric cardiac surgeon.
  18   Q. If we go back to the letter we were looking at a moment
  19     ago, it is dated 12th May and certainly the feeling
  20     behind that letter is from that of two persons concerned
  21     for the future of paediatric cardiac surgery who did not
  22     understand that at that stage a final decision had been
  23     taken to make the appointment. I do not know whether
  24     that helps at all, would it have been around that time?
  25   A. It does help. Please, I am sorry. I am sorry I cannot

   1     give you the dates. I would have to look up the health
   2     -- the Trust Board minutes and the records in personnel
   3     and so on.
   4        But in principle, during the course of that year
   5     we must have identified the funds. That would have been
   6     through the negotiation of the next year's contracts for
   7     cardiac surgery and that was done substantially before
   8     the end of the year, so that would have been done.
   9        Reading this it looks as though either we have not
  10     identified the money but certainly that they do not
  11     think we have. As the letter did not come I cannot date
  12     it to that. But there would be a time when I met
  13     Gianni Angelini, virtually from the time when he arrived
  14     when he was pressing me for the appointment of
  15     a paediatric cardiac surgeon.
  16        I feel that is getting a bit close to when we
  17     actually initiated it and I cannot see this time for
  18     this letter to have been written and then us to identify
  19     the money and then actually get him appointed in
  20     September. You can understand my difficulty, but I have
  21     not got the dates of this particular event. There were
  22     a lot of other things happening and at this time there
  23     was no dispute about paediatric cardiac surgery, which
  24     I knew, except the wish to improve it.
  25        So I have not got those dates firmly in my mind.

   1     Certainly I remember -- and it may well have been before
   2     this that Gianni was talking to me and so on -- but
   3     I remember Gianni being very impatient at the thought
   4     I would allow -- the fact I could not pay a paediatric
   5     cardiac surgeon to prevent me recruiting him.
   6   Q. Can I move on a little, we are examining events in May?
   7     I have already asked you about the events in June when
   8     the anaesthetists' letter was or was not shown to you.
   9        Mr McKinlay took over as Chairman, did he, in July
  10     of that year?
  11   A. I cannot remember the precise date but I would not
  12     dispute that, and I expect you know when he took...
  13   Q. 1st July 1994 he tells us?
  14   A. Yes, I would accept that, yes.
  15   Q. Can we have a look at WIT 102/27, which is his statement
  16     to us. Paragraph 15:
  17        "From my briefing by Mr Durie before I joined
  18     [that is before 1st July] I knew there were concerns
  19     about whether the duration of operations on very young
  20     children, as performed by Mr Wisheart, had a negative
  21     impact on the outcome. Within my first 3 months
  22     I discussed this point with Dr Roylance and Mr Wisheart
  23     who stated that within the profession there was no firm
  24     conclusion on this point, and that meticulous work was
  25     inclined to take longer, which was regarded by some as

   1     a positive factor."
   2        Pausing there, did Peter Durie ever express to you
   3     the view that there were concerns floating around about
   4     the duration of operations on very young children?
   5   A. I expect it is much more likely that I expressed that to
   6     him.
   7   Q. So you had a concern about it?
   8   A. No, I would not put it that way: I knew that some people
   9     found James Wisheart a slow surgeon. I do not want to
  10     give a tutorial about this. James Wisheart was
  11     appointed to raise the quality of paediatric cardiac
  12     surgery and adult cardiac surgery, he was the first all
  13     cardiac surgeon to be appointed in Bristol. He was, at
  14     that time, the equivalent of the young whiz kid, the
  15     dedicated cardiac surgeon which would only just be
  16     coming on the stream at that time and at that time my
  17     understanding is that with these difficult operations on
  18     small children, and adults for that matter, a meticulous
  19     attention to surgical detail was a prerequisite of
  20     getting a result. He had been appointed as -- supported
  21     by his referees and the Royal College -- as a very
  22     competent cardiac surgeon.
  23        I could not personally form a judgment as to
  24     whether his slowness was a risk factor or merely kept
  25     anaesthetists in theatre a long time.

   1   Q. Who was it then who was suggesting that he was an
   2     unusually and disadvantageously slow surgeon?
   3   A. I do not know. I mean I remember talking to Mr Hutter
   4     and asking him about Mr Wisheart and he said "he is one
   5     of the three surgeons that I would ever allow do
   6     a coronary artery bypass graft on me" and he was
   7     a cardiac surgeon.
   8        The fact he was a slow surgeon I knew. The
   9     implication that by definition this was a risk factor
  10     was by no means clear.
  11   Q. Something made you go to discuss that issue with
  12     Mr Hutter?
  13   A. Yes, somebody makes a comment about people I also have
  14     to go along and say "what is the strength of it". I was
  15     talking to people in all specialties not just this one,
  16     and if something comes up and -- I cannot remember who
  17     made the thing, it may have been (inaudible), I cannot
  18     remember who said it, but it was general knowledge that
  19     he was a slow surgeon.
  20        It was also known that his patients very rarely
  21     went back to theatre and some of the operations that
  22     took less time finished up back in the theatre in the
  23     evening. There were conversations about this. I could
  24     not judge about it. Nobody ever came to me and said
  25     "stop him operating".

   1   Q. There seems to be a link, from what Mr McKinlay recalls,
   2     being made by some people to Mr Durie -- however
   3     unjustified it may have been -- there seems to be a link
   4     between the slowness of the surgery and negative
   5     outcomes?
   6   A. No, I do not think that was the atmosphere at the time.
   7     There was a link between the wish to get one of these
   8     new super young whiz kids who did cardiac surgery and
   9     did three cases in the afternoon instead of one and that
  10     was part of the argument, the support for getting one of
  11     the new breed of paediatric cardiac surgeons. My
  12     understanding is now that they do more operations in
  13     a session and this was part of the argument to get
  14     a paediatric cardiac surgeon.
  15        It was generally recognised -- I do not know who
  16     told me and when it came up and so on -- but I knew the
  17     intention was, when the new paediatric cardiac surgeon
  18     was appointed Mr Wisheart was going to concentrate his
  19     efforts in adult cardiac surgery, but the conversations
  20     -- I have to emphasise this -- the conversations never
  21     strayed into the realm of "what is happening at the
  22     moment is unacceptable". "What is happening at the
  23     moment can be improved" is a conversation that happens
  24     whenever a more specialised clinician is swapped to
  25     replace what happens before.

   1        So these sorts of conversations would have
   2     happened when the thoracic surgeon was replaced by
   3     a cardiothoracic surgeon, they happened when the general
   4     surgeon was replaced by a thoracic surgeon; the whole
   5     process that I have been privileged to witness and
   6     within radiology take part in, of specialisation in
   7     medicine is something that has been going on for a very
   8     long time. The belief is, it has not always been
   9     confirmed by subsequent review, but the belief is that
  10     if you appoint a paediatric radiologist you will get
  11     a better service than a general radiologist who does the
  12     paediatrics and this is the discussion that was going on
  13     there.
  14        I really have to caution anybody against picking
  15     these bits to pieces and saying "conversations were
  16     taking place that the service was unacceptable". The
  17     first evidence I have ever seen of anybody saying the
  18     service was unacceptable was what we have just seen.
  19   Q. Dr Roylance, forgive me for asking you to pause, the
  20     question I was asking was simply this: did someone,
  21     however justified or unjustified it may have been,
  22     suggest to you that there was a link between
  23     Mr Wisheart's slowness of surgery and negative outcomes?
  24   A. I do not know. I do not think it was ever expressed to
  25     me in those terms and I was trying to explain why that

   1     was not the tone of conversations.
   2   Q. You are discussing the issue with Mr Hutter from the
   3     conversation that you recall where Mr Hutter says "if it
   4     was me I would like Mr Wisheart to operate on me because
   5     although he may be slow he is a very good surgeon",
   6     suggests that you were raising some concern as to
   7     a potential link between outcome and time of surgery;
   8     were you or not?
   9   A. No, I was asking him to explain the background to what
  10     I had been saying. It would have been quite wrong for
  11     me at any time to jump to conclusions about what was
  12     going on in paediatric cardiac surgery or adult cardiac
  13     surgery; I could not do that. But if somebody says to
  14     me "James is a slow surgeon" then I have to naturally in
  15     my informal conversation with colleagues say "what is
  16     this about James being a slow surgeon", and they say "he
  17     is a very good surgeon" --
  18   Q. You cannot answer for any particular view that Mr Durie
  19     may have formed are the reasons for it, but do you know
  20     of any reason why Mr Durie for his part may, as
  21     Mr McKinlay recollects, have drawn a link between
  22     slowness of surgery and a possibility that that might
  23     have affected outcome?
  24   A. The outcome there might have been that they spent rather
  25     longer in intensive care, which children did; I knew

   1     that, that is why they had an impact on the adult
   2     service. In terms of negative impact on outcome, it is
   3     not my memory that anybody (if I can put it bluntly) was
   4     saying "patients are dying because James Wisheart is
   5     a slow surgeon". That was never raised, if it was
   6     I would remember that absolutely clearly.
   7   Q. Can we move on to UBHT 61/273 --
   8   THE CHAIRMAN: I wonder while we are pausing there for
   9     a moment if I can explore with Dr Roylance whether
  10     I understand his approach clearly: you say if someone
  11     had said "Mr Wisheart is a slow surgeon" you might have
  12     said to someone "what is all this about James being
  13     a slow surgeon"; how does that fit in with your notion
  14     that some things are professional and some things are
  15     managerial and it really was not your role and your job
  16     to get involved in the professional, and I assume
  17     slowness or speed of surgery is a professional matter?
  18   A. Yes, yes. You are quite right to show that there was no
  19     way one can produce an absolute line between one and the
  20     other. What would have happened is that I had been
  21     there a long time, I knew everybody and I had informal
  22     conversations as John Roylance with John Hutter. It
  23     would not have been a conversation of the Chief
  24     Executive talking to one of the staff and saying "give
  25     me a report".

   1   THE CHAIRMAN: That is what I imagined you would say. Does
   2     it follow from that that others working in the
   3     organisation might not know what mode you were prepared
   4     to be in, namely sometimes Chief Executive, sometimes
   5     John Roylance and whether they could approach you in one
   6     manner and be told "that is a professional matter" or
   7     alternatively be listened to?
   8   A. Clearly I cannot guarantee that nobody ever
   9     misunderstood, but I was in the habit, the regular habit
  10     of telling people whether they were talking to
  11     John Roylance, whether they were talking to Dr John
  12     Roylance or whether they were talking to
  13     the Chief Executive. One of my phraseologies used to
  14     be, if it was in my office "the office is not bugged,
  15     there are no minutes, have a chat with me and then we
  16     will decide whether to tell the Chief Executive". It
  17     was a relationship I had previously had with the Deputy
  18     District Administrator, I remember on one occasion he
  19     said "you must not talk to me because I cannot take the
  20     hat off".
  21        So I tried to make sure everybody knew all the
  22     time whether we were having a formal conversation or
  23     whether we were just having an informal chat.
  24   THE CHAIRMAN: One last question to pursue that:
  25     I understand that and that is very helpful, how could

   1     one send that signal out at the beginning of
   2     a conversation short of wearing a badge saying I am X or
   3     Y?
   4   A. I did not because it might have been a conversation
   5     about football or something else I was interested in.
   6     If it became a topic I would always as a matter of
   7     routine -- I hope I did it every time, please, I cannot,
   8     that is why...
   9        But if they started talking about something
  10     I would do the equivalent of what the media do, "can
  11     this be off the record", "can we just have a chat and
  12     then if necessary we will have a proper conversation,
  13     a formal conversation" and it was the topic of the
  14     conversation which would precipitate it.
  15   MR LANGSTAFF: This letter from Professor Angelini to
  16     Dr Doyle, if we look at the second page, 61/274, is
  17     copied to you and you have ticked receipt of it?
  18   A. No, that is the tick of the secretary to say this is the
  19     one she is sending.
  20   Q. Can we go back to the first page. It has your writing
  21     on it?
  22   A. Yes.
  23   Q. So you saw this letter, you got this copy and you would
  24     have noticed -- can we scroll down, please -- that
  25     a senior medical officer in the Department of Health had

   1     written to Professor Angelini on 21st July expressing,
   2     it appears in the second paragraph, concern about some
   3     of the paediatric cardiac surgical work and
   4     Professor Angelini, admitting to him "there had been
   5     audits which had shown a greater mortality than perhaps
   6     could be expected in a particular surgical procedure.
   7     A matter of concern, although we tried very hard in the
   8     last few months to implement changes aimed at improving
   9     our results."
  10        He sets out the first change which is the
  11     appointment. He is obviously aware by now that that is
  12     taking place.
  13        The bottom of the page, a suggestion that a move
  14     to the Children's Hospital would be fortuitous. If we
  15     go overleaf, the second sentence "no doubt in my mind
  16     that the problem we have been experiencing is something
  17     which we can address".
  18        When you got this letter you would have realised
  19     that the Department of Health had been writing to
  20     a Professor of Cardiac Surgery in relation to concerns
  21     expressed about the unit, a unit in the hospital of
  22     which you were the Chief Executive; did that concern
  23     you?
  24   A. Yes. I did not know that Peter Doyle thought he was
  25     writing as an individual and not as a member of the --

   1     not as a senior medical officer in the Department of
   2     Health.
   3        I felt that if he was concerned about the quality
   4     issue within the unit, if for no other reason than
   5     common courtesy, he should have told me. The correct
   6     line of communication would have been through the
   7     regional medical officer and through the regional
   8     medical officer to me. Therefore I found this a bizarre
   9     letter, writing to somebody who at that time was the
  10     most junior NHS consultant who was an adult cardiac
  11     surgeon about problems in paediatric cardiac surgery.
  12        So my response to this was first of all to say to
  13     James politely "what on earth is going on" and,
  14     secondly, to write immediately to Peter Doyle so he
  15     wrote to me.
  16   Q. Did you speak to Professor Angelini?
  17   A. No. No, I did not want to be part of a conversation
  18     between the Department of Health and Angelini; I thought
  19     that was improper and I did not want to be in that line;
  20     I wanted to be in a proper relationship with the
  21     Department of Health.
  22   Q. Did you ask to see the letter which Peter Doyle had
  23     written to Professor Angelini?
  24   A. No.
  25   Q. Why not?

   1   A. Because I did not want to be part of this improper
   2     communication which I did not understand between him and
   3     Angelini. My letter was written so that if he had
   4     anything to say he would say it to me.
   5   Q. Here was the Department of Health apparently writing,
   6     expressing concern about part of the operation of which
   7     you were the Chief Executive and you deliberately chose
   8     not to see the letter?
   9   A. Yes, I think I have explained that, please, that I did
  10     not want to be part of an improper line of communication
  11     with what I thought was the Department of Health. I did
  12     not at that time know this was a personal correspondence
  13     between Peter Doyle acting, as he thought, in a personal
  14     capacity and talking to Gianni Angelini. I did not know
  15     that and I hope you can forgive me for when I see
  16     a letter addressed to him as Senior Medical Officer,
  17     Department of Health that is the capacity in which the
  18     conversation sprung up.
  19   Q. I appreciate that. Are you the sort of person, would
  20     you say, to whom the formalities are more important than
  21     the substance?
  22   A. No, I am concerned in the substance and I could not see
  23     any benefit, any merit, any anything between somebody in
  24     the Department of Health writing of all people in the
  25     Trust to Gianni Angelini. If he had written to the

   1     Medical Director I could have understood that. If he
   2     had written to the Chairman of the Medical Committee who
   3     was I think at that time different, I could have
   4     understood that.
   5   Q. However improper the correspondence, why did you not
   6     want to know what the concerns actually were?
   7   A. Because I wanted Peter Doyle to tell me, I wanted him to
   8     tell me. In the event, as you will know he wrote back
   9     to me and said "everything is fine, I am satisfied", end
  10     of correspondence.
  11   Q. UBHT 61/278. This is your letter then to Dr Doyle, is
  12     it?
  13   A. Yes.
  14   Q. Can we have a look at the text? Where in that letter do
  15     you ask Dr Doyle to tell you what the problem is?
  16   A. I do not.
  17   Q. You tell him in fact, do you not in the first paragraph,
  18     or you imply that you have actually seen the letter he
  19     wrote to Professor Angelini?
  20   A. I am sorry, if my English is inadequate I apologise and
  21     I have apologised before. I did not wish to imply that
  22     I had seen anything but what I had seen, and that was
  23     Gianni Angelini's letter that he had sent to
  24     Peter Doyle. If you would be happier that I had said "a
  25     copy of the letter he has recently sent to your

   1     department", I would be very happy for that amendment of
   2     English, but I did not wish to infer that I had seen the
   3     letter he had since sent to Gianni Angelini, I have not
   4     seen it so I would not have wished to imply that.
   5   Q. Can we go back to the letter? You say you wanted
   6     Dr Doyle to tell you what the problem was?
   7   A. No, I did not say that. I am sorry I did not say that.
   8     If I did say that I apologise, I wanted Dr Doyle to
   9     write to me is what I hoped I had said.
  10   Q. What you said twice, the question I asked you was
  11      "however improper the correspondence, why did you not
  12     want to know what the concerns were?" You said:
  13     "Because I wanted Peter Doyle to tell me, I wanted him
  14     to tell me. In the event, as you will know, he wrote
  15     back to me and said 'everything is fine, I am
  16     satisfied', end of correspondence." That is when I took
  17     you to your letter where --
  18   A. Yes, I did not say I wanted him to tell me the problem,
  19     I wanted him to explain the problem, I actually said
  20     I hope I wanted him to write to me, which I think I had
  21     a legitimate expectation, that if he wished to write
  22     about paediatric cardiac surgery to UBHT he should write
  23     to me, not to a professor of adult cardiac surgery.
  24   Q. Did you or did you not want to know what problems the
  25     Department of Health as you thought officially saw that

   1     your paediatric cardiac unit faced?
   2   A. At that time the problems in the paediatric cardiac
   3     surgery I knew was that we were wishing to improve it,
   4     and I keep saying this, that that was the problem. We
   5     had been struggling with it for a long time and it was
   6     a problem.
   7   Q. I do not think that is an answer to the question. The
   8     question was --
   9   A. I am sorry I hoped it was.
  10   Q. You have not answered the question, may I repeat it?
  11   A. I misunderstood it, I am sorry.
  12   Q. The question was: did you or did you not want to know
  13     what the Department of Health had by way of concerns
  14     about your paediatric cardiac unit?
  15   A. If they had any -- I have to say, I do not know how to
  16     answer that question. I wrote to Peter Doyle so that he
  17     would write to me. He wrote to me to say he had not any
  18     problems. I do not think at that time I thought "that
  19     is funny, would he tell me what the problems are".
  20        I am sorry, my mind did not work that way, that
  21     was not the issue and I think as a matter of record that
  22     Angelini's letter to him was wrong in that he said he
  23     did not know anything about the move to the Children's
  24     Hospital. I know he was on the project group overseeing
  25     it, I can only presume he never went to it.

   1   Q. Dr Roylance, let me try again for the last time: did you
   2     or did you not want to know what particular concerns the
   3     Department of Health had that had prompted them to write
   4     to Professor Angelini?
   5   A. No. No, not what had prompted him to write to Angelini,
   6     no. I did want him to tell me if he had any problems,
   7     and he did not. He actually wrote to say he did not
   8     have any problems.
   9        What you are asking me is, I think -- can
  10     I clarify this because I really feel very guilty if I am
  11     not answering your question because I really am trying
  12     to -- I think you are asking me did I want to know the
  13     nature of the conversation that Doyle was having with
  14     Gianni Angelini?
  15   Q. No, what I was asking you was did you want to know what
  16     concerns the Department of Health had that prompted them
  17     to write; that is the question?
  18   A. No, not that prompted them to write Gianni Angelini.
  19     I certainly gave him every opportunity to tell me if he
  20     had any problems.
  21   Q. Let me put the question another way: did you want to
  22     know what concerns the Department of Health had about
  23     your paediatric cardiac surgical unit?
  24   A. Yes, if they had any, and they told me they did not.
  25   Q. We have not finished looking at your response and your

   1     reply and we will do that after we have had a break
   2     which is now I think somewhat overdue.
   3   THE CHAIRMAN: Shall we take 15 minutes, until 5 past 11,
   4     thank you.
   5   (10.50 am)
   6               (A short break)
   7   (11.10 am)
   8   MR LANGSTAFF: When you wrote this reply on 12th September
   9     1994 to Dr Doyle and you write in the second
  10     paragraph that you felt you should write to confirm the
  11     Trust Board's awareness of this problem, from what you
  12     said you did not know what the problem was that the
  13     Department of Health had in mind.
  14   A. I thought I did. I mean, I thought there was no doubt.
  15     If you read Gianni's letter, he says there is
  16     a particular treatment with which they have had very
  17     poor results. That could only have meant, in my belief
  18     at the time, the neonatal switch procedure, which had
  19     stopped. That is what Gianni Angelini said. There was
  20     one problem, as I remember -- I cannot remember his
  21     exact words, but there was one problem of treatment,
  22     which was being addressed -- something like that.
  23     I knew, because we were at that time, as it says,
  24     seeking a paediatric cardiac surgeon to reinstitute
  25     neonatal switches.

   1   Q. The words he used were "a greater mortality than perhaps
   2     could be expected in any particular surgical procedure"?
   3   A. In "a particular surgical procedure", yes. I knew
   4     a particular surgical procedure was neonatal switches.
   5     It was part of the work-up to the appointment of
   6     a paediatric cardiac surgeon. So I thought I was
   7     entirely aware of what the conversation was about.
   8   Q. Did you know that the neonatal switch had in fact
   9     ceased the previous October?
  10   A. Yes.
  11   Q. A year before this, almost?
  12   A. Yes.
  13   Q. When you say you write to confirm the Trust Board's
  14     awareness, did you tell the Trust Board at this time of
  15     this correspondence?
  16   A. I do not know. I do not know. I may well not have
  17     done. I may have told them informally, but I certainly
  18     told the Trust Board about not doing neonatal switches.
  19     It was part of the case for the new consultant.
  20   Q. And the last paragraph: you continued to monitor the
  21     situation with Gianni Angelini. What were you
  22     monitoring?
  23   A. The arrival of the new surgeon and the move up the
  24     hill. I am sorry to say the Health Service has a long
  25     track record of not achieving its firm decisions, and

   1     that was what I was monitoring.
   2   Q. So we read "continue to monitor the situation" as
   3     meaning to ensure that these two promises are kept?
   4   A. Yes.
   5   Q. You get your response back from Dr Doyle, UBHT 61/279,
   6     which thanks you and leaves the matter to the Trust to
   7     effect the proposed changes as quickly as possible?
   8   A. Yes.
   9   Q. In the last paragraph, it looks forward to seeing "some
  10     greatly improved paediatric cardiac surgical audit
  11     results in the near future."
  12   A. Yes.
  13   Q. By now at any rate, were you particularly concerned to
  14     see what the audit results would in effect show, or
  15     not?
  16   A. No.
  17   Q. Because that was still a matter for the clinicians?
  18   A. It was still a matter, and it was a matter for the
  19     Department of Health. I think at that time we were
  20     still a supra-regional service.
  21   Q. What Mr McKinlay has told us in evidence is that he, as
  22     Chairman, was unaware of the correspondence between
  23     yourself and the Department of Health. Do you think he
  24     may be right on that?
  25   A. Yes, I think that is entirely possible. He did not

   1     develop a very close relationship the moment the new
   2     Chairman arrived. I do not want to be critical of him.
   3     He had other commitments at the time he took up his
   4     post, so he did not have a continuation of the close
   5     relationship I had had with his predecessor.
   6   Q. I appreciate there would have been many things you and
   7     he would need to discuss about the many other aspects of
   8     the Trust. Was correspondence such as this not
   9     something it was appropriate to show to your Chairman?
  10   A. No, I do not think so. I mean, I think that letter
  11     there does not raise in my mind anything other than an
  12     agreement that all is satisfactory. I do not think
  13     I would go and tell the Chairman everything that was
  14     satisfactory.
  15   Q. What Mr McKinlay also tells us -- before I deal with
  16     that let me just ask you for your help on one further
  17     issue which arises in respect of the Doyle
  18     correspondence, if I can call it that. You had asked
  19     James Wisheart for his comments?
  20   A. Yes.
  21   Q. You got those at UBHT 61/276. If we go overleaf,
  22      UBHT 61/277:
  23        "I have discussed it with Gianni and I shall
  24     discuss the source of information to the Department of
  25     Health with you on my return."

   1        Did he, Mr Wisheart, ever discuss with you,
   2     Dr Roylance, the source of information to the Department
   3     of Health?
   4   A. I do not remember him ever answering that question. He
   5     may have talked about the issue, but I do not remember
   6     him saying "this is the line of communication" or
   7     anything like that. No. I do not remember that. I may
   8     be wrong, but I do not remember that.
   9   Q. Why was it a matter of interest who should have been the
  10     source of the information, particularly if the
  11     information itself was not a major concern of yours in
  12     the sense of need to go and see what the Department of
  13     Health had written?
  14   A. Well, it was not of interest to me, but it clearly was
  15     something that was of interest to James. I mean, I have
  16     to say, we had a large Trust and it would not matter to
  17     me who had been talking to the Department of Health.
  18   Q. Was it a matter which upset you that whoever had spoken
  19     to Dr Doyle in order that he might contact Professor
  20     Angelini should have gone through other routes that were
  21     available to him or her in the Trust?
  22   A. I do not think my mind ever went as far as that, because
  23     I did not know in the sense, the source of information,
  24     that suggests the source of information was one person
  25     within the Trust, who I thought ought to have talked to

   1     me. I did not know what the source of information was.
   2     He was in the Department of Health and they knew the
   3     activities of our Trust in terms of neonatal and infant
   4     paediatric surgery, so -- I do not think that line ever
   5     exercised me at all.
   6   Q. Can we look at WIT 102/28? This is the witness
   7     statement of Mr McKinlay. Can we scroll down to the
   8     bottom and look at paragraphs 19 and 20?
   9        "When Dr Roylance returned from holiday, I raised
  10     the points made at the meeting with him and latterly
  11     with Mr Wisheart. Their position remained the same as
  12     before but I began to hear from Dr Roylance for the
  13     first time that the anaesthetists had concerns; the name
  14     Bolsin; and the name Peter Doyle from the Department of
  15     Health."
  16        Stopping there, did you think that Mr McKinlay is
  17     right about that?
  18   A. No, I do not, I am sorry to say.
  19   Q. He says he believes that you were very concerned about
  20     the situation, but not to the point that you agreed with
  21     those "both internal and external who were seeking an
  22     independent Inquiry."
  23        What is your response to that?
  24   A. I knew at that time that the anaesthetists were amongst
  25     the vociferous chorus of people who wanted to improve

   1     paediatric cardiac surgery. I knew that. I am not sure
   2     I understand what he is trying to say here, but if he is
   3     trying to say that some time in whenever it was -- when
   4     was it; before Christmas 1994 -- I was sharing with him
   5     any specific concerns of the anaesthetists, I am sure
   6     I was not. I do not want to read into there what
   7     I understand. I was sharing with him the whole issue of
   8     the wish to improve paediatric cardiac surgery and for
   9     somebody with no experience of the Health Service,
  10     I would have spent time taking him through that whole
  11     process, so that he understood.
  12   Q. Paragraph 20. There is a point on timing which I have
  13     already canvassed with you, where Mr McKinlay's
  14     recollection is that by the time he went home for
  15     Christmas, he and you had agreed that there should be an
  16     independent inquiry. That does not coincide with your
  17     recollection; I am not going to come back to that.
  18   A. Not at all no.
  19   Q. What he goes on to say is that -- it is the fourth line
  20     down:
  21        "There were telephone and letter exchanges between
  22     Dr Roylance and Dr Doyle and there were meetings between
  23     Dr Roylance and Dr Bolsin. Dr Roylance was upset that
  24     Dr Bolsin seemed to be making comments to Dr Doyle in
  25     a social atmosphere, which were then addressed to

   1     Dr Roylance by Dr Doyle. I was certainly annoyed at
   2     this triangular process and failed to understand why the
   3     Department of Health did not take some form of executive
   4     action if their concerns were as great as they seem to
   5     have indicated to Dr Roylance."
   6        At some stage were there conversations by
   7     telephone between yourself and Dr Doyle?
   8   A. Yes, but they were all in 1995.
   9   Q. In relation to the Joshua Loveday operation?
  10   A. Yes. That is why -- I am sorry to say, I do not want to
  11     be critical, there is a time slip in this. There is no
  12     doubt at all that we had a letter exchange which we have
  13     gone through in part detail, earlier in 1994. The
  14     subject was closed.
  15   Q. We shall see, coming on to it, that there was further
  16     correspondence between yourself and Dr Doyle after the
  17     Joshua Loveday operation.
  18   A. I had no contact of any sort by letter or telephone with
  19     Peter Doyle until January. None at all. So although
  20     there were telephone and letter exchanges and so on,
  21     there were, but they were all in 1995.
  22   Q. Albeit that this may then be talking about 1995 rather
  23     than 1994, Dr Roylance says Mr McKinlay was upset that
  24     Dr Bolsin seemed to be making comments to Dr Doyle in
  25     a social atmosphere, which were then addressed to

   1     Dr Roylance by Dr Doyle; is that right, do you think?
   2   A. No, I do not quite understand that, because the time
   3     that I was concerned, and would have talked to Bob
   4     McKinlay, particularly at the time when I was going away
   5     on leave to Australia, that this is all after the
   6     Hunter/de Leval report, this issue about Dr Bolsin.
   7   Q. What was the issue then, albeit after the
   8     Hunter/de Leval report, about Dr Bolsin, that you
   9     recall?
  10   A. Let me try and -- that was the issue then, about his
  11     secret audit, but I want to be clear. When Dr Doyle
  12     rang me about Joshua Loveday, I am quite sure he relayed
  13     to me Dr Bolsin's anxiety and he probably told me that
  14     that was supported by Gianni Angelini, I do not know,
  15     but I knew at that time that -- I mean, all Peter Doyle
  16     was doing was being messenger and relaying back to me
  17     anxieties he had heard from within the Trust. It is
  18     interesting that Dr Bolsin did not actually speak to me
  19     about the operation; he spoke to Peter Doyle.
  20   Q. And Peter Doyle spoke to you?
  21   A. That was the line of communication between Bolsin
  22     and I. I think that if I had been, as they say,
  23     "upset", I am quite sure I was disappointed that Bolsin
  24     chose to speak to me via the Department of Health.
  25   Q. You said a moment ago that it was interesting that

   1     Dr Bolsin chose to speak to Dr Doyle, and Dr Doyle then
   2     to you?
   3   A. Yes.
   4   Q. What was the particular point of interest in it for you?
   5   A. I am sorry, that is a slight euphemism. It is to me an
   6     unnecessary path of communication.
   7   Q. Are you conscious of anything which you may have done or
   8     said that would or might have led to that path of
   9     communication being used?
  10   A. No. None at all.
  11   Q. Are you conscious of any particular reason, from your
  12     knowledge of the Trust, its personalities and
  13     structures, why that method of communication might have
  14     been used?
  15   A. No.
  16   Q. One matter which perhaps I should take up with you
  17     before you move on to the Joshua Loveday operation.
  18     I had asked you whether you knew that the neonatal
  19     switch had ceased the previous October, a year before
  20     correspondence with Dr Doyle and you said yes, you did.
  21     Do you remember when it was that you first knew that the
  22     neonatal switch programme had stopped?
  23   A. No, I am not certain, but I do know I was aware of it
  24     and it was part of the conversation when we were
  25     developing the concept of appointing a paediatric

   1     cardiac surgeon.
   2   Q. So that must have been in the earlier part of 1994?
   3   A. Yes. I mean, I cannot be honest; if somebody found
   4     a record that I knew it in November the previous year,
   5     I would not dispute it.
   6   Q. Because it must have been some time before that that you
   7     knew, but you cannot say when?
   8   A. It was sufficiently long after the event not to be of
   9     any acute concern to me.
  10   Q. So the best we can do in terms of precise time is some
  11     time between October and May?
  12   A. Yes. I would think it was February/March, but I cannot
  13     really say.
  14   Q. It is unfair to ask you to speculate.
  15   A. I was just offering a feeling, if that was of any use.
  16     But clearly I knew when we were developing the case and
  17     going through the process of developing the job
  18     description and so on of the cardiac surgeon.
  19   Q. Can we turn, then, to the operation on Joshua Loveday?
  20     Before the operation took place, you were contacted,
  21     were you, by a number of concerned individuals?
  22   A. The ones I remember distinctly are James Wisheart, from
  23     whom I got the news. I am quite sure the first person
  24     who spoke to me was James Wisheart, and I remember that
  25     because if anybody else had spoken to me I would have

   1     sought out James Wisheart, and I did not. He told me.
   2        I am fairly sure -- I am certain -- that Gianni
   3     Angelini reinforced the message some time later, in my
   4     office. He came to my office.
   5   Q. By "reinforced the message", there are two messages: one
   6     is that the operation is going to take place; the second
   7     is that it is a matter of debate, discussion, concern?
   8     What is the --
   9   A. No, his view -- James Wisheart told me that he received
  10     advice, the view, that the operation should not take
  11     place and it was quite proper that they should tell him
  12     and he told me. Gianni Angelini came and I remember him
  13     taking the view that a switch is a switch is a switch
  14     and if they have trouble with neonatal switches, they
  15     should not do infant switches. There would have been
  16     other parts of the conversation, but that is an element
  17     of it that I remember, because it puzzled me, and
  18     I did -- I was going to say take advice. It would have
  19     featured in the conversation that I had with James
  20     later.
  21   Q. You were spoken to on the phone by Dr Doyle?
  22   A. Yes.
  23   Q. And that was, as you recollect it, Dr Bolsin talking to
  24     you through Dr Doyle?
  25   A. Yes. I mean, he was the messenger, and his phone call

   1     came later. The only way I can date that is to say it
   2     was after the clinical case conference had started, or
   3     I thought had started. That was the time Peter Doyle
   4     rang me. He relayed to me the message I had already
   5     heard.
   6   Q. Why do you think Mr Wisheart, Professor Angelini,
   7     Dr Doyle, were all speaking to you about it?
   8   A. I think there were different reasons. I think James
   9     Wisheart would tell me because he was the Medical
  10     Director and this was a unique situation, and he would
  11     have shared it with me, because he was the Medical
  12     Director. You are asking me why I think that.
  13     I believe the others asked me because they thought it
  14     was my responsibility to command that the operation
  15     should not take place. I cannot be sure of that, but
  16     I assume that is what they thought, that if operations
  17     were stopped, it was Chief Executives who stopped them.
  18   Q. Were they not right about that?
  19   A. Yes and no, I think. I could not stop an operation,
  20     I do not think -- I have not taken full legal advice on
  21     this, but my belief is that I could not stop the
  22     operation. What I could do is suspend a consultant so
  23     he was no longer in our employ. I suppose I could have
  24     suspended the anaesthetist or whatever, but I only had
  25     very coarse instruments and I could only use those on

   1     clear unambiguous advice.
   2   Q. So who was it, or was there no-one, that could have said
   3     "This operation will not go ahead"?
   4   A. I am not sure I am the right person to ask. It is my
   5     belief that at that time consultants were employed to
   6     exercise independent clinical judgment, and that
   7     management could only -- this happened elsewhere in the
   8     country, I do not know the full details -- can suspend
   9     consultants. That, I think, is possible. I do not
  10     know -- really, I mean, I cannot help you -- I do not
  11     know that anybody has ever said to me that I had the
  12     authority to interfere with clinical judgments as
  13     a Chief Executive. I do not think I did. The question
  14     did not arise, so I did not in a sense take advice on
  15     that.
  16   Q. If you had no absolute power, either yourself or on
  17     behalf of the Board, if that is in any case different,
  18     you would at least have had considerable influence and
  19     authority?
  20   A. Well, influence, yes.
  21   Q. Was it your view that it was appropriate to use that
  22     influence and possibly, I suggest, the authority that
  23     you had, to affect the outcome of whether there should
  24     or should not be an operation?
  25   A. If the clinical case conference had said -- I hope

   1     I answer your question -- "We do not think this
   2     operation should take place" and the surgeons concerned
   3     and the anaesthetists said "We do not believe that, we
   4     are going to do it", I hope I would have exercised my
   5     good offices and I hope I would have prevailed, so
   6     I would have used influence in that situation. I hope
   7     it would never have arisen in the sense that the group
   8     had said the operation should not take place, I cannot
   9     imagine the surgeons as I knew them would have gainsaid
  10     that, but you asked me a hypothetical question and
  11     I have given you a hypothetical situation in which
  12     I could have responded in the way I think you are
  13     suggesting.
  14   Q. Again, speaking hypothetically, the Trust controlled the
  15     facilities within which the operation was to be
  16     conducted?
  17   A. Yes.
  18   Q. And employed not only the consultants but also the
  19     nurses and so on.
  20   A. Yes.
  21   Q. Therefore, it might be suggested that the Trust could,
  22     if it wanted -- it is very hypothetical -- have said,
  23     "If you are going to do that operation that is a matter
  24     for you, but you are not going to do it here"?
  25   A. I am not sure how we could have implemented that view

   1     without, as I say, using my good offices. I think I was
   2     sufficiently influential. There were times when other
   3     clinicians had difficulty when I would, I think the
   4     modern term is "counsel" them, until they had formed
   5     a judgment which I think was healthy for them. But I am
   6     not sure, if you say to me, I could say "You are not
   7     doing it here", if the surgeon says "Oh, yes, I am". If
   8     we are talking about a real dispute, I do not know what
   9     I am supposed to do.
  10   Q. In any event, none of that arose, whether it might have
  11     done or not, because your view, as I understand it, was
  12     that "This is a matter for the clinicians, and the
  13     clinical conference, the conference, the meeting on the
  14     evening of the 11th will decide whether the operation
  15     goes ahead or not".
  16   A. Saying it is a matter for clinicians is a slightly
  17     shorthand way for saying I was faced with a conflict of
  18     clinical opinion and I thought -- it is a perfectly
  19     orthodox way of treating patients, although this was
  20     a very unusual situation for it to be used -- for the
  21     experts concerned, all the experts concerned, to review
  22     the situation in the light of the opinions that had been
  23     expressed and to form a judgment what was in the best
  24     interests of the patient.
  25   Q. Did you, being a doctor, have any responsibility, as you

   1     saw it, for the best interests of the patient?
   2   A. I had a responsibility, but I had no ability to
   3     determine what was in the best interests of the
   4     patient.
   5   Q. Mr Wisheart, I think, telephoned you after the meeting.
   6     Can we look at what you say about it at WIT 108/130? It
   7     is the top of the page:
   8        "Mr Wisheart telephoned you and reported to you
   9     that the outcome of the meeting had been that the
  10     operation was urgent because the patient was at
  11     increasing risk of a thromboembolic event".
  12        Those words, "a thromboembolic event", were they
  13     words he actually used?
  14   A. I do not know which shorthand he used. He might have
  15     said "He is at risk of having a stroke". I do not
  16     know. He may have used those words. He certainly
  17     conveyed to me the urgency of the problem, and the
  18     nature of the cause of that urgency. I cannot tell you
  19     which words conveyed that information, but whether we
  20     talk about a stroke, whether we talk about a vascular
  21     disaster, I do not know what terms he used. The fact is
  22     that the patient had persisting increasing cyanosis,
  23     which results in increasing erythrocytosis, that is,
  24     increasing red cell blood count, until the blood gets
  25     into a condition where it may clot at any moment, and

   1     having clotted, the clot may move elsewhere. This is
   2     a recognised complication of long-term cyanosis.
   3     I cannot tell you what precise words he used, but I have
   4     no doubt what he meant.
   5   Q. The reason I focus on those words, I think it is the
   6     second time you have used them. That is the way you
   7     explained it at the GMC when you were asked about this
   8     particular event, but although you may not be able to
   9     say what words he used to give you that impression, what
  10     was your idea of the urgency of the operation?
  11   A. I am sorry, I can only recall what I was told, the
  12     urgency of the operation and the need for it. I was
  13     told that it was the view of those -- I am not sure
  14     of -- what emerged at the case conference was that this
  15     child was not fit to wait for a transfer to another unit
  16     or to wait for the arrival of Ash Pawade. Those were
  17     the only two options.
  18   Q. What, if anything, was said to you about the possibility
  19     of transfer to another unit?
  20   A. I am sorry, that is what I have just said. He was not
  21     fit to wait for transfer to another unit, and not fit
  22     to --
  23   Q. My apologies.
  24   A. I am sorry, I may not have explained it well.
  25   Q. It is not your fault; I am sure it is mine. Mr Wisheart

   1     was plainly reflecting to you what the sense of
   2     a meeting or the meeting or the view of others was, was
   3     he?
   4   A. Yes.
   5   Q. When the operation continued and the sad result became
   6     known, you then had, I expect, phone calls and letters
   7     to deal with.
   8   A. Yes. I think there were people who expressed their
   9     disappointment with events, yes.
  10   Q. The event of having a meeting such as that to deal with
  11     the question of whether the operation should or should
  12     not go ahead was, as you describe it, extraordinary.
  13   A. In paediatric cardiac surgery, yes. In other areas
  14     where there is commonly difficulty in determining care,
  15     it is a very common process.
  16   Q. And it came against the background of concerns to
  17     a greater or lesser extent expressed to you. You knew,
  18     for instance, that part of the arterial switch programme
  19     had stopped. You knew that the Department of Health had
  20     been in correspondence with Professor Angelini about
  21     that as a matter of concern, and you knew that steps had
  22     been taken to rectify just that as part of the
  23     appointment of a new paediatric cardiac surgeon.
  24   A. Yes.
  25   Q. In retrospect, do you think you might, or indeed should,

   1     have used such influence as you had to persuade those
   2     involved that the operation should not go ahead?
   3   A. No. The reason for that is that I understood, and it
   4     was made quite clear to me that this child could, at any
   5     moment, have had a devastating vascular accident, which
   6     could either have been lethal or leave him permanently
   7     severely disabled.
   8   Q. Did anyone tell you that the operation had been
   9     scheduled on the ordinary elective surgery list?
  10   A. Oh, yes. That is how the thing arose. He had been on
  11     the waiting list some time. I now know that there had
  12     been agitation about expediting it. He had been
  13     admitted as an elective case and the operation was
  14     planned for a particular time. That was the space.
  15     I knew that. So the question arose: could this patient
  16     wait or would it be dangerous for him to wait? I was
  17     told that it was dangerous for him to wait.
  18   Q. Did you know that neither surgeon nor cardiologist had
  19     examined him, at any rate since the end of November when
  20     Dr Martin had last seen him for any examination?
  21   A. No.
  22   Q. Would it have made a difference if you had known that?
  23   A. No. I have to say that -- I am not a cardiologist and
  24     I am not an expert, but I do know, even from my medical
  25     student days, that the progression of these conditions

   1     is inexorable and that there was no way that his degree
   2     of cyanosis would suddenly have changed, or the
   3     progression of the erythrocytosis would have stopped.
   4     So that is a time-scale. If a cardiologist says --
   5     actually through Mr Wisheart -- that he has reached
   6     a stage where it is dangerous to wait, I would not have
   7     said, "Have you seen the patient?"
   8   Q. What was it that decided you to have a review?
   9   A. The fact that the case conference had disagreed with the
  10     other views expressed within the Trust. Can I just say
  11     that had the case conference met and been told "You are
  12     not to do this" and they had said, "We have had another
  13     look at it and we accept that advice, it is absolutely
  14     right", I would not at that stage have required a review
  15     because the solution would have been there.
  16   Q. So you required a review in order to sort out what
  17     appeared to be an internal difference of opinion?
  18   A. A persisting difference of opinion. I clearly was aware
  19     that the paediatric cardiac service was going ahead with
  20     an operation in the light of the fact that
  21     non-paediatric experts, as I understood them, but
  22     including one anaesthetist, who was in that group, there
  23     was a persisting view that that was not the right thing.
  24   Q. Consistent with your view that clinical matters were
  25     matters for a professional clinician, why was it not

   1     something you regarded as appropriate for the
   2     professional clinicians to sort out amongst themselves?
   3     Why was it something that, as you then saw it,
   4     necessitated an outside and independent review?
   5   A. It was, and they arranged it. The position is not
   6     a conflict. I did not personally arrange the review,
   7     but if you like, I used my influence to ensure that
   8     a proper way of going ahead was pursued. I mean,
   9     I cannot remember whether James said to me, "I am going
  10     to have a review" and I said "Good egg", or I said to
  11     him, "You have to have a review" and he says "I agree",
  12     or we talked and said "What are we going to do about
  13     this?" and it emerged in the conversation, but we were
  14     activating a clinical solution to a clinical problem.
  15   Q. As a management action?
  16   A. No. Why is it a management action?
  17   Q. If it was Mr Wisheart saying to you, he was Medical
  18     Director, that was the function presumably which you and
  19     he were talking about this operation --
  20   A. Well, it is not a management action, I am sorry. We can
  21     spend a long time on it. Mr Wisheart was a professional
  22     adviser to the Trust Board and apart from appointing
  23     consultants, did not exercise management
  24     responsibility.
  25   Q. So he advises you that in his view, if that is the way

   1     it happened, there should be a review; you think that is
   2     a good idea?
   3   A. Yes.
   4   Q. And a review occurs because you wish it. Is that not
   5     right?
   6   A. No, because it is wished. It is the right step
   7     forward. No, I --
   8   Q. Who does the wishing?
   9   A. I think everybody. I do not think this was a unilateral
  10     action imposed on anybody. It was my job to make people
  11     successful. I accept that. There was not a manager
  12     involved in the review, it was a clinical review.
  13     I knew it was happening.
  14   Q. I am not concerned with those involved in the review,
  15     I am concerned with the nature of the process, the
  16     decision to have one, and what you are I think saying to
  17     me is, "Well, it was a decision by everyone because it
  18     was the right thing to do", and what I think I am asking
  19     you is, well, whose decision was it? It could not take
  20     place without your influencing it at any rate --
  21   A. That is not true. James Wisheart could invite the
  22     Cardiac Society, I think it was -- it may have been the
  23     Royal College -- to nominate two independent assessors
  24     to come and review paediatric cardiac surgery. That did
  25     not need my authority. Why I am in difficulty is at the

   1     time we did not sit down and say who has made which
   2     decision and on what authority. We were moving forward
   3     properly and it was my job, I had the responsibility
   4     clearly to make sure things happened, but it did not
   5     make the review a management decision or a management
   6     process. It was activating a form of professional
   7     review and support.
   8   Q. Dr Doyle tells us, in any event, that he spoke to you
   9     by telephone.
  10   A. Yes.
  11   Q. He was asking you to have a review and he says that you
  12     agreed to do so. If that is right, the agreement to
  13     have a review was something which occurred during the
  14     course of his phone call with you.
  15        Is that or is that not your recollection of
  16     history?
  17   A. No, as far as I remember, he rang a day or two later.
  18     I am quite sure the day Joshua Loveday died did not
  19     close without a decision for a review having been
  20     taken.
  21   Q. You had correspondence -- we ought, I think, to look at
  22     a letter, UBHT 61/282, 25th January, the middle of the
  23     page:
  24        "From information received, including your letter
  25     of 12th September, I [Dr Doyle] had understood that

   1     steps had been taken to rectify the problem by the
   2     appointment of a new paediatric cardiac surgeon and
   3     transfer of the service to the Children's Hospital.
   4     I had assumed, mistakenly it would appear, that (at
   5     least high risk) neonatal and infant surgery would have
   6     ceased pending the arrival of the new consultant and the
   7     transfer.
   8        "As you know, I learned last week that far from
   9     this being the case, that surgery has continued at the
  10     Bristol Royal Infirmary."
  11        He deals with the conversation of the 11th, in
  12     which he says in this letter:
  13        "These suggested that under the circumstances it
  14     might not be advisable to proceed."
  15        Stopping there, is that in fact, as you recall it,
  16     an accurate reflection of what he was saying to you on
  17     the phone on the night of 11th January?
  18   A. Yes, I think "it might not be advisable to proceed" is
  19     probably a fair reflection of our conversation.
  20   Q. He then says:
  21        "We spoke again following that extremely
  22     unfortunate incident about the necessity of setting up
  23     an immediate inquiry using outside experts."
  24   A. Yes.
  25   Q. He goes on. Then your reply, HA(A) 146/109, the next

   1     day, underneath (c):
   2        "The Trust has decided not to perform complex
   3     neonatal or infant open-heart surgery until there has
   4     been resolution of the conflicting professional advice.
   5     We would reserve the right to exercise our judgment in
   6     the best interests of the patient in an emergency
   7     situation."
   8   A. Yes.
   9   Q. Was it, then, the Trust's decision as to what operations
  10     would or would not be performed?
  11   A. No. "The Trust" is used as a generic term for everybody
  12     in the Trust. The Trust had decided, because the
  13     decision, the place where that decision was made, was
  14     with the two paediatric cardiac surgeons and the support
  15     of their colleagues. If you mean the Trust Board has
  16     decided, then that is not the case.
  17   Q. So it is saying this, to Dr Doyle: you were in fact
  18     saying "all the relevant clinicians have decided"? Is
  19     that the effect of it?
  20   A. I am not sure. I mean, I was assisted by James Wisheart
  21     in the writing of this letter, and he assured me that
  22     they were not going to do any more complex neonatal or
  23     infant open-heart surgery. At that time, I had already
  24     talked to them and they told me that they were not going
  25     to do any high risk surgery, which was the way

   1     I satisfied myself that they understood -- we did have
   2     a conversation, can I explain, as to whether they should
   3     not do complex surgery. When I had a conversation with
   4     Janardan Dhasmana and James Wisheart, they said "Where
   5     do you draw the line, what is a complex operation?"
   6     I said "I have no idea, nor does anybody else. What
   7     I understand is that you would be ill-advised until
   8     after this review to take on any high-risk surgery at
   9     all". In fact, I think I used the term "I do not want
  10     another child to die until we have had the review and
  11     know what we ought to be doing". That was the
  12     conversation, not an instruction on my part.
  13     I satisfied myself at that time they had made that
  14     decision, because if they had not made the decision,
  15     I could not implement it.
  16   Q. So if the clinicians themselves, let us suppose, and
  17     purely hypothetical, suppose James or Janardan had said,
  18     "Well, look, I have got another couple of these
  19     operations on my operating list. I think it is
  20     important for the sake of the child that the operation
  21     is done. I propose to do it, one next Tuesday, one next
  22     Thursday". There was nothing you could have done about
  23     it, do you think?
  24   A. I would have used my good influences, but you are
  25     postulating a situation that would not occur and had not

   1     occurred, because they had both assured me they would
   2     not perform any high risk surgery, full stop. They had
   3     made that decision. I was satisfied they had made that
   4     decision.
   5   Q. Messrs Hunter and de Leval came to carry out their
   6     report?
   7   A. Yes.
   8   Q. You arranged that in the hope, did you, of having an
   9     independent report in your hands which gave you the
  10     fullest of information?
  11   A. Yes. I wanted their professional advice, yes. And
  12     I wanted it very quickly.
  13   Q. Did you use the phrase, in relation to the inquiry that
  14     you were commissioning, that it was to be "quick and
  15     dirty"?
  16   A. Yes, I did, but I would not want other people to
  17     misunderstand that. That is jargon which most people
  18     I think understand and that is, I think, that it is not
  19     a refined, formal report. It is accurate and proper,
  20     but we will not waste time polishing it. Perhaps it is
  21     an unfortunate term to be used in public, but it is
  22     a jargon term of "That is what we want: a quick and
  23     proper answer".
  24   Q. So that was arranged. Did you understand it to be an
  25     inquiry into the whole of the paediatric cardiac

   1     surgical service?
   2   A. Yes. I mean, they were kind enough to see me at the
   3     outset and I explained to them personally and
   4     informally, we did talk, and I said, "There are three
   5     things I need to know: first of all, is it right that
   6     the appointment of the paediatric cardiac surgeon is
   7     a proper solution to the problem? Is that the
   8     solution? Secondly, is moving up the hill proper?
   9     Thirdly, what should the Trust, the service, do between
  10     the time of then reporting and the arrival of Ash
  11     Pawade?"
  12        I mean, the whole basis of this clinical argument
  13     is that all cases should wait until Ash Pawade arrived,
  14     and I wanted outside advice to say, what should we do in
  15     that time, which is why it was urgent.
  16   Q. Were you present at all during the inquiry which
  17     Messrs Hunter and de Leval carried out?
  18   A. No, they came to my office. I think I summoned the
  19     local management, and wished them well, and I left them
  20     with the words that they could go anywhere, look at
  21     anything, and if anybody put up a barrier, they were to
  22     ring me and I would knock it down. I did not see them
  23     again.
  24   Q. At WIT 89/99, paragraph 24, we have the recollection of
  25     Rachel Ferris, who says after a meeting at which

   1     Dr Bolsin and Mr Wisheart were present during the visit
   2     of Messrs Hunter and de Leval, she was, and she could
   3     not when she was asked about it, recall quite how the
   4     walk began, but recalls walking over to Trust
   5     Headquarters with you, and you making some comment that
   6     you should not really have let James [Mr Wisheart]
   7     organise the day, but thought it might be good for him.
   8        Did you say that?
   9   A. No.
  10   Q. Who was it who did organise the day?
  11   A. Primarily, the visitors. I gave them full authority to
  12     ask for anything and guaranteed the Trust would provide
  13     them. I sent them off, I am fairly sure, with this
  14     manager as a sort of guide so they did not get lost.
  15   Q. Do you want to say anything about her perception of you
  16     as having had a casual approach to the day, and of, as
  17     she describes it, being seemingly unconcerned?
  18   A. Well, that is quite wrong. It has just occurred to me
  19     that in my clinical days, if we were dealing with
  20     a very, what shall I say, "dangerous" situation, I was
  21     known to become very relaxed and not get excited and to
  22     calm everybody so that everything went well. She could
  23     have known that, at times when there were difficulties,
  24     I would be like that, but it could not possibly have
  25     been in that situation. I would not have discussed,

   1     with her, the review. I certainly would never have
   2     discussed with her my asking James to organise the day,
   3     which he did not, as far as I know. I certainly would
   4     not have said to her, of all people, that it might be
   5     good for him. This is unthinkable. I cannot explain it
   6     but I have to say it is wrong.
   7   Q. It is not something you would have said if you were in
   8     "I am John Roylance" mode as opposed to Dr Roylance or
   9     Chief Executive mode?
  10   A. I would not discuss James with her behind James's back.
  11     I would not. You could not stay Chief Executive with
  12     any Trust at all if you behaved in that way. This is
  13     unthinkable. It is quite wrong.
  14   Q. You expected, as I understand it, you tell us in fact,
  15     it is WIT 108/130, the foot of the page, that you wanted
  16     Mr de Leval and Dr Hunter to be completely frank and
  17     blunt if necessary in their report and for that reason,
  18     you told them the report should be confidential to you?
  19   A. Yes.
  20   Q. So it was their report to you as Chief Executive?
  21   A. That is right.
  22   Q. And that is your understanding of what the relevant
  23     clinicians, the Trust, whoever it was that wished the
  24     review to take place, wanted?
  25   A. Yes. Yes.

   1   Q. When the report arrived, you were away on holiday?
   2   A. Yes.
   3   Q. The report had had some circulation.
   4   A. Yes.
   5   Q. Did you regret that it had the width of circulation that
   6     it did?
   7   A. I do not want to be critical of those who handled the
   8     report while I was away. I certainly was disappointed
   9     that I had been away and I did not think the report had
  10     come until I got back, to be perfectly honest. I wish
  11     I had been in the Trust Headquarters when the report had
  12     arrived, yes.
  13   Q. If it had come in, confidential to you, you would have
  14     seen it?
  15   A. Yes.
  16   Q. What would you have done with it?
  17   A. I would have read it and then I would have discussed the
  18     recommendations in whatever area I wanted. It mean, it
  19     actually advised me that, apart from the switch
  20     operation, a full service should be continued until the
  21     arrival of Mr Pawade, as I remember. It is a while ago
  22     now. As I remember the report, it advised that no
  23     switch operation should be undertaken until after the
  24     arrival of Mr Pawade. That did not strike me as odd.
  25   Q. It described Mr Wisheart as a "higher risk" surgeon.

   1   A. Yes.
   2   Q. And I think it made particular reference, did it not, to
   3     the AVSD operations with which he had principally been
   4     concerned?
   5   A. Yes. That is not entirely the thing, but, yes, it did.
   6   Q. What would you have done with that information had the
   7     report come to you confidentially, as you had hoped it
   8     would?
   9   A. If I did not already know, and I am not sure I did,
  10     I would have satisfied myself that James had already
  11     made the decision not to undertake another AVSD
  12     operation and have them all referred to Janardan, whose
  13     results were good.
  14   Q. Who was it who decided that after 1st May, when
  15     Mr Pawade came, that Mr Wisheart, save in some
  16     exceptional circumstances, would no longer operate on
  17     paediatric cases?
  18   A. I think Mr Wisheart. That had been his intention for
  19     some considerable time and he merely implemented his
  20     stated intention. There clearly was not room for three
  21     paediatric cardiac surgeons with the workload that was
  22     there, and he had already made it absolutely clear to
  23     everybody, the Trust Board knew, and everybody knew --
  24     I say everybody, everybody within that particular
  25     service knew, that it was James's intention to give up

   1     paediatric cardiac surgery.
   2   Q. Did you come back to a degree of discussion about
   3     whether the report could be accepted by the Trust
   4     Board?
   5   A. No. No. I think that was already -- those sort of
   6     discussions, it is slightly muddled in my mind what went
   7     on when I was away. We were well beyond that sort of
   8     stage.
   9   Q. You know that the report was changed?
  10   A. Yes.
  11   Q. From a first report, which was much more highly critical
  12     in some respects than a second report?
  13   A. Yes.
  14   Q. How did those changes come about?
  15   A. I informed the authors that a decision had been made to
  16     make their report public and asked them whether they
  17     would wish to modify it in that knowledge.
  18   Q. What do you have to say about the source of some of the
  19     alterations which were made? Suggestions I think were
  20     made to you about matters they might wish to change.
  21   A. I think they discussed, they were helped in their
  22     rewriting by some of the consultants, but the decision
  23     on what the report should be was made by, I think,
  24     Marc de Leval. I think it was only a telephone
  25     conversation with his colleague at that time.

   1   Q. Do you know who suggested the revisions to the original
   2     draft?
   3   A. No. No.
   4   Q. Did it concern you that a report which had been critical
   5     in a number of respects, on redraft was much less
   6     critical?
   7   A. No. No. I mean, that was the purpose of inviting them
   8     to look at the report in terms of its being made
   9     public.
  10   Q. I thought the purpose was that it should be "quick and
  11     dirty"?
  12   A. It was, but that was to be confidential. They wrote me
  13     a report which was going to be totally confidential to
  14     me and therefore it was not refined, it was blunt, it
  15     was clear and it was helpful to me. Had I been there
  16     when it arrived, it would have remained confidential to
  17     me. But having told them it would not see the light of
  18     day, it would not be made public, I returned from
  19     Australia to be told that it had been promised to HTV.
  20     It was clear to me that that would not have been
  21     a proper step.
  22   Q. Let me take it in stages. The purpose of having the
  23     report was to have something quick, dirty, confidential
  24     to you?
  25   A. Yes.

   1   Q. You, having had that report, were going to be no doubt
   2     considering what action you would take to implement its
   3     recommendations, and to discuss it with others?
   4   A. Yes.
   5   Q. If the report revealed serious concerns about particular
   6     aspects of cardiac surgery, or of a cardiac surgeon, was
   7     that not a matter which it was important for others to
   8     know?
   9   A. Which others? I am sorry, do you mean the public, the
  10     people on television?
  11   Q. Was it important for the Trust Board to know?
  12   A. Yes.
  13   Q. Would it have been important for the Medical Director to
  14     know?
  15   A. Yes.
  16   Q. Would it have been important for the clinicians working
  17     in the cardiac surgical services to know?
  18   A. Yes.
  19   Q. Since they collectively, as you put it earlier, had been
  20     responsible for agreeing that there should be this
  21     report, was the decision whether to make it public or
  22     not, not their decision?
  23   A. No.
  24   Q. Why not?
  25   A. Because I had invited some two outside experts to make

   1     a report to me and for the purposes of speed and to make
   2     sure there were no punches that were pulled, I promised
   3     them they could say whatever they liked and it would
   4     remain confidential to me, and I would act on their
   5     advice. That was the sort of conversation I had.
   6        I arrived back to be told that the local BBC
   7     television station had been promised the report. There
   8     was no way I could give them the report without
   9     contacting the authors and saying, "I am sorry, my
  10     promise cannot be kept". It was their decision -- their
  11     decision -- what report they were prepared to be made
  12     public, not mine.
  13   Q. If you have -- this is touching on the issue we have
  14     just mentioned -- an authoritative independent report
  15     which is critical of aspects of the Trust, is that not
  16     something which, in your view, anyone concerned with
  17     seeking treatment or providing treatment at that Trust
  18     should know?
  19   A. Yes. Yes, I have no difficulty with that.
  20   Q. So the last thing you would wish to be party to is any
  21     form of cover-up of any such report?
  22   A. There was no cover-up, no. I would not have tolerated
  23     that.
  24   Q. The distinction you are making between your suggesting
  25     or telling Messrs de Leval and Hunter that their report

   1     was to be made public and knowing that in some way
   2     changes had been made which toned down the criticism in
   3     it and the example I have just put to you, is that in
   4     the first place the report was intended to be
   5     confidential to you.
   6   A. Yes.
   7   Q. So this was entirely a reflection of the confidentiality
   8     with which you had first sought the report?
   9   A. It was a promise I had given to free them up from
  10     refining the report. I did not want to waste time. It
  11     was a promise I had given them. I came back and I was
  12     told my promise could not be kept, so I had to talk to
  13     them.
  14   Q. Did you have any reason to think that they would be
  15     prepared to say something to you in honesty,
  16     confidentially, which they would not be prepared to say
  17     in honesty publicly?
  18   A. Yes, because they were, to a certain extent, dealing on
  19     hunch and impression. I mean, can I say, you have not
  20     asked me, but I took the advice of the District
  21     Solicitor as well, and he said, if that report as it
  22     stood was made public, the authors might be liable to
  23     charges of defamation, and I could not --
  24   Q. It is fair that you should see that letter.
  25     UBHT 332/1. This is the letter you have in mind, is it,

   1     from Osborne Clarke?
   2   A. No, this is a personal conversation I had with the
   3     District Solicitor in my office, with James Wisheart
   4     present, and probably John Grey present, but I do not
   5     know.
   6   Q. Tell me what was said.
   7   A. It was said that in his view the phraseology of the
   8     report might be held to be slanderous -- I am sorry,
   9     libellous.
  10   Q. If we turn to UBHT 332/2, in fact we see the sentence
  11     near the bottom of the page:
  12        "There is current worry that as it stands the
  13     report may be defamatory."
  14   A. This was written to Graham Nix, not to me.
  15   Q. No, if we go back a page --
  16   A. I am sorry.
  17   Q. It may be your recollection.
  18   A. No, it was written to me, I am sorry. I have not
  19     recently seen this page. I do remember the
  20     conversation. I may also have had the view confirmed in
  21     writing.
  22   Q. Indeed, if we go to page 2, it confirms what you are
  23     saying under "defamation".
  24   A. Yes.
  25   Q. The second last paragraph on the page:

   1        "The problem will be ..."
   2   A. Yes, I apologise. This clearly was written to me.
   3     I have a clear memory of a direct conversation on the
   4     subject. But this is the same. This really confirms
   5     the content of that conversation I had.
   6   Q. If we go on to the next page, [UBHT 332/3],
   7     "Confidentiality" and the advice that you have there,
   8     the third paragraph:
   9        "I think the Trust could be criticised if it did
  10     not give the authors of the report a chance to know that
  11     there was a substantial feeling that there were many
  12     factual inaccuracies in the report."
  13   A. Thank you for showing me this letter. This confirms my
  14     recollection.
  15   Q. It confirms the substance of the recollection. I think
  16     the form you have it is as a telephone call, but it may
  17     have been a letter, perhaps. I do not know; it may have
  18     been both?
  19   A. I am sorry, this starts off by saying this letter is
  20     a result of a conversation he had with Graham Nix, is
  21     it, at the beginning?
  22   Q. Yes, you are absolutely right.
  23   A. That may be why I cannot remember that particularly.
  24     I had a conversation with him, as I often did in my
  25     office, in which he would give me his advice. I cannot

   1     tell you whether he wrote this before he gave me his
   2     advice, or afterwards.
   3   Q. I think afterwards, to be fair. You have not had
   4     a chance to look at this in greater detail than you
   5     might have done, UBHT 332/1: it is the first and second
   6     paragraphs.
   7   A. I am sorry, yes. I am sorry, I have been sort of
   8     hunting for -- this clearly was following the meeting.
   9     There it says Graham was present with James Wisheart and
  10     myself. So it was Graham Nix and not John Grey who was
  11     with us. The second paragraph says it records our
  12     conversation. I am grateful you showed me that.
  13   Q. After this, there were conversations, were there, that
  14     you had in relation to Dr Bolsin and the fact that he
  15     had chosen an unusual route to express some of the
  16     concerns which had now come to light?
  17   A. I remember only one time in 1995, that Steve Bolsin and
  18     I actually had a conversation. I think there was only
  19     the once.
  20   Q. At some stage in 1995, you were at a meeting and
  21     expressed the view which you told us you had expressed
  22     on a number of occasions in the early 1990s in respect
  23     of whistle-blowing.
  24        Can we look at WIT 245/9? It comes from Professor
  25     Stirrat. If we go down to the last six lines that are

   1     now on the screen:
   2        "I recall that during one of these meetings in
   3     1995 Dr Roylance made it clear that so-called
   4     whistle-blowers must not be pursued. He stressed on
   5     what I recall to be two of the meetings that Dr Bolsin
   6     must be treated properly within the Trust, lest any
   7     negative reaction towards him be construed adversely.
   8     I can confirm that there was no policy of exclusion of
   9     Dr Bolsin; indeed, it was to the contrary. I cannot
  10     give exact dates for these meetings."
  11        Is he right in his recollection as to what you
  12     said or made clear?
  13   A. Yes.
  14   Q. What was the point of it?
  15   A. The concept of whistle-blowing emerged about that time
  16     and a number of Trusts were trying to have what were
  17     described by the BMA as "gagging clauses". I made it
  18     absolutely clear the Trust would not have a gagging
  19     clause and the Trust Board accepted my advice.
  20   Q. We are talking about 1995.
  21   A. Yes. Well, I mean, there are two issues. One is that
  22     whistle-blowers must not be pursued. That is what I am
  23     answering. The second one would be, Dr Bolsin must be
  24     treated properly. At my understanding at the time,
  25     Dr Bolsin was not a whistle-blower, but he must be

   1     treated properly. What he did was something quite
   2     different.
   3        But we did say that any member of staff could go
   4     to the public and make statements to the television, to
   5     the radio. We did require them that they made it clear
   6     they were not the official Trust spokesman in so doing,
   7     and we asked them out of courtesy to ensure that they
   8     had discussed their misgivings with the Chairman or the
   9     Chief Executive before they went public. But we made no
  10     attempt ever to suggest that their wish to go public
  11     would be constrained.
  12   Q. Was there any particular reason for thinking that
  13     Dr Bolsin might be the target of others' hostility?
  14   A. Yes.
  15   Q. What was that?
  16   A. That he went on television and made what many staff
  17     thought were wholly improper accusations.
  18   Q. You were concerned then, were you, that he might be
  19     victimised?
  20   A. Well, people were very angry, yes.
  21   Q. You had a conversation with Dr Bolsin yourself?
  22   A. Yes.
  23   Q. We can pick this up in your comments on his statement if
  24     we go to WIT 80/13, if you give me a moment to find the
  25     exact passage. If we go overleaf, please, and again ...

   1     [to WIT 80/16], you say that it was 1995 and not 1994,
   2     and you will be relieved to know that he agreed, in
   3     questioning. You asked to see Dr Bolsin. You described
   4     the circumstances. Can we go over, please?
   5        "A patient under his care had received an
   6     incompatible blood transfusion and died. Dr Bolsin was
   7     for a time ..."
   8        You go on about the investigation. Can we scroll
   9     down, please? You describe how Mr McKinlay had come
  10     from a commercial background -- in aircraft, was it not?
  11   A. Yes.
  12   Q. Did you go on to say to Dr Bolsin, "Well, if someone
  13     does not put the bolts on the rotor blades, you cannot
  14     expect him to keep his job for very long", or words to
  15     that effect?
  16   A. No, "he would not be allowed to bolt any more", is what
  17     I said.
  18   Q. You were saying, then, were you, that somebody who does
  19     not do the job properly should not do the job?
  20   A. No.
  21   Q. Or would not be allowed to do the job?
  22   A. No, no. I was saying that we were moving into a new
  23     situation in which a Trust Board contained a number of
  24     people straight from industry who I think properly
  25     believed that it was their job to introduce the better

   1     elements of industrial management into the Health
   2     Service. It was at a time when issues of negligence
   3     were for the first time beginning to be an issue for the
   4     Trust Board. Before that, the District Health Authority
   5     had continued to look after all the matters of
   6     negligence prior to the creation of the Trust Board and
   7     because of the delay in these issues, it was only now
   8     that they were beginning to be the responsibility of the
   9     Trust Board.
  10        It was at a time when -- I am sure you could find
  11     a record in the Trust Board minutes -- we had
  12     a breakfast seminar with the District Solicitor,
  13     a representative from I think it was the Medical
  14     Protection Society, a doctor adviser, who came to
  15     explain to the Trust Board the issues of medical
  16     negligence and the custom and practice of dealing with
  17     matters of medical negligence. I was very anxious, at
  18     the time, that the better elements of the way of coping
  19     with medical negligence should be retained.
  20   Q. So what message did you want Dr Bolsin to take from the
  21     analogy with the man bolting on helicopter blades?
  22   A. I wanted him not to irritate the Trust Board, because it
  23     was my job to make sure that he was dealt with in a way
  24     that he would have been dealt with before the Trust was
  25     created and took that responsibility. I mean, it is

   1     a long subject, but there was an evolution of
   2     responsibility for, what shall I say, indemnity against
   3     medical negligence, which initially had been a direct
   4     relationship between doctor and the Defence Society.
   5   Q. What was he to do to avoid irritating the Trust Board?
   6   A. Anything. I was appealing for his co-operation with me
   7     to ensure that we did not have any disruption of the
   8     normal relationships. I was aware that Mr McKinlay came
   9     from a totally different environment.
  10   Q. The natural interpretation from someone in, I suspect,
  11     Dr Bolsin's position, of the analogy that if a man was
  12     paid to bolt on helicopter blades and does not do the
  13     job properly, he will not do the job again, is that if
  14     he, someone in his position, makes a mistake, then he
  15     will get sacked. Was that part of the message you were
  16     trying to get across to him?
  17   A. That was a concern. I was endeavouring to ensure it did
  18     not happen and did not arise. I use the analogy, I have
  19     to say, because I found Steve Bolsin rather difficult to
  20     communicate with.
  21        I subsequently found I was not alone in that, but
  22     I had difficulty in communicating with him, so I used an
  23     analogy, as one often does, to try explain a point.
  24     This was not an explanation of his position, it was
  25     describing a potential attitude of the Chairman of the

   1     Trust and perhaps one or two others, which I was trying
   2     to ensure did not emerge, that we were actually
   3     educating the Trust into the right way. I was
   4     describing -- I think it says there -- that that was an
   5     approach that I did not want an opportunity to develop,
   6     and, it says here, Bob McKinlay and some of the other
   7     non-executive directors.
   8   Q. So you are saying to Dr Bolsin that it would only be
   9     natural for the Chairman to take the same approach he
  10     would in industry: if it looks as though you are making
  11     mistakes on the job, then you will not be doing the job?
  12   A. I did say -- yes, I did explain to him that I had an
  13     initiative to take the Trust in the right direction,
  14     which involved having a seminar and a lot of other
  15     things. I was so concerned that he was misunderstanding
  16     me that I rang up the POWAR, the Place of Work
  17     Accredited Representative, the BMA shop steward,
  18     I suppose one might describe him --
  19   Q. Dr David Coates?
  20   A. Yes -- who was a colleague of his in the Anaesthetic
  21     Department, and related to him, as his BMA
  22     representative, the content and aim of my conversation,
  23     and I did ask him to try and reinforce the message of
  24     that conversation.
  25   Q. You gave the same analogy to him?

   1   A. Having talked to Steve Bolsin, I thought it would be
   2     very helpful if the POWAR gave the same message -- not
   3     the same analogy but the same message -- to him as
   4     I had.
   5   Q. So putting it in crude vernacular, what you were saying
   6     to him was, was it, "Nice little job you have here.
   7     Shame if anything were to happen to it. You ought to be
   8     careful it does not."
   9   A. No. You are converting this as a personal threat to
  10     Steve Bolsin. It was not. It was a personal request of
  11     mine to Steve Bolsin for help. It was not the reverse,
  12     as you have implied. It was because I was having
  13     difficulty in communicating with him that I asked his
  14     colleague to reinforce that message.
  15   Q. What were you asking for help with?
  16   A. Not being the first person who was reviewed for an act
  17     of negligence, I was concerned that it was an act of
  18     negligence that was very easily comprehended by the
  19     Trust Board.
  20   Q. How could Dr Bolsin influence that, given that the
  21     events which gave rise to the potential charge had all
  22     happened; they were all historical?
  23   A. He was not going to influence the event. The event was
  24     historical. I did not ask him to do that.
  25   Q. So what were you asking him specifically to avoid doing

   1     that would help you and help him?
   2   A. Anything that would irritate the directors of the Trust
   3     Board which might precipitate them to take a posture
   4     I did not want them to take. Anything. There is no
   5     mention of any particular event. I did not want him to
   6     be a fall-guy. I wanted to protect him.
   7   Q. I am asked to and I do scroll down the screen. I think
   8     it is the next paragraph after this. Just read it
   9     through. You describe how the Chairman had arrived from
  10     a commercial background, as had some other of the
  11     non-executive directors. Non-medical negligence within
  12     the Trust had been dealt with ...
  13        Can we go overleaf? [WIT 80/18]. You say you
  14     were concerned to ensure that doctors are treated
  15     sympathetically but incidents of professional negligence
  16     were not treated as disciplinary offences."
  17   A. Yes.
  18   Q. Can we scroll on down? Just keep that last -- can we go
  19     back up? It is that sentence there, that expresses what
  20     you want to say on this, is it?
  21   A. I believe so. I was moving the non-medical professional
  22     staff, culture, away from treating matters of mistake,
  23     matters of negligence, as matters of discipline into
  24     matters of competence. We had actually managed to
  25     develop, negotiate and implement what I would call

   1     a "competency procedure".
   2   Q. Can we go further down still, please? You use the
   3     analogy of the helicopter, you say, because that was the
   4     business Mr McKinlay had been in prior to joining the
   5     Trust, because you wanted Dr Bolsin to understand you
   6     did not want the Trust Board to use this commercial type
   7     of approach to medical negligence. You were trying to
   8     steer him in a different direction that would be
   9     supportive of and sympathetic to doctors. You were
  10     concerned that Dr Bolsin's involvement in the programme
  11     when his own case was likely to be coming before the
  12     Board might jeopardise your efforts to establish an
  13     appropriate policy at Board level.
  14   A. Yes, thank you.
  15   Q. You felt, did you, that Dr Bolsin's efforts might be
  16     undermining Mr McKinlay's discussions with Mr Hill, who
  17     was preparing a TV programme?
  18   A. Yes. When I came back, Mr McKinlay was leading the
  19     relationship with the media. Dr Bolsin came to me
  20     because he thought the de Leval report that was going to
  21     be released was unfairly critical of Dr Bolsin.
  22     I cannot tell you which bit he thought was critical, but
  23     he thought it was critical of him. He asked -- it was
  24     a fairly firm "ask" -- that I would issue a Trust
  25     statement, make a public statement absolving him of any

   1     implied criticism, that I would disagree with the
   2     external report and say that if it is criticising
   3     Dr Bolsin, then that is wrong; Dr Bolsin is blameless.
   4     I cannot remember the precise words, but that was the
   5     content. Would I issue -- I think there is a document
   6     somewhere requiring me to issue a --
   7   Q. Dr Bolsin has told us that he was seeking your assurance
   8     that you would say something publicly to exculpate him.
   9   A. That is right, thank you, and I was not prepared to do
  10     that.
  11   Q. So your advice was that here was Dr Bolsin proposing to
  12     become involved in the programme, to put his own point
  13     of view?
  14   A. Yes.
  15   Q. And you were saying, "Well, if you do that, you will be
  16     undermining the Chairman's efforts, with Mr Hill --
  17   A. Yes.
  18   Q.  -- or might be seen by the Chairman to do so, and the
  19     Chairman will take a dim view of it."
  20   A. Yes, I think it was no secret that the Chairman would
  21     have wished him not to do that.
  22   Q. And it was then that the analogy of the helicopter came
  23     in, was it?
  24   A. Yes. I was saying, now, of all times, it is not the
  25     time to irritate the Chairman. You can see why,

   1     I hope. It was not a threat. It was not a threat that
   2     had even been generated or thought of by Mr McKinlay; it
   3     was a hazard that I was wishing to avoid.
   4   MR LANGSTAFF: Dr Roylance, the time has come, I think, for
   5     us to have a break for lunch. I have, I think, probably
   6     about five minutes of questions left for you.
   7     I understand that Mr Francis would wish to ask some
   8     questions in re-examination so it may be that we have
   9     a break now, rather than later. I anticipate, without
  10     wishing to put Mr Francis under any undue pressure, that
  11     you may be away by somewhere between half past 1 and
  12     a quarter to two, thereabouts.
  13   DR ROYLANCE: I am at your disposal.
  14   THE CHAIRMAN: That is extremely helpful for all of us. May
  15     I suggest, and looking for assistance, if we say until
  16     10 past or a quarter past 1, would that be appropriate?
  17   MR LANGSTAFF: I think quarter past, sir, yes.
  18   THE CHAIRMAN: I am grateful to all of you. Thank you very
  19     much.
  20   (12.37 pm)
  21            (Adjourned until 1.15 pm)
  22   (1.20 pm)
  23   THE CHAIRMAN: Mr Langstaff, I am sorry we have delayed
  24     you. My apologies.
  25   MR LANGSTAFF: Could we have on the screen, please, 89/106?

   1     Can we scroll down, please. This is the statement of
   2     Rachel Ferris. She describes being present -- it is
   3     paragraph 57 -- at a discussion with Mrs Maisey at which
   4     she thinks you were present, when the issue of sacking
   5     Dr Bolsin was mentioned although he was not mentioned by
   6     name, if it could be proved that he was leaking
   7     information to the press.
   8        Did such a conversation take place in your
   9     presence?
  10   A. No.
  11   Q. Did you ever suggest to anyone that Dr Bolsin's
  12     employment might be terminated prematurely?
  13   A. No.
  14   Q. When Dr Monk rescheduled or agreed with Dr Bolsin to
  15     reschedule Dr Bolsin's anaesthetic commitments, had it
  16     been indicated to him do you know by anyone on or on
  17     behalf of the Trust management that Dr Bolsin's future
  18     career at the Trust might be in some jeopardy?
  19   A. No. I mean you asked the question whether it could have
  20     been said by somebody else. It was not said with any
  21     Trust Board or Chief Executive authority.
  22   Q. The next matter, this is something of a ragbag of
  23     matters --
  24   A. Before you go on, could I just say to amplify this
  25     because I think it is important, that I made great

   1     efforts to restore proper professional relationships for
   2     Dr Bolsin and all my actions were in precisely the
   3     opposite direction from that that is claimed. Far from
   4     thinking of sacking him, I did everything I knew how to
   5     make him continue to be a welcome member of staff.
   6   Q. You said that when you met Dr Bolsin in the conversation
   7     about the helicopter blades and so on you found that he
   8     was difficult to communicate with?
   9   A. Yes, I would not have used an analogy if that were not
  10     the case.
  11   Q. How many occasions had you spoken to him?
  12   A. 1990 and 1995.
  13   Q. You formed the view he was difficult to communicate with
  14     as a consequence of those two conversations?
  15   A. No, no. I am saying when we were having the
  16     conversation in 1995, I found it very difficult to
  17     convey the concepts I was conveying to him.
  18   Q. I would like to take you right back to your initial
  19     contact which was when he wrote you the letter and you
  20     spoke to him by telephone and referred him to Mr Dean
  21     Hart?
  22   A. Yes.
  23   Q. Do you remember, did you send Mr Dean Hart a copy of the
  24     letter or not?
  25   A. No, he did. There was no need for me to. Mr Dean Hart

   1     was one of the recipients of the letter.
   2   Q. Mr Wisheart was not one of the nominated recipients; did
   3     you send him a copy?
   4   A. No.
   5   Q. Did you tell Mr Wisheart of the letter?
   6   A. No.
   7   Q. Did you speak to anyone else as you recollect about that
   8     particular letter?
   9   A. I think the then Chairman of the Division of
  10     Anaesthetics spoke to me some time later, Dr Brian
  11     Williams.
  12   Q. Next, can I take you back to the letter of 12th May
  13     1994, which was written to Mr Durie? You recall that
  14     you say you did not see the letter which you sent to
  15     him?
  16   A. No.
  17   Q. Your recollection was that he had some doubt about
  18     whether it had arrived or not?
  19   A. I have a recollection that he had not seen it and could
  20     not find it in the files, yes.
  21   Q. What Mr Durie told us when he came to give evidence was
  22     this. I will read it out to you, we cannot show it to
  23     you on the screen. He said:
  24        "At the time the letter would have arrived at the
  25     Trust Headquarters, I [Mr Durie] actually was abroad.

   1     It could have been rather than wait it was moved on.
   2     I just do not recall at the time having seen that
   3     letter.
   4        Question: Where would it have been moved on to?
   5        Answer: It would have been given to the Chief
   6     Executive to work on I guess.
   7        Question: If you had got the letter at the time
   8     you would have taken the concerns expressed in it to the
   9     Chief Executive as well?
  10        Answer: I would.
  11        Question: So by whatever route, either missing
  12     you out or not, matters would have got to the Chief
  13     Executive.
  14        Answer: It would have."
  15        Do you have any comment to make on that?
  16   A. No, I cannot explain. To the best of my knowledge,
  17     there is no record of that letter within Trust
  18     Headquarters, but the slight difficulty I have is
  19     because I knew of the matters which formed the substance
  20     of the letter -- I do not think I saw the letter at all,
  21     but I knew of the suggestion of using "soft money" as
  22     a consultant senior lecturer because I remember
  23     explaining why that would not do.
  24   Q. Was it in fact the system, as Mr Durie has described,
  25     for the letters which came to him in his absence to be

   1     forwarded on to you?
   2   A. No, it was not the system but I would not deny that his
   3     secretary might offer him initiatives, say he ought to
   4     deal with something like that.
   5        My memory is that whenever he left there was
   6     a Deputy Chairman who acted as Chairman and popped in
   7     from time to time and dealt with the post. I do not
   8     think I acted as Chairman in his absence.
   9   Q. This is perhaps the last question bar one I shall ask
  10     you: from 1989 onwards you were obviously extremely
  11     busy, first with the shadow Trust and then being a first
  12     wave Trust and having to stay throughout that period
  13     within budget, all of which you achieved, and with some
  14     success.
  15        Could it be that in this heat you may have taken
  16     your eye off the ball when it came to paediatric cardiac
  17     surgery, whether perhaps in retrospect you feel you may
  18     have paid it more attention?
  19   A. No, I do not think that is possible. If you say "eye
  20     off the ball". My responsibility was to ensure that
  21     a proper clinical environment existed and that they
  22     stayed within budget and they exercised their clinical
  23     freedom and I certainly did not take my eye off that
  24     ball at all.
  25        If you say is it possible that I was so busy that

   1     somebody would come and tell me they are killing
   2     children in cardiac surgery and I would not have
   3     noticed, I have to say that is quite unthinkable.
   4   Q. I have asked you all the questions I am going to ask
   5     you, Dr Roylance, save for this last one: is there
   6     anything which you think needs to be added which I have
   7     not asked you about which you would wish to volunteer to
   8     us or wish to say by way of amplification by way of any
   9     of the answers you have given over the last day or so?
  10   A. Please, if there is anything that I think of in further
  11     reflection which I think I know that would be of help to
  12     the Inquiry, I hope I may submit that in writing.
  13        If you say is there any general comment I wish to
  14     make, I would like to accept this as my first
  15     opportunity because the whole of this issue arose after
  16     I retired, that as a person who spent over 40 years in
  17     health care, who is the father of four children and the
  18     grandfather of six, I actually understand the tragedy of
  19     the loss of a child very acutely. I understand the
  20     enormous magnification of that tragedy if there is
  21     a thought that the loss may possibly have been
  22     avoidable. My heart goes out to all the parents of
  23     these children.
  24        I very much regret that I was never put in
  25     a position to prevent any avoidable death. I very much

   1     regret that nobody ever made it known to me that the
   2     service was not merely ripe for improvement and
   3     requiring improvement, but was ever thought to be
   4     unacceptable.
   5        I say that with absolute confidence because that
   6     is not a statement that can ever be misunderstood or in
   7     any way overlooked. It is not a matter of my
   8     responsibility as a doctor and my responsibility as
   9     a Chief Executive; it is my responsibility as a human to
  10     avoid any unnecessary death. Looking back over the
  11     past, as you will understand I have done, a great deal,
  12     I really cannot pick any point when the information
  13     given to me was other than "You must do your very best
  14     to improve the service".
  15        I would like to just finish by saying that I do
  16     not look to this Inquiry to reveal my personal
  17     innocence; I do not look to the Panel to exonerate me --
  18     I am unimportant in this -- but I do hope that they will
  19     be able to find a way of preventing this happening
  20     without the very real risk, which is already in my view
  21     present, of high risk patients not being treated lest
  22     a poor outcome produces some improper criticism.
  23     I think there is a very real risk that high risk babies,
  24     for instance, may be being deemed inoperable when in the
  25     past they may have been deemed operable.

   1        That is a personal belief that I am grateful to be
   2     able to share. I just hope you will be able to deal
   3     with it.
   4   MR LANGSTAFF: Dr Roylance, thank you.
   5   THE CHAIRMAN: Dr Roylance, the Panel have no questions.
   6     Before Mr Francis rises, just simply to say, we have
   7     heard what you say and we will do our best to do exactly
   8     that.
   9        Mr Francis?
  10            RE-EXAMINED BY MR FRANCIS:
  11   MR FRANCIS: Dr Roylance, there are two matters really
  12     I would like to ask you about. The first concerns the
  13     correspondence with Dr Doyle, the questions Mr Langstaff
  14     asked you concerning why it was you did not come to see
  15     Dr Doyle's letter to Professor Angelini.
  16        Firstly, perhaps we can look at it, I think it is
  17     UBHT 61/274 [document UBHT 61/273 on screen].
  18        In the second paragraph of that letter Professor
  19     Angelini made a reference to a "greater mortality than
  20     perhaps could be expected in a particular surgical
  21     procedure".
  22        I think you have given this answer but just to
  23     confirm it, what was your understanding, reading that,
  24     that Professor Angelini meant?
  25   A. The aborted -- the abandoned programme of neonatal

   1     switch operations which had been introduced, not been
   2     successful and had been stopped.
   3   Q. Did you believe he could have been referring to anything
   4     else?
   5   A. No, no. I have to confess that at the time I thought
   6     I knew what this letter was about.
   7   Q. We see at the top of the page in the handwriting your
   8     request to Mr Wisheart for his comment; did you make
   9     that request and did you receive his comments before you
  10     yourself wrote to Dr Doyle?
  11   A. Yes, yes.
  12   Q. Could we have a look at those comments, please, which
  13     I think are at UBHT 61/276. In the first paragraph of
  14     that he says:
  15        "This letter rightly emphasises that the problem
  16     is with one procedure only. The rest of the work is
  17     entirely acceptable or better."
  18        At the time he wrote that to you, did you have any
  19     reason to believe that what he said was inaccurate?
  20   A. No, not at all.
  21   Q. When you wrote to Dr Doyle and you said that the Trust
  22     was aware of the problem, were you referring to any
  23     problem other than the switch procedures, which had been
  24     stopped?
  25   A. No, no.

   1   Q. Could we now please look at the letter you did not see
   2     at the time, Dr Doyle's letter to Professor Angelini,
   3     which is UBHT 52/287. Just to get this clear: when did
   4     you first see this letter?
   5   A. After I retired.
   6   Q. If you had seen an assertion by Dr Doyle on Department
   7     of Health notepaper that there are concerns about
   8     mortality rates for paediatric, especially neonatal
   9     infant cardiac surgery and that he, Dr Doyle, was saying
  10     that if the problem has been recognised and adequate
  11     remedial steps not taken, it is an unacceptable tragedy,
  12     would you have written the letter you wrote that you had
  13     been aware of that concern on the part of Dr Doyle?
  14   A. No. I would like to modify that "No". If I had seen
  15     that and had accepted the reassurance of both Gianni
  16     Angelini and James Wisheart that the excess mortality,
  17     excess deaths were entirely within the neonatal switch
  18     operation, I might have written a similar letter, but
  19     I actually think I would have rung him up to clarify his
  20     thoughts a great deal more before I wrote.
  21   Q. If you had had any hint that there was some difference
  22     of emphasis if nothing else between what Dr Doyle was
  23     saying to Professor Angelini and what he was in reply
  24     identifying as being the problem, would you then have
  25     wanted to see Dr Doyle's letter?

   1   A. If it had occurred to me at all that the letter was
   2     other than a letter which said "We know you have had
   3     a problem with neonatal switch operations and what have
   4     you done about it?" then I would have wanted to see that
   5     letter.
   6        At the time, as I say, I thought I understood
   7     fully the topic of the conversation. I had been
   8     slightly cautious because I do know that both James
   9     Wisheart who had not seen this letter and Gianni
  10     Angelini who had both said the only problem -- I thought
  11     both said the only problem was with neonatal switch
  12     operations. Even with that advice and that letter, I do
  13     believe I would have rung Peter Doyle up and had a frank
  14     conversation with him to understand what was behind that
  15     particular letter.
  16   Q. Looking at Dr Doyle's letter now and recalling what you
  17     yourself said to him and his reply to you, in retrospect
  18     do you consider you were talking to each other at
  19     crossed purposes?
  20   A. We certainly may have been. I cannot be sure, this is
  21     why I say I would have rung up. I cannot be sure that
  22     they say -- the second paragraph, if I can read it:
  23     "There are concerns about mortality rates, especially
  24     neonatal and infant cardiac surgery". The problem
  25     I knew related to neonatal, I think of all the words,

   1     I think the two words "excess deaths" and "infant" there
   2     would have made me wonder whether he was talking about
   3     something else.
   4   Q. In answer to Mr Langstaff you said one of the reasons
   5     you did not require to see this letter (and I am
   6     paraphrasing) was because that was a conversation
   7     between Dr Doyle and Professor Angelini. Would that
   8     reservation or reluctance have prevailed if you had felt
   9     there was some debate to be had about what the problem
  10     was?
  11   A. No, I mean it would not have. I actually thought at the
  12     time I understood the precise nature, the subject that
  13     was being discussed. I knew about a situation which in
  14     itself is mutual, that is the abandonment of a newly
  15     introduced programme of work. I thought, and the letter
  16     that Gianni had written in reply reinforced if you like
  17     my possible misunderstanding, but reinforced the view
  18     that I knew what the topic was and I knew what the
  19     answer was and it did not occur to me to say "This is
  20     a different question".
  21   Q. Can I with perhaps two questions turn to a different
  22     issue which concerns events surrounding the publication
  23     of the de Leval report. Firstly did you yourself make
  24     any suggestions to Mr de Leval as to what if any
  25     alterations he might wish to make to his report?

   1   A. No, none at all.
   2   Q. Secondly, at the time you came back from your holiday
   3     and you as it were passed the report back to him with
   4     the news that something was going to be published, did
   5     you consider it appropriate that information about that
   6     report should be put in the public domain?
   7   A. I had no objection at the time. I hope I am answering
   8     your question. I had no objection at the time to the
   9     fact of the review, the fact of the independent inquiry
  10     and the nature of the response, in other words the
  11     report being in the public domain, no anxiety about that
  12     at all.
  13        I did have an anxiety that I could not place the
  14     authors in a position of risk by breaking my word to
  15     them.
  16   Q. In the context of the question I have just asked, can
  17     I ask you to look at the letter you received from the
  18     solicitors, UBHT 332/1. Could we scroll down a little
  19     bit and go to the next page. I think it is six
  20     paragraphs down: "... and I agree that it is in
  21     everyone's interests that the matter which is the
  22     subject of the report be debated properly because behind
  23     that thinking lies the reason why you commissioned the
  24     confidential report in the first place."
  25        Does that reflect or did that reflect your

   1     thinking at the time?
   2   A. Yes. I mean I was a Chief Executive of a public
   3     organisation which lived in the public sector, and
   4     I spent what seemed a significant amount of my time
   5     talking to the media and making public reports. There
   6     was never any question that the issue was to be debated
   7     in public. At the absolute minimum, it would have been
   8     debated at a public meeting of the Health Authority,
   9     although that was not usually enough to get into the
  10     media.
  11        The reason for two reports was nothing to do with
  12     publication or not publication; it was because I had not
  13     asked them for a report which was fit for public view.
  14   MR FRANCIS: Dr Roylance, thank you very much.
  15   THE CHAIRMAN: Dr Roylance, just before I thank you for
  16     being with us, may I pursue once again -- and it will
  17     not involve the need for Mr Francis to come back because
  18     I wanted to expand on your observations about the sense
  19     in which you felt the obligation in this Inquiry,
  20     amongst other things, was to ensure that matters which
  21     may have happened should not happen again, but at the
  22     same time, make sure that high risk procedures which
  23     patients needed should not be in any way prevented from
  24     taking place. Do you have any further thoughts on that
  25     tension?

   1   A. Yes, if I could -- I can only say -- this is entirely
   2     hearsay and I am not criticising other people, I am
   3     expressing a personal anxiety.
   4   THE CHAIRMAN: That is what I wanted to hear.
   5   A. Provided I do that, I think there is a very real risk
   6     that some Down's Syndrome babies with high risk heart
   7     disease will be deemed inoperable so there will never be
   8     a question with the parents that "we could operate on
   9     this but it is too high risk"; the surgeon will say
  10     "I am sorry that is inoperable".
  11        I cannot get up and affirm in a court of law --
  12     because I face serious risk -- that I know that is
  13     happening. I have been in the Health Service long
  14     enough and read the signs that I fear that is already
  15     happening; that is an example. It is so easy to say to
  16     a parent -- and there have been cases in the newspaper
  17     that one can read between the lines -- where children
  18     with a condition have been told that their condition is
  19     inoperable.
  20        I do not know the details of the case. I share an
  21     anxiety that any oppression on the basis of outcome in
  22     very small series will put undue pressure on surgeons.
  23   THE CHAIRMAN: Thank you.
  24   MR LANGSTAFF: Before Dr Roylance takes his leave of us, may
  25     I mention that in the course of his re-examination,

   1     Mr Francis is correctly recorded as having asked to see
   2     UBHT 61/274. The document in fact that was displayed
   3     and to which he wished to refer, and did refer, was
   4     UBHT 61/273. The reason I mention it is for the sake of
   5     the transcript and those of the later and wider audience
   6     who may pick it up, as so many do in the evening to see
   7     the events of the day, and make sure that the right
   8     document is in the right place. Forgive me,
   9     Dr Roylance, for an entirely practical matter.
  10        Sir, may I suggest we take a break for, say 10
  11     minutes before Dr Halliday joins us to complete his
  12     evidence?
  13   THE CHAIRMAN: We now conclude your evidence, Dr Roylance,
  14     thank you very much indeed for coming again to be with
  15     us for a day and a half. Now let us adjourn until 2.00.
  16   (1.50 pm)
  17               (a short break)
  18   (2.00 pm)
  19   MR LANGSTAFF: Sir, may we have Dr Halliday back, please.
  20           DR NORMAN HALLIDAY (SWORN):
  21           Examined by MR LANGSTAFF:
  22   MR LANGSTAFF: Dr Halliday, you have been with us before,
  23     you are Dr Norman Pryde Halliday. You gave us
  24     a statement which we had in WIT 49/1 to 9 and you have
  25     now given us a supplementary statement dealing with some

   1     matters that arose during the course of your last
   2     examination and which have arisen since and which you
   3     have been asked to address?
   4   A. I have.
   5   Q. Do we find that at WIT 49/10. Does that go through to
   6     page 28 where, at the foot we see your signature of
   7     yesterday?
   8   A. You do.
   9   Q. You have had the chance, have you, of seeing since then
  10     comments upon your witness statement from Sir Terence
  11     English which we have at WIT 49/29?
  12   A. No.
  13   Q. You have not. In that case, sir, what I shall suggest
  14     is that we have a short break because it is important
  15     that Dr Halliday sees the comments made upon his
  16     statement by Sir Terence English which we have at
  17     WIT 49/29 through to 49/33.
  18   THE CHAIRMAN: Are you suggesting a break now, you would
  19     prefer it to be now rather than wait?
  20   MR LANGSTAFF: I think it is only fair that Dr Halliday sees
  21     what Sir Terence has to say, about which I shall in due
  22     course be asking you questions.
  23   THE CHAIRMAN: Of course that must be right. The way
  24     I think we should do it is that Dr Halliday take such
  25     time as he feels he needs with his advisers and then he

   1     will let you know and you can indicate to us when we
   2     should reconvene; would that be satisfactory?
   3   MR LANGSTAFF: Certainly.
   4   (2.05 pm)
   5             (A short adjournment)
   6   (2.45 pm)
   7   MR LANGSTAFF: Dr Halliday, may I make it quite clear
   8     that the fact that you had not had a chance to see and
   9     look at Sir Terence English's comments on your statement
  10     is no reflection upon those who advise you. We have, as
  11     you may know, in the past had what may best be
  12     delicately described as "problems of communication" with
  13     witnesses represented by the Department of Health and
  14     that is not the case here. It simply is that Sir
  15     Terence's comments came in I think last Friday to this
  16     Inquiry, you had not as it happens had a chance to see
  17     them before today, it is no-one's fault but you now
  18     have?
  19   A. I could not agree that it is no-one's fault. It was
  20     received on the 3rd and now I am faced with this today
  21     on the 7th. You know I am dyslexic. I find it
  22     difficult to read under stress and this is an
  23     astonishing letter. Sorry.
  24   THE CHAIRMAN: I think it is very important that you make
  25     your views clear. Let me say to you that Mr Langstaff

   1     will want to talk to you for a while and maybe others.
   2     If at the end of the period of time we have had an
   3     opportunity to talk there are other things that you wish
   4     for us to hear and bring to our attention, then you have
   5     that opportunity in writing and that opportunity will
   6     exist for some time thereafter. So do not, please, feel
   7     that this is the only occasion on which you will have an
   8     opportunity to say anything about anything. This is an
   9     opportunity to as it were start and, if we are
  10     fortunate, complete the conversation. If we are not
  11     then you will be able to make representations
  12     additionally afterwards.
  13   A. Thank you, I very much regret starting off. I am not
  14     sure you appreciate the impact it has had on me.
  15   THE CHAIRMAN: Mr Langstaff will begin the questioning and
  16     then we will see how we proceed.
  17   MR LANGSTAFF: Mr Halliday --
  18   A. Dr Halliday, yes.
  19   Q. I do beg your pardon. Can we have on the screen,
  20     please, RCSE 2/188?
  21        This is a letter which I will take you through and
  22     read it to you so that you are clear on it. It is
  23     something which you will have seen before. It is
  24     a letter from John Zorab to Sir Terence English. It is
  25     dated 15th July 1992. It reads:

   1        "Some time last autumn I made one or two efforts
   2     to get to see you in order to discuss the delicate and
   3     serious problem of mortality and morbidity following
   4     paediatric cardiac surgery in Bristol. I have no vested
   5     interest in this and the problem is outside my immediate
   6     sphere of influence, but great anxieties were being
   7     expressed by some of my colleagues at the Royal
   8     Infirmary. In the event, I never made contact with you
   9     and the matter passed from the forefront of my mind.
  10        "Matters have come to a head once again and the
  11     enclosed piece from Private Eye, whilst possibly having
  12     some inaccuracies, quotes some statistics which have
  13     been confirmed elsewhere. One of the newer consultant
  14     cardiac anaesthetists feels that the mortality rate is
  15     too distressing to be tolerated and is job-hunting
  16     elsewhere."
  17        When I asked Sir Michael Carlisle about that in
  18     evidence here what he said was this:
  19        "If there was a risk to a service with which I was
  20     associated, I would have pressed for enquiries to be
  21     made very urgently indeed and I think I said to you
  22     earlier that if there had been any reluctance for that
  23     to take place I would have taken it right up to the top
  24     of the Department of Health, to ministers, if necessary
  25     but certainly the chief medical officer because I am

   1     appalled if that sort of correspondence was around on
   2     15th July, I cannot remember the date of that Advisory
   3     Group meeting.
   4        "The other point I have to say is that if this
   5     sort of information had been around even on
   6     a person-to-person basis, without any member of the
   7     Advisory Group whether he is the President of the Royal
   8     College of Surgeons or not, and it was not reflected to
   9     the group, I would take a very strong view about that
  10     indeed."
  11        Then he had difficulty controlling himself. His
  12     view is, therefore, that if he had known of the concerns
  13     reflected by a letter such as this he would have taken
  14     them right up to the top of the Department of Health, to
  15     ministers if necessary, but certainly the CMO. If you
  16     had known of concerns such as this, would you have done
  17     the same?
  18   A. Yes, but I think there are stages before taking it to
  19     the top of the office. I think that my first reaction,
  20     if I had been alerted from any source by this letter,
  21     would have been to approach the President of the Royal
  22     College of Surgeons to ask for his advice. Of course
  23     I would be briefing Sir Michael Carlisle on the issue
  24     and have his agreement for so doing.
  25   Q. You would speak to Sir Michael Carlisle and then speak

   1     to the President of the Royal College of Surgeons?
   2   A. The President of the Royal College of Surgeons. Of
   3     course I would also in parallel alert the chief medical
   4     officer to this development.
   5   Q. So you would in fact take it to the chief medical
   6     officer?
   7   A. But I would not take it for him necessarily to take
   8     action at that time. Most of the problems we had in the
   9     Supra-regional Service Advisory Group could be resolved
  10     without involving the Chief Medical Officer or indeed
  11     ministers, the Colleges were very helpful. We have had
  12     many examples where, if we had a difficulty we went to
  13     the colleges and they assisted us. If it was a clinical
  14     matter. If it was not a clinical matter we would go to
  15     the regional general managers if it was a management
  16     issue or finance because all of these bodies were
  17     represented on the Advisory Group.
  18   Q. Do you remember that when you were here last I asked you
  19     if you had heard of any concerns being expressed by
  20     Professor Henderson?
  21   A. Yes.
  22   Q. And you did not recollect that you had heard any?
  23   A. That is correct, yes.
  24   Q. You have now had the opportunity -- let us have a look
  25     at what you say, WIT 49/26, the very foot of the page.

   1     You say that your recollection of a meeting with
   2     Professor Crompton has been prompted by having I think
   3     read or having seen his evidence?
   4   A. Yes.
   5   Q. And you now recall hearing from Professor Crompton the
   6     views that Professor Henderson was expressing around
   7     that time?
   8   A. Well, what views he told me, yes. I imagine he
   9     expressed other views that I did not know about.
  10   Q. So you knew, did you, that Professor Henderson was
  11     suggesting that Bristol was at the bottom of the league
  12     for paediatric cardiac surgery?
  13   A. Yes.
  14   Q. And that he was suggesting that the quality of service
  15     was so poor that Welsh children should not go to
  16     Bristol?
  17   A. I am not sure I was aware of that but I knew he made
  18     statements to the effect that it was at the bottom of
  19     the league, but I cannot remember.
  20   Q. You recall, you tell us, hearing not only from him but
  21     from others the views that Professor Henderson
  22     expressed.
  23   A. Yes.
  24   Q. Who else?
  25   A. I mean Wales was not part of our remit so what was going

   1     on in Wales really was not our responsibility. I was
   2     aware that there was quite a campaign to get their own
   3     paediatric unit in Cardiff, that was a well-orchestrated
   4     campaign and that meetings were being held and there
   5     were television programmes and newspaper coverage to
   6     strengthen that appeal. I was aware there was
   7     a Professor Henderson very active in that area and that
   8     Professor Henderson was expressing views which were
   9     contrary to those of the Royal College of Physicians,
  10     which is normally the leading body in such areas in
  11     terms of policy. So, yes, I was aware of it, yes.
  12   Q. What if any steps did you take to tell others of the
  13     concerns that Professor Henderson was expressing about
  14     what was going on in England?
  15   A. I was not aware that Professor Henderson was expressing
  16     concerns that I needed to take note of.
  17   Q. If he was saying that Bristol was bottom of the league,
  18     did you know precisely what that might imply?
  19   A. You have to take into account that here was a Professor
  20     of Cardiac Medicine in Wales who was expressing views
  21     which were contrary to the policy of the Royal College
  22     of Physicians and which undermined the credibility of
  23     his views to begin with. He was alleging that one of
  24     the units was at the bottom of the league, but one of
  25     the units has to be at the bottom of the league, they

   1     cannot all be at the top. A league table is exactly
   2     that, some at the top, some in the middle and some at
   3     the bottom.
   4        But I was reassured because every single visit by
   5     anybody appointed to visit Bristol, be it on behalf of
   6     the Welsh Office or the Royal College of Physicians or
   7     by working groups set up at the request of the
   8     Department of Health, all gave Bristol a clean bill of
   9     health, all the colleges had knowledge as a result of
  10     their training visits and none of them gave any
  11     indication there were any problems in Bristol.
  12        So against all of these informed opinions by
  13     leading experts, we had a Professor of Medicine who had
  14     expressed views which suggested that one unit was at the
  15     bottom of the league and that also did not agree with
  16     the Royal Colleges' policies.
  17   Q. Let me be clear about this, you had those concerns
  18     expressed to you by the Chief Medical Officer of Wales?
  19   A. I think you must put it in context: we did not have
  20     a formal meeting. Professor Crompton was not coming to
  21     me to say "I have a major concern here that I need you
  22     to address", because had he done so we would have
  23     arranged a formal meeting, we would have had agendas, we
  24     would have taken minutes, we would have considered
  25     future action. There was nothing like that at all.

   1     He came to see me and it was -- the kind of meeting we
   2     had had many times before and on this occasion he
   3     expressed the views that Professor Henderson had
   4     allegedly made.
   5   Q. Let me break it down stage by stage: the Chief Medical
   6     Officer of Wales was expressing concerns, passing on
   7     concerns to you about this particular unit in England?
   8   A. Yes.
   9   Q. You took and listened to those concerns which matched
  10     others that you had heard from others at the time?
  11   A. I am sorry, the only concerns I had heard about Bristol
  12     was that the referral rates were low and there was
  13     a reluctance of clinicians to refer -- apparently there
  14     was a reluctance of clinicians to refer to Bristol.
  15     I was never able to ascertain why that was so. No one
  16     ever questioned the outcome in Bristol; no one was
  17     questioning the clinical standards there.
  18        All of the reports we had had, and we had had many
  19     of them, not only reports but reports of visits, all
  20     gave Bristol a clean bill of health and then we have one
  21     individual who the only evidence I get is that he
  22     alleges it is at the bottom of a league table and no
  23     detail is provided.
  24   Q. Dr Halliday, it may help if you concentrate on the
  25     question and try and answer it. Thus far you and I have

   1     agreed that the Chief Medical Officer of Wales had
   2     expressed concerns to you about the quality of surgery
   3     in Bristol.
   4   A. No, no, he came to see me and he said "Professor
   5     Henderson, a cardiologist in Wales has been making these
   6     allegations".
   7   Q. The fact is, is it, that you took those allegations in,
   8     to yourself, and took them no further?
   9   A. When you say "took them no further", if I had had
  10     anything to back up this evidence, I would have done
  11     something about it, yes.
  12   Q. The answer is, yes, you took them no further. The
  13     explanation is that you had nothing to back them up.
  14   A. Yes.
  15   Q. This is what I mean by listening to the question and
  16     trying to answer it, please.
  17   A. I am sorry, but you receive information, you do not
  18     necessarily take action, but you do not dismiss it; you
  19     retain the information and if something else comes along
  20     to complement what you have just been told then you
  21     might well take action.
  22        In terms of what Professor Crompton had told me,
  23     I had no justification for taking action. What was
  24     I expected to do? I could not go to the Royal College
  25     and say "A Professor Henderson in Wales is alleging

   1     there is something wrong in Bristol". It would be
   2     irresponsible of me to ask the College to investigate on
   3     that basis. If, however, I was presented with some
   4     evidence, some data to suggest there was something wrong
   5     then, yes, I could do something.
   6   Q. We are agreed -- I am sorry to have to come back to
   7     this, to break it down -- that the Chief Medical Officer
   8     of Wales spoke to you, he passed on concerns which
   9     Professor Henderson had about the quality of surgery in
  10     Bristol, you took the information, you retained it for
  11     possible future reference and you did nothing in respect
  12     of it?
  13   A. Yes, I agree with almost everything you say except for
  14     the question of quality because what he was saying was,
  15     that Bristol was at the bottom of a league and it had
  16     not improved year on year. These were the only two
  17     statements he made to me about Bristol.
  18   Q. Have a look at the next page of your statement where you
  19     set it out. You say you do not recollect exactly what
  20     Professor Crompton said but you accept if he says that
  21     he repeated comments that Professor Henderson had made
  22     to that effect, you would have accepted it?
  23   A. No, what I said is, if he said -- I have difficulty
  24     reading, but I think I can read this -- if he repeated
  25     the comments Professor Henderson had made, namely that

   1     Bristol was not improving year on year or even that
   2     Bristol was at the bottom of the league for quality,
   3     then I accept that he did.
   4   Q. Which is I think exactly what I was putting to you.
   5   A. Except that is what he is now saying. The issue I have
   6     now here is that "quality" is now a jargon term, it has
   7     an understanding which is perfectly acceptable in this
   8     age. "Quality" in the time that we are talking about
   9     did not have that understanding, it was not so widely
  10     used. In fact the whole question of quality was just
  11     beginning to come into the business jargon at that time,
  12     far less into the Health Service. So it is the question
  13     of "quality" I am objecting to. I accept that he said
  14     it was not improving year on year. I accept that he
  15     said Bristol was at the bottom of the league and he now
  16     says "quality". I am prepared, in the present
  17     understanding of "quality" to accept that that is the
  18     case. But it was not a question of anything to suggest
  19     that the outcome was poor, clinically poor. Being at
  20     the bottom of the league was of no consequence, one unit
  21     had to be at the bottom of the league.
  22        I am sorry, Professor Kennedy, I am afraid the
  23     start of this afternoon has got me in the wrong mood for
  24     this. Carry on.
  25   Q. You appreciated that Professor Crompton had been

   1     sufficiently concerned to go to the Chief Medical
   2     Officer of England who had referred him to you?
   3   A. The Chief Medical Officer in Wales has said here in the
   4     Inquiry it was a discussion en passant, he did not go to
   5     the Chief Medical Officer to report this fact, he
   6     happened to meet him and said "I have a problem" and the
   7     Chief Medical Officer said "Go and see Dr Halliday".
   8   Q. When Professor Henderson was saying that Bristol was at
   9     the bottom of the league, apart from recognising that
  10     somebody had to be bottom, you had no way of knowing how
  11     far the bottom unit was from the second bottom, not
  12     without making enquiries, did you?
  13   A. No, not without making enquiries, yes.
  14   Q. Except that obviously one unit has to be bottom, one
  15     unit has to be top and it may not tell you an awful lot
  16     unless it is top by far or bottom by far, in which case
  17     it might imply something, might it not?
  18   A. Yes.
  19   Q. Did you make any enquiries as to whether Bristol was so
  20     far bottom as to be worrying?
  21   A. One of the reasons why a unit would be at the bottom of
  22     any league is they are not doing enough work to develop
  23     their expertise. The fact that the throughput in
  24     Bristol was low was well-known. We had a number of
  25     reviews and each time the experts in this field looked

   1     at it, none of them said that there was any reason not
   2     to refer to Bristol. Indeed, the Society's report in
   3     1988 actually recommended that the referral should be
   4     increased to Bristol so as to improve their expertise.
   5   Q. So far as the point about numbers and quality is
   6     concerned, you expected if the numbers were low the
   7     quality would be poor?
   8   A. The quality would be lower than the other units doing
   9     more, yes.
  10   Q. "Poor" may be the wrong word, but lower certainly. You
  11     would have appreciated that Bristol was either the
  12     lowest in terms of throughput or if not the lowest very
  13     close to it?
  14   A. Yes.
  15   Q. Certainly for open heart operations you would have
  16     appreciated it was the lowest in that category, would
  17     you not?
  18   A. Yes.
  19   Q. So on that alone you would have expected it to have low
  20     results unless they were remarkably good beyond
  21     expectation in some particular types of operation.
  22     I can understand you not being surprised that Bristol
  23     was at the bottom, but one comes back to the question
  24     I asked and I do not think you answered it. You may
  25     need to reflect on it: did you make any enquiries to

   1     find out by how far Bristol was actually bottom of the
   2     league?
   3   A. We made every effort by every means and you have the
   4     evidence here. We have asked the Society of
   5     Cardiothoracic Surgeons, we asked the Royal College of
   6     Surgeons repeatedly to assist us in this area. Indeed,
   7     when the joint working party of the Royal College of
   8     Physicians and the Royal College of Surgeons considered
   9     this in 1986, they were aware that Bristol was in it.
  10     So every single professional report supported the
  11     continuance of the designation of Bristol. I needed
  12     some evidence for me to question that further.
  13        I will give you an example. I am not particularly
  14     impressed by views of clinicians in another country for
  15     which you have no responsibility, because it is a common
  16     feature to have competent expert able clinicians in your
  17     own country who oppose the national policy. You have
  18     already heard evidence from Professor Tynan, his
  19     report. Professor Tynan was totally opposed to the
  20     supra-regional service designation. He wanted it
  21     de-designated and felt that interventional cardiology
  22     was the way forward.
  23        I took much greater note of Professor Tynan's
  24     evidence because he was a man actively involved in the
  25     service in England. But to have allegations,

   1     unsubstantiated by any evidence, from a clinician in
   2     Wales who was known to be the leader of a campaign to
   3     have their own unit in their own principality, it had
   4     nothing from Professor Henderson which would have
   5     allowed me to take it forward.
   6        Had Professor Henderson written to me and said
   7     "Dr Halliday, I have these concerns" then I most
   8     certainly would have done something, or if Professor
   9     Crompton had written to me as Chief Medical Officer of
  10     Wales and said "I have these concerns", that is
  11     a different matter. For Professor Crompton to meet me
  12     in my office, no formal arrangements, just "I have
  13     a problem I would like to discuss with you", that is
  14     a different problem altogether and no data on which
  15     I could act.
  16   Q. Did you ask him for data?
  17   A. You are asking me about a meeting 13 or 14 years ago,
  18     I cannot remember exactly what we discussed and I said
  19     that in my statement.
  20   Q. In terms of data you knew, I think, that every year the
  21     units sent data on their operations to the Society for
  22     Cardiothoracic Surgeons?
  23   A. Yes.
  24   Q. You knew that there the results of any particular unit
  25     were evaluated and the unit had a return which showed

   1     them the average for particular classes of diagnosis and
   2     the treatment of it throughout the UK?
   3   A. Yes.
   4   Q. Is it the case that the Supra-regional Services Advisory
   5     Group was not told of the aggregate data for the UK for
   6     a particular operation?
   7   A. One of the strengths of the Society's Registry would be
   8     the fact that it allowed all clinicians in that
   9     speciality to have knowledge about what is going on in
  10     all the units. That was one of the reasons why I was
  11     reassured by all the reports and all the visits by the
  12     same individuals, who had at their fingertips all the
  13     information necessary to make such a judgment.
  14   Q. Forgive me; you knew, did you not, that the data once it
  15     got to the centre, once it got to the society, was
  16     anonymised so that no one surgeon receiving the results
  17     would know how another unit had performed?
  18   A. Yes, but before it was anonymised it would be analysed
  19     so they would know what was happening. Although the
  20     data is anonymised, that is for you or I but not for the
  21     cardiac surgeons. They know perfectly well which unit
  22     it is. They can tell by the referral numbers. It was
  23     not anonymised in the sense that they could not identify
  24     which unit was behaving poorly.
  25        In any case, when they received the data, they

   1     knew when they were receiving it; it was not anonymised
   2     data they received, they received the data from the unit
   3     because there were two units in particular that
   4     constantly refused to provide evidence. So they knew
   5     where the evidence was coming. They knew exactly which
   6     unit's data was poor and which unit's data was good, but
   7     once it was produced in a report it was anonymised.
   8   Q. We heard from Sir Kenneth Calman, and when he came and
   9     gave evidence to us, I asked him who was responsible for
  10     monitoring the quality of care in the Supra-regional
  11     Services Advisory Group, particularly the paediatric
  12     cardiac services at Bristol. His answer to me was this:
  13        "It seems to me that the Supra-regional Services
  14     Advisory Group was responsible for that and if there was
  15     a problem then as part of the Department of Health, they
  16     would have referred that upwards to somewhere else
  17     within the Department, either through the Chief Medical
  18     Officer or the Chief Executive."
  19        Is he right?
  20   A. No.
  21   Q. He said, a few passages later on:
  22        "I considered that it would be the responsibility
  23     of the Supra-regional Services Advisory Group to ensure
  24     that there was a process of monitoring and that that
  25     process and the outcome was reported to the

   1     Supra-regional Services Advisory Group."
   2   A. I would accept that: a process.
   3   Q. A process for monitoring, but not the first answer that
   4     he gave. Let me remind you of it so you have it,
   5     because I appreciate it may be difficult for you to take
   6     in. The question I asked again of him was:
   7        "Who was responsible for monitoring the quality
   8     of care in the Supra-regional Services Advisory Group,
   9     particularly the paediatric cardiac services at
  10     Bristol?"
  11        The answer was:
  12        "It seems to me that the Supra Regional Services
  13     Advisory Group was responsible for that and if there was
  14     a problem, then as part of the Department of Health,
  15     they would have referred that upwards to somewhere else
  16     within the department, either through the Chief Medical
  17     Officer or the Chief Executive."
  18        You did not agree with that.
  19   A. No, I do not agree with that.
  20   Q. Why not?
  21   A. I was the architect of the supra-regional service
  22     arrangements. It was I who drafted all the papers, made
  23     all the proposals and negotiated with the profession.
  24     At no time did we consider that the Advisory Group which
  25     would be eventually set up would have monitoring

   1     responsibilities for any of the services. Their role
   2     was to advise the Secretary of State on which services
   3     should be centrally funded. It was a funding
   4     arrangement.
   5        The only quid pro quo that we had which was
   6     a selling point for Ministers was that it gave us an
   7     element of control over the proliferation of complex
   8     services. But the multi-regional, subsequently called
   9     supra-regional services, were no different from the
  10     scores, if not hundreds, of multi-regional services
  11     which are within the NHS, in the sense that their
  12     management and any audit arrangements that were
  13     necessary were the responsibilities of the health
  14     authorities. That was clearly set out in statute and
  15     continued until the reforms in 1990/1991.
  16   Q. I have misattributed the question; it was not my
  17     question, it was Sir Brian Jarman's. Sir Kenneth Calman
  18     went on to answer:
  19        "They were responsible for ensuring the system
  20     was in place for monitoring the outcome. They could not
  21     do the monitoring themselves. They would get the data
  22     once it had been monitored, and if there was a problem,
  23     presumably they would talk to an appropriate person
  24     within the Department of Health."
  25        Is that the way it worked or not?

   1   A. Again, you need to consider this prior to the reforms
   2     and post the reforms. Prior to the reforms audit really
   3     was in its infancy and I was very active in encouraging
   4     audit of the medical profession in all the specialities
   5     for which my division was responsible, which was the
   6     vast majority of the acute hospitals sector. I was
   7     instrumental and involved in setting up NCEPOD.
   8     I caused the Royal College of Physicians to change many
   9     of their activities in terms of addressing medical
  10     audit, so it was an important factor for me. When the
  11     Advisory Group was set up, although we had no
  12     responsibility for audit at all in those days,
  13     I endeavoured to encourage all the services which were
  14     designated to begin to develop their audit arrangements.
  15        Post the reforms, in endeavouring to cover the
  16     contractual aspects, quite clearly, as in any business
  17     contract, the quality of the service is an important
  18     factor. So for the NHS, it was introduced that all the
  19     contracts must include audit. That gave us an
  20     opportunity to do similarly with the contracts in the
  21     supra-regional service arrangements.
  22        But it was the department's policy that medical
  23     audit -- audit generally was a matter for the Health
  24     Authority and the Trusts after the reforms, and medical
  25     audit was a matter for the profession. That was not

   1     a view I particularly agreed with. I felt the
   2     department had a role to encourage the development of
   3     these areas. Post the reforms, of course, large sums of
   4     money were made available to assist in this field.
   5     Prior to the reforms, no such monies were available.
   6        It was all very well saying, "Leave to it to the
   7     profession", but if the profession had no resources with
   8     which to develop their audit arrangements, very little
   9     could be done.
  10        I think you have already had evidence about the
  11     problems we had just identifying -- yes, you do have
  12     evidence. It was identified that some of the cardiac
  13     surgical units were including interventional cardiology
  14     within their funding arrangements, which was not
  15     a designated service. But the difficulty we had, even
  16     getting financial and activity data to identify that was
  17     exceedingly difficult.
  18        So "simple", in inverted commas, management data
  19     in terms of activity and costs were extremely difficult
  20     to get. To move into a field of audit where there was
  21     no resources available was nigh on impossible in these
  22     days. Nevertheless, the profession met with us,
  23     discussed possible avenues in which we might introduce
  24     audit, and these have come to fruition since resources
  25     have been made available.

   1   Q. If I can unpick that answer: what Sir Kenneth Calman was
   2     telling us that the Supra-regional Services Advisory
   3     Group were responsible for, ensuring a system was in
   4     place for monitoring outcomes, relates, does it, to the
   5     post 1991 reforms?
   6   A. Post, yes.
   7   Q. What do you say, then, was the position prior to those
   8     reforms? Was there no such responsibility?
   9   A. Audit was not a major interest of the Department of
  10     Health at that time. Myself, I kept it as a policy
  11     issue within my division all the time that I headed the
  12     division, which was for 15 years.
  13        Each year I was constantly told that medical audit
  14     was not part of the Department's responsibility and
  15     I should drop it, and I argued that I should retain it
  16     as long as I met all my other targets in terms of work.
  17     As long as pursuing that activity did not affect my
  18     other work, I should be allowed to retain it, and
  19     I did.
  20        So we were very active in encouraging medical
  21     audit in the field, despite the fact that it was not
  22     Departmental policy at that time.
  23   Q. Sir Michael Carlisle told us that, as a contractor -- it
  24     may well be that by use of that phrase he was looking at
  25     the time after purchaser/provider came in. As

   1     a contractor, the Department of Health obviously had an
   2     accountability as well, in talking about supra-regional
   3     services?
   4   A. Yes.
   5   Q. So post the 1991 reforms, the Department of Health was,
   6     was it, accountable in that sense for the neonatal and
   7     infant cardiac services provided?
   8   A. In theory, yes, but in practice, if you wanted to make
   9     the Supra-regional Services Advisory Group a purchaser,
  10     then you would really have had to change the nature of
  11     the Supra-regional Advisory Group. For example, you had
  12     two Presidents of the Medical Royal Colleges as members
  13     of the Supra-regional Services Advisory Group. The
  14     medical Royal Colleges are not part of the NHS and
  15     therefore could not really be purchasing services.
  16        They were a key source of advice to us and so
  17     either you had an arrangement whereby the membership of
  18     the Advisory Group were people who could legitimately
  19     purchase, and then you would have to have another
  20     arrangement for getting advice. But no one suggested
  21     that the Advisory Group should be changed, with one
  22     exception: the Administrative Secretariat of the
  23     Advisory Group, in 1992/1993, became members of the
  24     staff of the NHS Executive, so in a sense they would be
  25     fitting in with the normal contractual arrangements with

   1     the NHS. The rest of the Secretariat, myself included,
   2     were still on the policy side of the Department, who had
   3     no responsibility for management, nor the contracts.
   4   Q. This conversation about the question of monitoring and
   5     accountability arose in response to what you say that
   6     Professor Crompton and you discussed when he came, very
   7     much in line with what he says about the way he
   8     expressed Professor Henderson's concerns to you.
   9        Can we have a look at what you say, WIT 49/27?
  10     Scroll down, please, to paragraph 73:
  11        "Professor Crompton could also have detailed any
  12     concerns through the Welsh Office representatives on the
  13     Supra-regional Services Advisory Group but did not, so
  14     far as I am aware. Professor Henderson, who is a senior
  15     member of the medical profession in Wales, could also
  16     have formally made known his concerns to any of the
  17     appropriate bodies."
  18        What point are you making there?
  19   A. I am making the point that Professor Crompton did not
  20     raise with me formally any concerns at the Welsh
  21     Office. Apart from Professor Crompton not raising any
  22     concerns formally on behalf of the Welsh Office, he had
  23     representatives at the Supra-regional Service Advisory
  24     Group meetings who at any stage could have raised it
  25     with us, not just at the meetings but at any time during

   1     the year.
   2        All that Professor Crompton was doing was
   3     conveying to me the allegations made by Professor
   4     Henderson. As I have said, Professor Henderson, as
   5     a senior reputable member of the medical profession in
   6     Wales, had many avenues by which he could have made
   7     known his concerns.
   8   Q. Do you and I agree or not that the fact that something
   9     is raised is more important than whether it is raised
  10     formally or informally?
  11   A. I agree with you, a matter is raised, but I do not think
  12     you appreciate, I headed a division that dealt with the
  13     acute hospital sector in England. I was having issues
  14     raised on a daily basis in all the services that we
  15     had. Some of these were backed up by evidence, in which
  16     case we followed them up. Others we took note of for
  17     future action if they were substantiated by any other
  18     source. Professor Henderson's allegations were never
  19     substantiated from any other source. I am not sure what
  20     you would have expected me to do.
  21        As the head of the division, I had a number of
  22     options. I could have said, "I have heard about
  23     allegations from Wales", which, as I say, is nothing to
  24     do with the supra-regional service arrangements in
  25     England. "I have no evidence to back this up, but

   1     I think you should be aware of this". I am sure, if
   2     I had done this with the CMO, he would have said,
   3     "I will take note of that". We would not have alerted
   4     ministers without having something to go on. You do not
   5     pester ministers with allegations from an individual,
   6     whose main theme in life was to get his own unit in
   7     Cardiff and therefore if you could discredit any other
   8     units in so doing, so be it.
   9   Q. What stopped you saying, or saying to the CMO, "This is
  10     what is being said ... Let us get the figures from the
  11     Society of Cardiothoracic Surgeons and that will put an
  12     end to the matter"?
  13   A. You would not get the figures from the Society of
  14     Cardiothoracic Surgeons.
  15   Q. "Let us ask Bristol for their figures and compare those
  16     with the figures from the Society of Cardiothoracic
  17     Surgeons and see what that shows."
  18   A. Mr Langstaff, I was doing this almost on a daily basis.
  19     We had concerns expressed that the referral rate in
  20     Bristol was not as good as it should have been. That
  21     was a matter of real concern to me. I therefore made
  22     repeated visits to Wales. I met with Professor Crompton
  23     and his staff, and with clinicians, and with GPs in
  24     Wales. I met with clinicians in Bristol. I have spoken
  25     to all the paediatric cardiologists and all the

   1     paediatric surgeons and I could not ascertain any reason
   2     why the referral rate was low. The evidence that you
   3     have in terms of data was available to all the cardiac
   4     surgeons to whom I spoke. I had no reason to collect
   5     additional data, they already had it.
   6   Q. Was it not your understanding that the only people who
   7     would have the data about the Bristol results would be
   8     the Bristol surgeons?
   9   A. Not at all, they have put their data into the Society's
  10     returns. I do not know how often they do it, probably
  11     monthly, but they made returns to the society.
  12   Q. It may then come as a surprise to you to know that the
  13     way it worked was this: that each unit was invited,
  14     annually, to submit its returns of both workload,
  15     results, mortality, in a number of different categories
  16     to the Society of Cardiothoracic Surgeons; that the
  17     society took that data from each individual unit that
  18     supplied it. The analysis was conducted in confidence
  19     so that it was not revealed to any surgeon. The results
  20     were aggregated, and by virtue of that, anonymised, and
  21     each unit then got back from the society the results for
  22     England and Wales. They themselves could compare their
  23     own results against the English and Welsh results. That
  24     is the way in fact it worked.
  25   A. I understand they also got their own results back from

   1     the society.
   2   Q. Did you understand that was the way it worked at the
   3     time?
   4   A. The society was very secretive. I tried for years --
   5   Q. Concentrate on the question: did you understand the way
   6     that I have described it was the way it worked at the
   7     time?
   8   A. I did not know how they did it.
   9   Q. That is what I wanted to establish. That is all I was
  10     asking. You did not know?
  11   A. No, because I had a member of the staff whose job it was
  12     to liaise. I have repeatedly said that Dr Michael
  13     Prophet should be invited to give evidence, because
  14     Dr Michael Prophet was charged, as were all the doctors
  15     in my division were charged, with taking forward audit
  16     arrangements in their own specialities, as Jane Ashwell
  17     has told you. Michael Prophet was the doctor
  18     responsible for cardiac surgery before Jane Ashwell and
  19     it was his job to liaise with the Society of Cardiac
  20     Surgeons to take forward audit. I am aware, from
  21     reports from him, the difficulties he had in getting any
  22     progress with the society.
  23   Q. Can I move away from that for a moment and go down to
  24     the bottom of this page we have on the screen. You say
  25     you had great difficulty with the remainder of Professor

   1     Crompton's recollections. You are sure you did not
   2     discuss waiting lists. With the exception of heart,
   3     lung and liver transplantation, waiting lists were not
   4     a serious problem in any of the supra-regional
   5     services. You were not aware that delay in treatment
   6     was ever a problem in neonatal and infant cardiac
   7     surgery, and you were not aware of the Supra-regional
   8     Services Advisory Group having discussing waiting times.
   9        I wonder again if you can help us. One of the
  10     features of the evidence that we have heard about
  11     Bristol is that there were, throughout the late 1980s,
  12     substantial waiting lists for paediatric surgery, to the
  13     extent that we heard from Mr Dhasmana, that he was
  14     operating upon children rather later than he would have
  15     wished. There are repeated documentary references to
  16     just that happening.
  17        One of the reasons for that appears to have been,
  18     if one accepts the evidence, that there was an impact of
  19     adult service affecting waiting lists for children
  20     because the operations were conducted in the same unit,
  21     in the same place, in the same theatre. Do you follow
  22     the point?
  23   A. Yes.
  24   Q. Did any of that concern about waiting lists in Bristol,
  25     or indeed the split site in Bristol, ever percolate

   1     through to you at the Supra-regional Services Advisory
   2     Group?
   3   A. No. In asking me that question, you actually said
   4     paediatric cardiac surgery. I accept -- and I have said
   5     in my evidence -- that in paediatric cardiac surgery, as
   6     opposed to NICS, there was waiting list, there was
   7     a backlog of patients who required treatment. That was
   8     a major problem throughout the country, not just in
   9     Bristol.
  10        In terms of neonatal and infant cardiac surgery
  11     Bristol was funded, provided with the resources, to
  12     reach a target activity which they never ever reached.
  13     Therefore, Bristol had spare capacity year on year and
  14     should have no reason whatsoever to have had waiting
  15     lists for neonatal and infant cardiac surgery. If they
  16     had waiting lists for paediatric cardiac surgery, that
  17     is a different matter entirely; that is not
  18     a supra-regional service.
  19        I think some of the cases you have discussed here
  20     were not neonatal infant cardiac cases but paediatric
  21     cardiac surgical cases.
  22   Q. You are absolutely right on that. Our terms of
  23     reference are paediatric, which of course covers both?
  24   A. It covers both. You see, there would be no point in
  25     Professor Crompton raising issues of the problems of

   1     waiting lists in paediatric cardiac surgery with me in
   2     the department. It was a well-known fact throughout the
   3     country. It was a major problem, but it was a problem
   4     that had to be addressed by the health authorities prior
   5     to the reforms and by the Trusts post the reforms; it
   6     was not a matter for the department per se.
   7   Q. The two matters which you thought were Bristol's
   8     problems were the numbers and Bristol's failure to
   9     "recruit", if I can put it that way, a greater
  10     throughput?
  11   A. Throughput, yes.
  12   Q. That was it?
  13   A. That was it. Well, that is all I could find evidence
  14     for. There was nothing else to suggest there were
  15     problems in Bristol.
  16   Q. Earlier this afternoon you said to me that you drew
  17     comfort from the fact that, although Bristol had low
  18     numbers, the advice which you were given by the Royal
  19     Colleges in their report to the Supra-regional Services
  20     Advisory Group was that what needed to be done was to
  21     give Bristol greater numbers.
  22        Was the point this: if poor numbers produced poor
  23     results, then the logic of the position would be that
  24     you should scrap the service in that particular unit as
  25     opposed to what they recommended, which was increase the

   1     throughput?
   2   A. I am sorry, I do not follow your question. I mean, if
   3     the experts tell us that there are problems in Bristol
   4     and they do not recommend that we close Bristol -- no
   5     report has ever recommended that -- but on the other
   6     hand, in their expert opinion, what we should do is
   7     increase the referrals, that is the best advice we could
   8     have.
   9   Q. You had a sensation, a view, that poor numbers meant
  10     poorer results, lower results?
  11   A. My concern about all the services which were under my
  12     responsibility, either as policy or within the
  13     supra-regional service group, was that if I became aware
  14     of any problems of outcome, action would be taken. And
  15     action was taken in every instance when such matters
  16     were raised. If you are reassured by the experts in the
  17     field that there are no problems, I may still have had
  18     anxieties, but without evidence what can I do?
  19   Q. You were being told I think, were you not, in the report
  20     as you recollect it that there is a problem at Bristol
  21     but the answer is to increase throughput?
  22   A. Right.
  23   Q. I want to know why it is that you drew comfort from
  24     that. I had supposed a particular reason which
  25     I suggested to you, but perhaps I should ask you what it

   1     was about that that you drew comfort from?
   2   A. Okay, if the report had ended full stop that the
   3     referrals were low, that would have continued to cause
   4     me concern. But when the experts, and these are your
   5     leading experts, not only in the UK but of the whole of
   6     Europe, in some of them in the world, if they then said
   7     "What we need to do is to encourage the referral"
   8     I would not have expected such responsible, capable and
   9     able physicians and surgeons to recommend you increase
  10     the referral to a unit about which there was any cause
  11     for concern about outcome, that is what reassured me.
  12   Q. Because if the outcomes had been poor in consequence of
  13     anything other than throughput, you would have expected
  14     them to recommend closure?
  15   A. Yes, I would have done, yes.
  16   Q. Did Sir Terence when he spoke to you ever suggest that
  17     Bristol on its own should be de-designated?
  18   A. I do not think Sir Terence has ever said to me that we
  19     should de-designate Bristol. I think he has expressed
  20     that he had concerns about Bristol and actually the only
  21     time this really came up was when the last report, which
  22     was received in 1992 in which the working party had
  23     recommended continuance of designation, he expressed
  24     reservations about Bristol but there was nothing more
  25     than expressing reservations about Bristol.

   1   Q. When he expressed reservations about Bristol, did you
   2     understand him to be saying to you, "I am recommending
   3     that Bristol should no longer be designated"?
   4   A. That is one interpretation but you have to accept that
   5     I had just received the report of his expert committee
   6     with a covering letter from him himself saying "Here is
   7     the report and I commend the authors of the report [or
   8     words to this effect] for the hard work they have done
   9     and the splendid job they have done". So I had a report
  10     referred to me by the experts and blessed by the
  11     President of the Royal College of Surgeons, who was also
  12     a member of the Supra-regional Service Advisory Group.
  13   Q. That is DOH 3/13. It is to you:
  14        "Dear Norman,
  15        "I have pleasure in enclosing the report ..."
  16        Can we go down to the last paragraph:
  17        "The working party collected a lot of data on
  18     which to base their recommendations and should be
  19     congratulated on a report which has the full support of
  20     the Royal College of Surgeons".
  21        He signs that as the President of the Royal
  22     College. That is dated 2nd July 1992 and at that stage
  23     he is giving full support to that report.
  24   A. Yes.
  25   Q. That report did not suggest the de-designation of

   1     Bristol, it suggested the continuance of all the
   2     neonatal and infant cardiac units, did it not?
   3   A. It did.
   4   Q. Indeed, you may not have seen this letter but you need
   5     I think in the light of the questions I am about to ask
   6     you, to have a look at it. It is RCSE 2/179.
   7        This is Sir Terence to Professor David Hamilton,
   8     to "thank him very much indeed for the excellent
   9     report". There is no reason why you should have seen
  10     that, but it is entirely consistent with what you did
  11     see?
  12   A. Exactly.
  13   Q. The next thing which happened was the letter which
  14     I showed you earlier from John Zorab to Sir Terence
  15     English, RCSE 2/179. Again it is not a letter you saw
  16     at the time. Can we scroll down, please. 15th July.
  17     So the 2nd July he sends you the report; the meeting is
  18     going to be what, on 28th July?
  19   A. Yes.
  20   Q. 15th July, almost two weeks beforehand, John Zorab
  21     writes to Sir Terence English. We looked at the letter
  22     when we started. He is raising concerns to Sir
  23     Terence. At some stage after that did you get
  24     a telephone call from Sir Terence?
  25   A. I did.

   1   Q. His recollection of that telephone call is that he told
   2     you that he had concerns about the mortality at Bristol?
   3   A. No, he does not say that at all. He never mentions
   4     mortality in any of his letters or in his GMC
   5     statement. He never mentioned mortality at any time.
   6        For Terence English to have raised mortality in
   7     cardiac surgery, to me would have really rung bells
   8     because, as you are probably aware, Sir Terence was the
   9     lead behind setting up the Society's Registry. He
  10     believed that the Registry was the only way in which you
  11     could carry out audit in cardiac surgery and in fact
  12     point blank refused to provide evidence to the
  13     Department other than in an anonymised form on cardiac
  14     surgery and for him to raise mortality with me would
  15     have really rung bells, but he never did so and he does
  16     not say now in this letter that he did.
  17   Q. What he told us was this. I said to him:
  18        "Dr Halliday for his part maintains stoutly that
  19     you [Sir Terence] never said anything to him about
  20     mortality statistics at all."
  21        His answer to me:
  22        "It was the only reason why I would ever have got
  23     into this. The report had gone on, gone through, the
  24     activity figures were all there. We were not
  25     questioning those. The whole issue of having to do

   1     something at such short notice arose through Dr Zorab's
   2     letter and a review of mortality statistics, and that
   3     was made absolutely clear, so that was -- I mean, again,
   4     the reason for Professor Hamilton reconsidering his
   5     position. I mean, he must have. He may have forgotten
   6     it, but that is the reason for....", and he went on to
   7     say, talking to you.
   8        I came back to the question of the content of the
   9     conversation and said:
  10        "One of the matters raised by Norman Halliday's
  11     evidence is his suggestion that not only did you not
  12     mention the matters to the group, or not only did you
  13     not mention matters in writing or at any stage after the
  14     phone call you say you had with him, he tells us you
  15     never mentioned them to him during that phone call
  16     either. Do you think he may be right about that?"
  17        Sir Terence's response:
  18        "I think he is wrong, and I think the evidence of
  19     the correspondence from the various parties confirms
  20     that."
  21        I returned a third time to it:
  22        "In the light of your obvious uncertainties as to
  23     what had happened until you saw the documents, are you
  24     still sure that you said to Dr Halliday something about
  25     the mortality statistics at Bristol and how disturbing

   1     they were?"
   2        His answer:
   3        "Absolutely. There could be no other explanation
   4     of the correspondence and what I said there."
   5        That is what he is saying to us.
   6   A. Yes.
   7   Q. Is he wrong?
   8   A. He also sent you a letter dated 2nd December, in which
   9     he was responding to my statement. This was the
  10     opportunity for Sir Terence to get things correct. He
  11     could have, and I would have expected him to state in
  12     here, that he had discussed mortality with me. He does
  13     not say that at all; he makes no mention of mortality.
  14     He makes mention of his GMC statement, which makes no
  15     mention of mortality.
  16        My understanding of the discussion we had, as
  17     I believe confirmed already by Keith Ross, because the
  18     only concern I had, and rather astonishingly it is
  19     denied here, was that Sir Terence was proposing to take
  20     unilateral action and withdraw the Colleges' report.
  21     That was to me quite unacceptable because we depended on
  22     the reports of the Colleges to ensure that we were
  23     formulating the right policies and for our report to be
  24     unilaterally withdrawn by the President after having
  25     sent it in in such glowing terms would have discredited,

   1     not only that report but future reports from the
   2     College.
   3        Because of my concern I contacted Keith Ross and
   4     David Hamilton and said that I was deeply concerned that
   5     Sir Terence wanted to withdraw the report and they
   6     shared my concern.
   7        Now Sir Terence in his letter of 2nd December to
   8     the Inquiry states there was never any suggestion made
   9     by me that the report of the working party should be
  10     withdrawn. But you also have a letter dated 3rd August
  11     from David Hamilton, in which he explains that he and
  12     Keith had considered the suggestion by Sir Terence that
  13     he would take Presidential and Chairman's action and
  14     withdraw the report. All the evidence you had is
  15     consistent, I would suggest, with my interpretation of
  16     what Sir Terence had told me.
  17   Q. I will come to the letter of 3rd August in a moment.
  18     Let us examine what you say took place. You say that
  19     Sir Terence telephoned you and wanted to withdraw the
  20     report?
  21   A. Yes.
  22   Q. Did he give you a reason?
  23   A. No, the sequence was this: it was not unusual to get
  24     a call from Sir Terence, because we normally met with
  25     Presidents and the GCC before the meetings to ensure

   1     they understood the nuances of the administrative
   2     arrangements, if not the clinical arrangements, so it
   3     was not unusual to have a call. But I was quite
   4     startled when he said that he was ringing because he now
   5     had concerns and he wanted the report withdrawn and
   6     amended.
   7        I first of all said that was not possible because
   8     the reports had already gone out. Of course it would
   9     still have been possible. If Sir Terence had insisted
  10     on withdrawing the report, all we would have done is to
  11     tell the members of the Advisory Group to ignore the
  12     report and that the Colleges wanted to look at it
  13     again. He did not, however, insist, but he accepted it
  14     was no longer possible to withdraw the report.
  15        I went on to say to him that in any case I do not
  16     think it is going to make a lot of difference because my
  17     understanding of what was likely to happen at the
  18     Advisory Group was that they would be de-designating the
  19     service and Terence was not at all happy about that. He
  20     alleges I had not said that to him. He had of course
  21     already received my paper and it was my paper given to
  22     the February meeting, written by me, unambiguously
  23     saying "These are the reasons why we cannot continue to
  24     designate this service and I am recommending to the
  25     Advisory Group that we de-designate the service" which

   1     had been on the cards since 1987.
   2        Having explained that to him, he then said "If it
   3     cannot be withdrawn, I have major reservations about
   4     Bristol and I want these reservations to be communicated
   5     to the Advisory Group" and I said "Yes, I will do that".
   6   Q. He said he had concerns; did you ask him what the
   7     concerns were?
   8   A. He did not offer an explanation of his concerns and
   9     I assumed his concerns were the usual ones, that is that
  10     the referral rate and the throughput was low.
  11   Q. Everyone knew and had known for years about the referral
  12     rate and the throughput being low?
  13   A. Yes.
  14   Q. There was nothing new in that?
  15   A. There is nothing new in it.
  16   Q. That would be, would it not, a very surprising reason
  17     for him at the eleventh hour as it were to telephone you
  18     and say "I have reservations about Bristol on those
  19     grounds"?
  20   A. It was a very unusual telephone call. I mean I have
  21     received a report written by the leading experts in
  22     Europe on a subject, blessed by the President as being
  23     an authoritative report and, as he said in his letter,
  24     all the data that was available had been considered. He
  25     said that at the last paragraph of his report, words to

   1     that effect.
   2        Then to ring me up and say "I want to withdraw the
   3     report", it was an astonishing telephone call.
   4   Q. So you asked him why he changed his mind, presumably?
   5   A. No, no, it is not for me to question the President of
   6     the Royal College of Surgeons why he wants to withdraw
   7     a report by his experts; that is a matter for him and
   8     the College. My concern was that we had the report of
   9     the College by the leading experts. It does not matter
  10     whether an individual is the President of the College or
  11     the Secretary of the College or any other office, it is
  12     only one opinion as opposed to all the experts involved
  13     in formulating that original report. His view was only
  14     one view, but he could have taken Presidential action
  15     and withdrawn the report. He could have insisted that
  16     that report was withdrawn and I would have withdrawn it.
  17   Q. You deferred to the Royal Colleges, the Royal College of
  18     Surgeons amongst them, on any matter which was a matter
  19     of medical input, did you not?
  20   A. Yes.
  21   Q. And the President spoke for the Royal College, did he
  22     not?
  23   A. Yes.
  24   Q. So if the President said he had reservations, that was
  25     in effect the Royal College saying it had reservations,

   1     was it not?
   2   A. Yes.
   3   Q. It was not for you to judge that you would prefer the
   4     experts who had given their report or the President;
   5     that was a matter for the Royal College, was it not?
   6   A. If he left the report with me, the report was the report
   7     of the College. If he insisted on withdrawing it, yes,
   8     that is his prerogative but he did not insist on
   9     withdrawing it, he allowed it to go forward and asked me
  10     simply to express his reservations about Bristol.
  11   Q. He was indicating to you, was he not, that he thought
  12     Bristol should be de-designated?
  13   A. Yes, obviously -- when I say "obviously" no, I do not
  14     know. He was saying "I have reservations about Bristol"
  15     but he did not clarify that and he could have done. If
  16     I had been in his shoes having just received a letter
  17     from Zorab warning him that things were not well in
  18     Bristol, I think I would have offered an explanation to
  19     myself rather than me having to extract it from him.
  20   Q. What he, as he recollected, was asking was the
  21     withdrawal and amendment of the report that you had had.
  22   A. Yes.
  23   Q. The amendment from what he was saying presumably would
  24     relate to Bristol, would it?
  25   A. I imagine so, yes.

   1   Q. It would not, from anything which you knew, would it,
   2     have related to throughput because that was well-known?
   3   A. I had no evidence to believe that it was anything other
   4     than throughput because, as Sir Terence himself said,
   5     they had collected all the data and they had analysed
   6     it. Not only did they have the data from their own
   7     Registry, they had all the data I had. I went to
   8     meetings of that working group and provided them with
   9     everything they asked for. So they had all the data
  10     they could possibly have to make their decisions. They
  11     had made their decisions. I had no reason whatsoever to
  12     question other than the throughput of Bristol.
  13   Q. The suggestion as to withdrawal was, as I understand the
  14     way you recollect it, withdrawal with a view to
  15     amendment and resubmission?
  16   A. Yes.
  17   Q. So it was not withdrawal of the report, it was amending
  18     the report really rather than withdrawal?
  19   A. Yes, but what was to be achieved? Since 1987 the
  20     profession had been on warning that they were not
  21     meeting the supra-regional service criteria and we would
  22     have to de-designate. The profession argued they would
  23     be able to rationalise the service. So we gave them the
  24     benefit of the doubt and we asked them to do reports.
  25     They did reports and they did reports and each time they

   1     failed to bring about the rationalisation we had hoped
   2     for. We had reached the stage where the Advisory Group
   3     had decided there was no way back, this was the crunch
   4     time.
   5        The fact that he was going to take back his report
   6     and amend it really had no great significance for the
   7     outcome of the Advisory Group meeting because all the
   8     criteria that had to be met were not being met.
   9   Q. It might have had, might it not, was not the view
  10     expressed at the February meeting that what the Advisory
  11     Group were looking for were no more than 8 centres doing
  12     the work and designated as such.
  13        The report endorsed by the Royal College of
  14     Surgeons was suggesting, as I understand it 9, one of
  15     them being Bristol. The reduction in numbers might have
  16     made a difference, might it not?
  17   A. No, no, no, you have all the evidence here already to
  18     show that since, indeed, almost since the day of
  19     designation, there were more units carrying out neonatal
  20     and infant cardiac work than was allowed by the
  21     criteria. Despite the warnings that the profession were
  22     given that they had to rationalise the service, there
  23     was no evidence whatsoever that that rationalisation was
  24     taking place. In fact three non-designated units had
  25     secured funding from various sources such that they

   1     could continue their activities. So we had no support
   2     from management in the field to help us to bring about
   3     that rationalisation.
   4        Faced with that, there was no option but to
   5     de-designate this service.
   6   Q. You say you draw comfort from the letter of 3rd August
   7     from Mr Hamilton to Sir Terence. Let us have a look at
   8     that, please, RCSE 2/210.
   9   A. I did not actually say I draw comfort --
  10   Q. It supported your view you said, I think?
  11   A. Tell me what I said.
  12   Q. We will look it up in the transcript. While that is
  13     being looked up, let me read you through this letter so
  14     that you follow it. It is 3rd August 1992:
  15        "Dear Terence,
  16        "I hope that you had a highly successful trip to
  17     and safe journey back from Pakistan, and are refreshed
  18     after a demanding but successful term as President.
  19        "Following our telephone conversations of Thursday
  20     evening, July 23rd, and Friday afternoon, 24th, I was
  21     not entirely happy about our agreement to take
  22     Presidential and Chairman's action over the Working
  23     Party's report. On reflection, I realised a possible
  24     specific source of breach of confidentiality which could
  25     arise and a further feeling that the de-designation of

   1     one of the units would probably leak out in the course
   2     of time. Also, the members of the Working Party were
   3     unanimous in their findings and gave considerable
   4     thought to their recommendations. Like you, I was
   5     unable to contact Keith Ross, but did so early on Monday
   6     morning, the 27th, after he had returned home from
   7     holiday. He was equally concerned that we had changed
   8     the report and suggested on reflection that we should
   9     both speak with Norman Halliday to reverse the decision
  10     and the instruction that you had given him.
  11        "The report is an advisory document to be
  12     considered along with other letters and reports, both in
  13     [I cannot read the next word] and hearsay evidence, no
  14     doubt, and as such the Working Party could be requested
  15     by the Advisory Committee on supra-regional funding to
  16     reconsider the mortality figures of specific units or
  17     unit, and possibly to amend its findings."
  18        It is that part that I wanted to ask you to focus
  19     on.
  20   A. Which part? It is a big paragraph.
  21   Q. The second last line of that paragraph:
  22        "... to reconsider the mortality figures of
  23     specific units or unit and possibly to amend its
  24     findings".
  25        That letter would suggest, would it not, that

   1     although you were not party to the discussions, the
   2     discussions between Mr Hamilton and Sir Terence had
   3     involved the issue of mortality findings?
   4   A. It would.
   5   Q. That would be entirely consistent with Sir Terence
   6     having got the letter from Dr Zorab which was concerned
   7     with mortality rates and having raised his concerns with
   8     Mr Hamilton on that basis, would it not?
   9   A. It would. Before we leave that, I trust you are not
  10     assuming that I saw this letter in 1992?
  11   Q. No --
  12   A. Because I never saw this letter until the Inquiry,
  13     I obtained it through the Inquiry, 1999.
  14   Q. What you said to us, the reference is page 152, line 22,
  15     you said to me "... but you also have a letter dated
  16     3rd August from David Hamilton in which he explained
  17     that he and Keith had considered the suggestion by
  18     Sir Terence that he would take Presidential and
  19     Chairman's action and withdraw the report. All the
  20     evidence you had is consistent, I would suggest with my
  21     interpretation of what Sir Terence had told you."
  22   A. That is what I said, yes.
  23   Q. What I am pointing out to you --
  24   A. Can I clarify that. I mean if I had not seen the
  25     3rd August letter in 1999 I would not have been able to

   1     refute what Sir Terence had said in this letter. I am
   2     suggesting that although Sir Terence states in his
   3     letter of 2nd December "there was never any suggestion
   4     made by me that the report of the working party should
   5     be withdrawn", there is not any ambiguity here at all
   6     because the discussion that he had with David Hamilton
   7     and Keith Ross was that the report should be withdrawn
   8     and amended.
   9   Q. I think the conflict may be, may it not, between you and
  10     he as to whether the report was to be withdrawn fully as
  11     opposed to withdrawn for amendment, amended and
  12     resubmitted, in other words amended in effect. The
  13     difference may be, may it not, between "withdrawal" and
  14     "amendment"?
  15   A. No, no, Sir Terence as a member of the Advisory Group
  16     and an individual intimately involved in this speciality
  17     was well aware the Advisory Group had given the cardiac
  18     surgeons as much leeway as they possibly could to bring
  19     their house in order so that it could continue to be
  20     designated. Sir Terence knew that the crunch time was
  21     1992 and to suggest that he wanted his report back again
  22     to amend and then resubmit, there was not time to do
  23     that.
  24   Q. I would invite you to look at another letter which
  25     Sir Terence considers supports his recollection. It is

   1     RCSE 2/195. This is Sir Terence responding to Dr Zorab,
   2     dated 27th July, dictated on 25th. It is the second
   3     paragraph. He is saying he is going away on holiday:
   4        "I will make a full response when I return from
   5     holiday in mid-August. Suffice it to say at this stage
   6     Bristol is not included in the paediatric cardiac
   7     surgical units recommended by the Royal College of
   8     Surgeons for continued designation for supra-regional
   9     funding. The Working Party report will be considered on
  10     28th July."
  11        What he appears to think is that it is an
  12     amendment of the recommendation rather than a withdrawal
  13     of the report.
  14        Can I take you back further to RSCE 2/193. Again,
  15     it is a letter you would not have seen at the time.
  16     There is no date on this copy, but I think you can work
  17     out what date it is. It is to Professor Browse, the new
  18     President of the Royal College of Surgeons. He thanks
  19     him for the letter dated 21st July with a copy of John
  20     Zorab's letter of the 15th. He says he had not
  21     appreciated the situation was as serious as that
  22     described by John Zorab.
  23        In the third paragraph he states that he discussed
  24     the matter with Professor David Hamilton from Edinburgh,
  25     who was Chairman of the recent Royal College of Surgeons

   1     report to the Supra-regional Services Advisory Group on
   2     the future policy with regard to designation.
   3        "In this report, which is to be considered [so it
   4     is obviously prior to the meeting] by the Supra-regional
   5     Services Advisory Group on 28th July, Bristol was
   6     included as one of the centres for designation.
   7     However, it is clear from a review of table 1 in the
   8     report, that their mortality statistics, both for the
   9     infant age group and the older age group, is worse than
  10     any other centre. David Hamilton agrees that sufficient
  11     attention was not paid to this by his Working Party.
  12        "We agreed, therefore, that to allow Bristol to go
  13     forward with support from the College might jeopardise
  14     designation of the whole service and, with David's
  15     agreement, I have spoken to Norman Halliday who will
  16     inform the supra-regional services group on Tuesday,
  17     28th that the College does not support the inclusion of
  18     Bristol; I am sure this is the right action."
  19        That is what he is saying shortly after speaking
  20     to you and before the meeting?
  21   A. We do not know that, you do not know the date of the
  22     letter.
  23   Q. We do. We are told by him that he dictated the letter
  24     to Zorab which we just looked at which is dated the
  25     27th, on the next day. So he wrote this letter, he

   1     says, on the 26th and we know it is before the 28th
   2     because --
   3   A. He was not in the country on the 26th.
   4   Q. Dictated on the 25th, I am sorry. The letter, if you
   5     look at the dating in it -- I am sorry, Dr Halliday, it
   6     is plainly after the 21st July if you look at the first
   7     line: "Thank you for your letter dated 21st July" and it
   8     was plainly before 28th July because he talks about the
   9     report which is to be considered; it is between the
  10     21st and the 28th. He says he has spoken to you, so it
  11     is obviously after the telephone call that he has had
  12     with you?
  13   A. Right.
  14   Q. So between the telephone call he has had with you and
  15     the meeting?
  16   A. Yes, if this is correct, yes.
  17   Q. And it is contemporaneous, or purports to be.
  18        What appears to have been in Sir Terence's mind
  19     when he wrote to Professor Browse as having been the
  20     content of your conversation, was that he had agreed
  21     with you that you would have told the Supra-regional
  22     Services Advisory group that he would not support the
  23     College, would not support the inclusion of Bristol as
  24     a designated centre.
  25        Is that as you recollect it the effect of the

   1     conversation that you had with him?
   2   A. I mean what he said to me, as I have said before,
   3     is: "If the report cannot be withdrawn, I wish my
   4     reservations about Bristol to be communicated to the
   5     Advisory Group, full stop." The implications of that is
   6     that Bristol would probably be de-designated.
   7        But I am not sure why we are sweating over
   8     Bristol. It did not matter at all to the outcome of the
   9     decision of the Advisory Group whether the College had
  10     recommended de-designation of Bristol or designation of
  11     Bristol because the problem we had was that there were
  12     already 13 units in England, there was one about to
  13     start in Wales and there were two in Scotland carrying
  14     out this work; the criteria of the Supra-regional
  15     Advisory Group was therefore not being met.
  16        Whether Bristol was a factor in this discussion or
  17     not was really quite irrelevant. Taking Bristol out, we
  18     still had 12 units in England, which was too many for
  19     a designated supra-regional service. You have to take
  20     in mind that this was a funding arrangement and only
  21     a funding arrangement, and we had to justify each year
  22     an expenditure in excess of œ100 million each year.
  23        The Treasury were not at all happy that we did not
  24     allocate this in the normal way to the health
  25     authorities. So we had to ensure that any services

   1     designated met the criteria, and it was repeatedly
   2     pointed out to us by our colleagues in various parts of
   3     Government that NICS was not meeting the criteria. We
   4     had given them as much rope as we could in order to
   5     allow them the opportunity of putting pressure on their
   6     peers to bring about a rationalisation of the service.
   7     Since management were not even assisting in this matter,
   8     given they were funding non-designated units, there was
   9     no way we could justify such central expenditure.
  10   Q. The reason, Dr Halliday, we are "sweating over Bristol",
  11     as you put it, is this: it is suggested that you knew,
  12     because you were told by Sir Terence English, that the
  13     Bristol results were so bad that Bristol should be
  14     de-designated. The suggestion then is, had you known
  15     that, because the service continued to be designated
  16     until it became de-designated two years later --
  17   A. No, it was de-designated in 1992. It was funded for two
  18     years after that, but that was not a matter for the
  19     Advisory Group.
  20   Q. It remained, did it not, the responsibility of the
  21     Advisory Group?
  22   A. No, it did not, no.
  23   Q. The suggestion is that you in the Department of Health
  24     were told of the poor mortality results in Bristol and
  25     the suggestion continues that in default of your

   1     responsibilities you did nothing about it; that is the
   2     suggestion?
   3   A. That is the allegation, yes.
   4   Q. It turns obviously upon the extent of your
   5     responsibilities and it turns upon the extent of the
   6     telephone conversation, that is why I am pushing you
   7     about it?
   8   A. Yes.
   9   Q. If we go to the handwritten notes which Sir Terence made
  10     at the time, at WIT 71/47, he records here
  11     a conversation with Professor David Hamilton:
  12        "Heard figures were pretty bad down there.
  13     Present review last three years. Had to chase Bristol
  14     for them."
  15        Then there is something about Dhasmana. Scroll
  16     down the page.
  17   A. Do we know when that was written?
  18   Q. He tells us contemporaneously with his telephone call
  19     with David Hamilton. "Need to telephone Norman
  20     Halliday"; I do not think what follows is the telephone
  21     call which is material, but these are notes: "known for
  22     a long time some centres not good, Newcastle, Leeds had
  23     improved, Bristol had failed to develop paediatric
  24     services, [that is underlined]. JW [I think
  25     James Wisheart] sent full report for 4 years" and then

   1     we see set out a number of results for simple
   2     intermediate and complex cases.
   3        If we go to 71/49: "Discussion with
   4     Norman Halliday", 25/8/92. Let me come back to 71/47,
   5     I beg your pardon. I think this is his note of his
   6     conversation with you, at least some notes that he made
   7     at the time. If you have a look at that, does any of
   8     that ring a bell with you?
   9   A. No, not at all. For Terence English to discuss
  10     mortality figures with me would have been quite an
  11     unusual event and, as you are aware from the evidence
  12     from Keith Ross, when I spoke to Keith immediately after
  13     -- as soon as I could get him, which was I think the
  14     Monday, he has confirmed that we did not discuss
  15     mortality.
  16   Q. No, he has not.
  17   A. Sorry?
  18   Q. He has not, with respect. What he has said is he cannot
  19     say that he did; there may be a difference between the
  20     two. You are quite right, there is no evidence against
  21     you --
  22   A. I would suggest that someone as eminent in the field of
  23     cardiac surgery as Sir Keith Ross would not have
  24     forgotten that the President of the Royal College of
  25     Surgeons had called him and said the mortality in any

   1     unit is so bad that we should de-designate it; that is
   2     not something a clinician forgets.
   3   Q. Let us have a look and see what in fact he says. It is
   4     WIT 31/6. The foot of the page --
   5   A. What am I reading?
   6   Q. You are reading Sir Keith Ross's witness statement to
   7     us:
   8        "It is safe to say that when David Hamilton
   9     telephoned me at home on 27th July 1992, when I had just
  10     returned from Scotland, I had no idea of the events
  11     leading up to the telephone call. I am sure
  12     David Hamilton did his best to explain the sequence of
  13     events, but under the circumstances (and I have no clear
  14     memory of the conversation), I must have agreed with his
  15     concern regarding the working group's conclusions being
  16     altered. Whether he or I suggested telephoning
  17     Dr Halliday is immaterial but he had to be given our
  18     views. There was no way I could have talked to
  19     Terence English who was either in or on his way to
  20     Pakistan, nor was there time to reconvene the working
  21     party before the SRSAG meeting, which was due the next
  22     day or the day after."
  23        He then goes on, page 8:
  24        "Finally, I have no recollection of suggesting to
  25     Dr Halliday that the working party could be requested to

   1     reconsider the mortality figures of specific units with
   2     a view to possibly amending its findings. I would like
   3     to think that I would have recommended this, but as
   4     explained above, this never happened."
   5   A. That was my understanding.
   6   Q. What he appears to be saying is he has no recollection
   7     of suggesting that the working party could be requested
   8     to reconsider the mortality figures. He does not say
   9     whether he did or whether he did not talk to you about
  10     mortality figures; that is why I put to you what I did
  11     and what he says has to stand and speak for itself, has
  12     it not?
  13   A. It does.
  14   Q. So that I am not in error and misleading you at all, can
  15     we go back to WIT 71/47 where it said: "need to
  16     telephone Norman Halliday" and then there are some
  17     notes.
  18        Do you remember I had some doubt as to whether
  19     this was or was not a note of a telephone call. It has
  20     been checked and we think Sir Terence in fact said that
  21     he did normally take notes of telephone conversations,
  22     but in fact he had not taken one of the conversation
  23     with you, or at least he did not have it. It is not
  24     a note of a conversation with you.
  25   A. I am quite sure it is not a note of a conversation with

   1     me.
   2   Q. Our recollection is that he said it was a note from his
   3     conversation with Mr Hamilton?
   4   A. David Hamilton.
   5   Q. My apologies if that was inaccurate and misleading.
   6        After considering what Sir Terence has told us,
   7     what he wrote to others at the time and your own
   8     recollection of events, do you then still maintain that
   9     he said nothing to you as to the reason for his
  10     suggesting the de-designation of Bristol or having
  11     reservations about Bristol as being that he was
  12     concerned about the rate of mortality in the unit?
  13   A. Such a question actually raises my blood pressure, but
  14     I was so concerned that Sir Terence English should take
  15     such an approach of unilaterally suggesting he was going
  16     to withdraw the report, for whatever reason.
  17        I have already put this in my statement: when
  18     a new President takes over in any of the colleges, they
  19     immediately become the members of the Supra-regional
  20     Service Advisory Group which meant that in effect
  21     Sir Terence was no longer a member of the Advisory Group
  22     come that July meeting.
  23        So as soon as I had heard from Sir Terence about
  24     his concerns -- and they did ring bells for me, but not
  25     for the reasons that have been suggested -- I went to

   1     see Norman Browse, the new President, and I explained to
   2     him the machinery of the Advisory Group and then I said
   3     to him "given that Sir Terence is concerned, would you
   4     be agreeable for Sir Terence to accompany you or indeed
   5     to attend the September meeting so that he could voice
   6     any concerns he had?"
   7        Norman Browse said yes, he was only too happy to
   8     allow Sir Terence to attend. So Sir Terence was allowed
   9     to attend the September meeting. At the September
  10     meeting he raised no reservations whatsoever about
  11     Bristol. He raised reservations about the fact that we
  12     were de-designating the whole service and therefore
  13     depriving those designated units of central funding. He
  14     was slightly reassured when he was told that the funding
  15     would continue outside of the supra-regional service
  16     arrangements for at least another year; in fact it
  17     continued for two years.
  18        But it is certainly not true that he suggested
  19     that funding should continue, because the problem that
  20     the Advisory Group faced on that occasion was that we
  21     were now in a pre-reformed NHS and the previous
  22     arrangements that we had for ensuring that service did
  23     not suffer when they were de-designated, which was to
  24     continue the funding centrally as a non-designated
  25     service for another year; there were no such

   1     arrangements available to us in the new reformed NHS.
   2        But Chris Spry, who was the Regional General
   3     Manager, member of the Advisory Group, said he would
   4     liaise with his Regional General Management colleagues
   5     and would bring up some scheme which would ensure that
   6     for a period, and we thought it was a year but in the
   7     end it was for two years, their funding would be
   8     protected.
   9        We, the Department, had no idea how we were going
  10     to fund them for those two years and there was certainly
  11     no way Sir Terence, as is alleged here, could have
  12     recommended what that funding arrangement was. No-one
  13     in the Advisory Group knew how we would do it. It was
  14     only subsequently when Chris Spry spoke to his Regional
  15     General Management colleagues that he came up with an
  16     arrangement that worked.
  17   Q. You told us last time you came to give evidence how you
  18     found it useful to pick up information very often from
  19     chatting to clinicians at conferences and so on and how
  20     in many ways those conversations gave you a lot of
  21     information and insight, words to that effect?
  22   A. Yes.
  23   Q. You met Sir Terence at the meeting which was called in
  24     September?
  25   A. Yes.

   1   Q. No doubt you have met him on occasions since?
   2   A. Yes.
   3   Q. Did you ever say to him "Sir Terence, those reservations
   4     that you mentioned about Bristol and never explained to
   5     me in the telephone call in July, that remarkable
   6     telephone call, what actually were they?"
   7   A. No, I did not, no.
   8   Q. Why not?
   9   A. Because there were no -- I mean when I spoke to Keith
  10     Ross and David Hamilton, they were as concerned as I was
  11     that Sir Terence was suggesting the withdrawal of the
  12     report. Now I did not know what the reasons were, and
  13     that was not my concern, the concern for standards of
  14     services rests with the management -- managers in the
  15     service. Before the reforms that was by statute, the
  16     health authorities. Post the reforms the responsibility
  17     rested with the Trusts who were directly responsible to
  18     the Secretary of State.
  19        It was not a matter for the Advisory Group. If
  20     somebody presented us with evidence which suggested
  21     there were real problems, then we would pursue these.
  22     But I had more than enough to do than to be asking
  23     Sir Terence to explain his very unusual behaviour.
  24   Q. There is one completely separate matter I want to ask
  25     you about before I finish. It is this: when Dr Baker,

   1     who was the consultant in public health for the Avon
   2     Health Authority gave evidence to us, he was asked:
   3        "Did you have any responsibility to check that
   4     the service for either the under or the over 1s was
   5     producing an acceptable outcome?"
   6        He said: "Yes, certainly in terms of children
   7     over 1, they were part obviously of our overall planned
   8     or later commissioned services [I think he was talking
   9     there for the Region]. Within the breadth of our
  10     responsibilities for understanding whether we were
  11     getting the services we wanted to, that would have been
  12     generally the case.
  13        Question: In relation to the under 1s?
  14        Answer: Not in relation to the under 1s, my
  15     understanding always was that the supra-regional service
  16     was supervised through their own arrangements."
  17        This is Dr Baker of Region here thinking that the
  18     under 1s were supervised through arrangements which the
  19     Supra-regional Services Advisory Group made; do you have
  20     any comments on that?
  21   A. First of all I would ask when did Dr Baker take up his
  22     post? I have no recollection of ever meeting --
  23   Q. We can find out.
  24   A. The point I am making is, I do not believe Dr Baker was
  25     in post in the period we are considering, so he is

   1     giving you his view about what he thought was happening;
   2     that is the first point.
   3   PROFESSOR JARMAN: I thought he was in post.
   4   A. I have never met him. I think it would be worth
   5     checking.
   6        But before the reforms there is no ambiguity about
   7     the arrangements because it is laid down in the NHS Act
   8     that the Health Authorities are responsible for the
   9     provision of the services and for maintaining
  10     standards. The Advisory Group was exactly that, it was
  11     an Advisory Group to the Secretary of State and any
  12     recommendations that were being made in terms of the
  13     funding arrangements had to be cleared by the Regional
  14     Chairman before the advice was given to the Secretary of
  15     State because it was the Regional Chairman and the
  16     District Chairman who were responsible for providing the
  17     services.
  18        So up until the reforms there was no doubt
  19     whatsoever who, or there should have been no doubt
  20     whatsoever who was responsible for monitoring the
  21     standards of the service.
  22        Post the reforms I accept there may well have been
  23     some ambiguity because the nature of the Advisory Group
  24     might well have been changed to fit with the new
  25     arrangements but it was not changed, it was a policy

   1     group involving members who were not part of the NHS to
   2     advise the Secretary of State.
   3   MR LANGSTAFF: Thank you. We will tell you in a moment when
   4     Mr Maclean has brought it up on his screen the time that
   5     Dr Baker -- he says from July 1984 until October 1991 he
   6     was District Medical Officer of the Bristol and Weston
   7     Health Authority.
   8   A. District Medical Officer, yes, not Region.
   9   Q. No --
  10   A. During the period in question one of my, who had been
  11     a member of my staff was the Regional Medical Officer in
  12     Wessex.
  13   Q. In October 1991 he was reappointed as a consultant to
  14     public health medicine.
  15   A. Where?
  16   Q. That was for the two health authorities, Bristol and
  17     Weston Health Authority merged with the health
  18     authorities of Frenchay and Southmead to form the
  19     Bristol and District Health Authority.
  20   A. It is still not at Region. So he was not at Region so
  21     he could not speak from an informed view on what was
  22     happening with the supra-regional services.
  23   Q. I suppose I ought to have asked you this last question:
  24     let us suppose contrary to your evidence that
  25     Sir Terence had indeed expressed new concerns in respect

   1     of the mortality at Bristol, you would, would you, have
   2     mentioned that to Sir Michael Carlisle?
   3   A. Of course.
   4   MR LANGSTAFF: I have nothing further to ask you,
   5     Dr Halliday, save this: have you anything further you
   6     would wish to add at this stage? Remember you are free
   7     to supplement anything you have said today in writing to
   8     us and to amplify anything you have said in writing,
   9     indeed, to comment on anything that others may yet say
  10     to us. Please, take advantage of that. We are still
  11     receiving such evidence.
  12        For the moment, if there is anything you would
  13     wish to add to amplify your evidence, to explain what
  14     you think may have been left unclear or deal with
  15     anything which has not yet been brought up, this is your
  16     chance to do so.
  17   A. First of all I would like to apologise because receiving
  18     this letter of 2nd December has really thrown me this
  19     afternoon --
  20   THE CHAIRMAN: No apology is required.
  21   A. Really some of the statements in that letter are,
  22     I find, quite astonishing and had I had a few days to
  23     ruminate on it I would have come back in a better frame
  24     of mind to answer your questions, I do apologise.
  25   THE CHAIRMAN: I repeat, no apology is required.

   1        We have no questions from the Panel. Mr Pirani?
   2   MR PIRANI: I have no questions, thank you.
   3   THE CHAIRMAN: I am grateful to you. I repeat what
   4     Mr Langstaff has said: if there are matters that you
   5     would wish to remind us of having had further
   6     opportunity to reflect, we are here to receive them and,
   7     as you said at the outset, you might like to have an
   8     opportunity to reflect further on a letter that you have
   9     only recently read. Do feel free to do so. The fact
  10     that oral hearings end on 16th December in no way means
  11     we will not be receiving evidence for some time
  12     hereafter.
  13   A. Professor Kennedy, could I ask, is David Hamilton giving
  14     evidence?
  15   THE CHAIRMAN: We have a statement from Professor Hamilton
  16     and under our procedure which proceeds as much by
  17     written evidence as by oral evidence, therefore, we have
  18     evidence from Professor Hamilton.
  19   A. I have every confidence his statement to you will have
  20     supported what I have said this afternoon, without
  21     having seen it.
  22   THE CHAIRMAN: I am grateful to you. Thank you very much
  23     for coming and spending an afternoon with us. We are
  24     most grateful to you.
  25   A. Thank you.

   1   THE CHAIRMAN: You may want to step down, if you will, and
   2     Mr Langstaff will tell me about tomorrow.
   3   MR LANGSTAFF: Sir, tomorrow and indeed Thursday we shall
   4     hear from Dr Joffe. Dr Joffe will be the last of the
   5     cardiologists who we anticipate will give evidence
   6     before us.
   7   THE CHAIRMAN: Thank you, Mr Langstaff.
   8   MR LANGSTAFF: 9.30.
   9   THE CHAIRMAN: I was about to say, we adjourn now and
  10     reconvene at 9.30, so I say good afternoon to everyone.
  11   (4.30 pm)
  12     (Adjourned until Wednesday, 8th December 1999 at
  13     9.30 am)
  14
  15
  16                I N D E X
  17
  18     DR JOHN ROYLANCE (recalled):
  19        Examined by MR LANGSTAFF (continued) ......... 1
  20        Re-examined by MR FRANCIS .................... 106
  21
  22     DR NORMAN HALLIDAY (sworn):
  23        Examined by MR LANGSTAFF ..................... 114
  24
  25

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Published by the Bristol Royal Infirmary Inquiry, July 2001
© Crown Copyright 2001