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Daily transcripts
Hearing summary
9th 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, the Inquiry heard from Dr Hyam Joffe, Paediatric Cardiologist,
Bristol Children’s Hospital, United Bristol Healthcare NHS Trust (UBHT). This
morning’s evidence focussed on discussion about the subject of communications between
clinicians from different specialties and with parents. Dr Joffe then talked about
informing parents of risks associated with various surgical procedures, especially in
relation to the introduction of the arterial switch operation. During the afternoon Dr
Joffe discussed several individual cases included within the Inquiry’s Clinical Case
Note Review. He continued his evidence by telling the Inquiry about the awareness within
the BRI and BCH during 1994 and 1995 of the concerns being raised by Dr Stephen Bolsin,
Consultant Anaesthetist and Professor Gianni Angelini, Professor of Cardiac Surgery and
commenting on professional relationships between clinicians. Dr Joffe ended the
week’s hearings by commenting on the discussions surrounding the decision to proceed
with the arterial switch operation on Joshua Loveday in January 1995.
|
FULL TRANSCRIPT
1 Day 91, Thursday, 9th December 1999
2 (9.40 am)
3 THE CHAIRMAN: Good morning, everyone. Good morning,
4 Mr Langstaff.
5 MR LANGSTAFF: Good morning, sir.
6 MR LANGSTAFF: RE INVESTIGATIONS
7 INTO LEGAL POSITION ON
8 TISSUE AND ORGAN RETENTION:
9 MR LANGSTAFF: Sir, may I begin by dealing with an issue
10 which has come to national interest and importance
11 during the course of the last week or so, if not over
12 a longer period where there has been considerable
13 material in the national press dealing with the concerns
14 that parents and others have expressed as to the
15 retention of tissue and organs by hospitals following
16 surgery.
17 Anyone who has been following the work of this
18 Inquiry closely will be aware that we are some way down
19 the road in taking evidence and considering the issues
20 thrown up by the Bristol situation which, although
21 Bristol is the focus of our attentions, inevitably must
22 have a wider national reflection and has to be set of
23 course in the national context, at least in the years
24 1984 to 1995 with which we are concerned and it appears
25 from press comment, many of those elsewhere in the
0001
1 country are also concerned.
2 One of the issues which needed to be explored were
3 the views that were current in 1984 to 1995 as to the
4 legality of the practices that may or may not have been
5 adopted in Bristol. In order to explore that background
6 the Inquiry commissioned an expert opinion from the
7 solicitors firm CMS Cameron McKenna. Members of that
8 firm have a detailed knowledge of this area of the law.
9 The firm was asked to address the subject, amongst
10 others, of the legality of tissue or organ retention
11 following postmortem examination.
12 In addition, the Inquiry has received submissions
13 on the same aspects of the law from the Bristol
14 Children's Heart Action Group. These two submissions
15 are published by the Inquiry today. For those of you
16 who access the web site, the Cameron McKenna report,
17 INQ 23, is to be found under the "Background papers"
18 button and the Bristol Children's Heart Action Group's
19 submission, SUB 1, is at a new button on the web site
20 called "Submissions". Part 1 submissions received will
21 be posted there.
22 It would perhaps be helpful if I mention the main
23 features of each of those papers, but can I begin by
24 emphasising that although one is a commissioned paper
25 and the other is a submission, neither should be taken
0002
1 as the view of the Panel or the Inquiry, least of all of
2 Inquiry counsel as to the actual state of the law,
3 whatever it may be.
4 Dealing firstly with what the Cameron McKenna
5 paper considers: it reviews the traditional legal
6 position relating to dead bodies. The law has
7 traditionally been that there is no property in a dead
8 body. Relatives and others lawfully in possession of
9 the body have limited rights over it in order to dispose
10 of it by burial or otherwise. That rule has been
11 criticised in recent times, but, say Cameron McKenna,
12 and I quote, "there seems little doubt that it remains
13 an established part of English law".
14 Against that background are set the rules on
15 postmortems and inquests. So far as inquests are
16 concerned, they allow a Coroner to authorise
17 a postmortem without the consent of parents. The
18 retention of tissue may be permitted as part of that
19 Coroner's postmortem in order to ascertain the cause of
20 death.
21 The paper then considers the legal power to keep
22 tissue after a Coroner's postmortem has concluded and
23 states that by this stage the hospital or pathologist
24 who hold the tissue will be the person lawfully in
25 possession. Cameron McKenna do not consider there is
0003
1 any obligation to seek further permission or
2 authorisation for continued retention of the tissue.
3 However, their paper adds "The legal position is
4 unclear and outdated in many ways and it may well be
5 that the current position [as they see it] would be
6 found to be in breach of the human rights of the
7 relatives when the Human Rights Act comes into force."
8 The main features of the Bristol Children Heart
9 Action Group submissions are these, and it needs to be
10 said that those submissions are also carefully
11 researched and argued: the group's lawyers put forward
12 a different answer to the problem, they argue that once
13 the Coroner's postmortem has finished, he has a legal
14 obligation to return any body parts to the relatives or
15 executives or administrators if they claim possession in
16 order to bury or otherwise dispose of the body. Whether
17 there is a hospital postmortem or a Coroner's
18 postmortem, it is up to the relatives or executors or
19 administrators to decide what should be done with any
20 body parts.
21 A central difference, therefore, between the two
22 views that have been expressed in these papers is the
23 question of whether the pathologist in whose hands the
24 actual tissue is at the conclusion of a Coroner's
25 postmortem has any right in any capacity to retain the
0004
1 tissue. It may be instructive to the Panel to know that
2 on so central a point two carefully researched,
3 respectable and closely argued opinions can come to such
4 diametrically opposed conclusions. At the very least
5 this may argue the necessity for a clarification of the
6 law.
7 I cannot finish this announcement without
8 a warning, and it needs to be said that this very brief
9 summary does not do justice to the work that has gone
10 into each of the papers to which I have referred. I am
11 quite sure the people will want to read them for
12 themselves, and certainly they should not take my
13 inadequate summary as a full statement of that which
14 they contain, but it needs to be understood by all
15 readers, all those who are interested in the Inquiry,
16 that neither paper, whether from Cameron McKenna or from
17 the Heart Action Group represents the views of the
18 Inquiry panel or those of counsel to the Inquiry upon
19 this legal issue. The Inquiry has received in evidence
20 the contemporaneous views upon the legality of practices
21 on tissue retention held by clinicians at the UBHT at
22 the time.
23 It has heard evidence from interested national
24 parties such as the Royal College of Pathologists upon
25 the topic and upon the changes in practice which they
0005
1 now recommend.
2 To those views which are not those of lawyers have
3 been added the opinions expressed in the legal
4 submission presented on behalf of the Heart Action Group
5 and the advice of Cameron McKenna. The Inquiry Panel
6 will wish to consider both of these expressions of
7 opinion as such as well as any further views that may be
8 expressed by any other participant in the Inquiry in
9 their closing submissions to the Inquiry.
10 If the Panel should request advice from Inquiry
11 counsel on this matter, any advice that we give will be
12 published so as to enable scrutiny by interested parties
13 and the Panel will of course then reflect on the views
14 expressed and form its own judgment, if it is necessary
15 to do so, upon the legality of the practices adopted.
16 The judgment may of course be that the Panel is not in
17 a position to resolve the difficult, complex and
18 conflicting issues of law, but in a position to
19 recognise that those differences, conflicts and views
20 exist (and existed) in 1984 to 1995 and recommend
21 appropriate action in recognition of the complexity, the
22 difficulty and the uncertainty that the law may
23 represent, if that is the view to which it comes.
24 As counsel to the Inquiry, it is proper for me to
25 advise you, the Panel, that one thing you may properly
0006
1 conclude from the two submissions is this: that at the
2 time with which you are concerned, 1984 to 1995, there
3 is considerable and reasonable scope for different
4 understandings of the law in this area.
5 Secondly, it was (and remains) a difficult and
6 complex area. It is perhaps this difficulty and
7 complexity which you may feel is one reason for the
8 grief and distress which has so obviously been caused to
9 so many and of which the Inquiry has heard eloquent
10 testimony from parents and, indeed, clinicians.
11 So I cannot finish without our usual plea and
12 encouragement to those who have views which may assist
13 in understanding what those involved in postmortems in
14 the 1980s and 1990s understood the law to be and on what
15 basis to tell us of those views, the submissions file is
16 open. We as an Inquiry are of course open to anyone who
17 wishes, in respectable form, to advise us on, we would
18 hope, a well argued and researched basis of their view
19 of the law if they think that would assist your
20 deliberations.
21 THE CHAIRMAN: Mr Langstaff, thank you very much indeed for
22 that, that was a very helpful resume of where we are at
23 the present moment and I am very grateful.
24 I would like also to express the Panel's thanks to
25 both the experts and to the legal team of the Bristol
0007
1 Children Heart Action Group for their different
2 submissions.
3 Speaking as someone who used to have a passing
4 familiarity with the area, I am impressed by the quality
5 of the research into this difficult area. Of course we
6 are not in this area talking only about law, but you are
7 right to remind us that the law sets the framework in
8 which all have worked and will work in the future.
9 There is no doubt that the law during the time of
10 our terms of reference and still, is both complex and,
11 if I may say so, obscure. I therefore am sure that the
12 Panel will press for clarification of the law and,
13 indeed, will probably make some suggestions of its own.
14 I am also sure that the Panel will seek to give guidance
15 on what is ethically appropriate in such circumstances
16 because we are not, I remind us again, talking only of
17 the law. Indeed, what is ethically proper should as it
18 were come before what we decide the law to be because
19 the law must be guided by what we think is proper
20 behaviour.
21 Thank you again very much indeed.
22 DR HYAM JOFFE (RECALLED):
23 EXAMINED BY MR LANGSTAFF (CONTINUED):
24 MR LANGSTAFF: Dr Joffe, we have been joined this morning by
25 Dr Houston, he should be sworn before we begin.
0008
1 DR ALAN HOUSTON (SWORN):
2 THE CHAIRMAN: Good morning, Dr Houston.
3 MR LANGSTAFF: Dr Houston, thank you for coming back to join
4 us.
5 May I continue where we were yesterday? We were
6 talking at the end, just before the break, Dr Joffe, if
7 you remember, about the change in your practice, in the
8 light of the way in which you perceived others to be
9 doing it, as to telling parents about the nature of the
10 surgery that their child was to undergo.
11 A. Yes.
12 Q. I think the impression you were giving us, and please
13 tell me if this is right or wrong, was that from your
14 perspective you sought to reassure parents at a time
15 that was inevitably going to be distressing for them?
16 A. Yes, as far as one could.
17 Q. Indeed, you took the view in the early 1990s that it
18 would be distressing or difficult for parents to have to
19 make decisions with the fullest of information which is
20 why you as a clinician would, I think, indicate a course
21 of action and would not necessarily mention that this
22 was the first time that a particular operation had been
23 done in the hospital?
24 A. That is right, at that time, yes.
25 Q. At that time?
0009
1 A. Yes.
2 Q. Plainly your views have changed?
3 A. Yes.
4 Q. We heard earlier, if I can pick this up with you now,
5 from Mrs Pottage. Her son's case was a neonatal switch
6 operation. At the time that her son was operated upon
7 the unit had, in 1992, the sad experience of having had
8 five deaths in five operations, if you recall, it was at
9 the start of the neonatal switch series?
10 A. Yes.
11 Q. Then there was a pattern of the next two children
12 survived, the next one died, the next survived and the
13 next died. So in 1993 there had been five operations
14 and two had failed to save the child?
15 A. Yes.
16 Q. In deciding or advising what might happen to Thomas,
17 Mrs Pottage recalls the discussions that she and you had
18 because I think he was one of your cases; do you
19 remember the case at all?
20 A. I do, yes, but not any detail at all.
21 Q. She recollects the way you put it was you said to her
22 that it was for Mr Dhasmana to decide what operation he
23 should have, because you had I think outlined there were
24 two possibilities, the switch and it must have been the
25 Sennings?
0010
1 A. Yes.
2 Q. She does recollect that you said that the switch was
3 quite a new operation.
4 A. Yes.
5 Q. That the unit had been performing it for two or three
6 years but that you were very pleased with the success of
7 the operation.
8 A. Yes. I am not answering that in the affirmative, I am
9 just saying, yes, I acknowledge that, yes.
10 Q. That is her recollection of what you said; is it the
11 sort of thing you think you might have said at that
12 time?
13 A. It really is almost impossible for me to remember the
14 precise words I would have used with any of these
15 cases. With that qualification, however, I do not
16 believe I could possibly have said that I was "very
17 pleased" with the neonatal switch operations. If I used
18 words of that kind it may be that I was referring to the
19 non-neonatal switches, in which case I would have said
20 so. So I am afraid I must simply state that I do not
21 recall my having said this and I do not believe I would
22 have knowing that there were, as you put it, two
23 failures out of the five in that year.
24 Q. You do not think that there may be possibly
25 a reconciliation between Mrs Pottage's recollection of
0011
1 what was said and perhaps your view that you may have
2 been talking about switches generally?
3 A. There may be. I was trying to identify how I could have
4 used a phrase of that type.
5 Q. If you had been talking of switches generally, would you
6 do you think have said the unit was pleased with the
7 success of the operation?
8 A. No, if I used words of that sort at all it would have
9 been in relation to the non-neonatal switches only.
10 Q. It would be the case --
11 A. May I amplify?
12 Q. Yes, of course.
13 A. As I think Mr Dhasmana pointed out to you, during that
14 time, that is January 1992 when the neonatal switch
15 programme started and October 1993 when it ended, there
16 were, to be precise, 7 non-neonatal switches, all of
17 whom survived. So the only way I could have made that
18 sort of comment would have been in relation to those
19 cases. I really do not believe I would have said that
20 as far as neonatal switches are concerned I was pleased
21 with the success rate by any means.
22 Q. So far as the non-neonatal switches are concerned, then,
23 were you pleased with the success rate at that time?
24 A. Well, I was pleased at that time that the 7 previous
25 operations had been successful and overall, this was
0012
1 later of course, by early 1995, we had mortality rates
2 of around 20 per cent which was in line with other
3 centres in this country and abroad, as far as we knew.
4 Q. Would you have had in mind at all in talking to a parent
5 about the neonatal arterial switch what the success rate
6 had or had not been in the non-neonatal switch?
7 A. Yes, I may well have raised that.
8 Q. So you might have seen the neonatal and the non-neonatal
9 switch operations as switches as opposed to broken down
10 into the categories of non-neonatal and neonatal?
11 A. I think I just made the point that I would have had
12 a different perception for each category of switch
13 operation.
14 Q. That is why I am asking it.
15 A. Yes.
16 Q. You are confirming that you probably would have had
17 a different perception of each?
18 A. Yes.
19 Q. Would there have been any cause to talk to any parent
20 whose child was facing a neonatal switch, any cause to
21 talk to them about a non-neonatal switch series and how
22 the unit had succeeded in those?
23 A. Well, in general there may have been but I certainly
24 would not have dwelt on the non-neonatal switches, I was
25 using that to explain whether I possibly made this
0013
1 comment or not. I do not remember making it, but (as
2 indicated) I could only have made it in relation to
3 non-neonatal switches and maybe that is where the
4 confusion arises so I cannot answer any more than that.
5 Q. Slightly different, but along the same theme of what you
6 may have been saying to parents, taking it from the
7 general, where you accept that you were reassuring in
8 a way that you would not be today because of the need to
9 give parents the fullest of information. We heard as
10 well from Mrs Helen Johnson about operations on her
11 daughter Jessica. She had a coarctation of the aorta
12 and was operated upon by Mr Dhasmana. Indeed she is
13 alive to this day.
14 Her recollection is that having met you, you
15 explained what was wrong and she was shocked and
16 disturbed by that, as I imagine many parents are.
17 A. Invariably.
18 Q. And she describes how she told you that Mr Dhasmana
19 would be coming in to see Jessica and how she was
20 shocked and felt like hitting you because the news was
21 so awful?
22 A. Yes.
23 Q. She says that she can remember asking someone -- it may
24 have been you, it may not have been you -- when Jessica
25 would be going to Great Ormond Street because that is
0014
1 where she assumed she would have the operation, and the
2 reply was she would not have to go because Mr Dhasmana
3 was an excellent surgeon and he was in Bristol; do you
4 think you may have said that?
5 A. Yes, I have no reason to doubt that I would have said
6 that, if it was me.
7 Q. She recalls asking a cardiologist -- it was either
8 Dr Martin or you, because you are here I will ask you
9 about it -- if there was a risk of brain damage. You
10 had quoted a risk, or Mr Dhasmana had quoted at least
11 a 70 per cent chance of success in the operation in
12 terms of mortality --
13 A. Sorry, I am not sure if you are asking me now about
14 cerebral risk or mortality risk?
15 Q. You are quite right, it is not very clear. She recalls
16 asking you or Dr Martin if there was a risk of brain
17 damage, to which the answer that she had from yourself
18 or from Dr Martin was that it was "so rare that it never
19 happens"?
20 A. I would not have put it in those words, I would have
21 said "It is rare, but it does unfortunately occasionally
22 happen"; I would not have given a figure, indeed I do
23 not believe there is a known reported figure in the
24 literature for that, for the incidents of brain damage
25 following a cardiopulmonary bypass for congenital heart
0015
1 disease in children, but I would have (if pressed or
2 asked) said it is of the order of 1 per cent or
3 thereabouts, 1 to 2 per cent.
4 Q. Dr Houston, what do you see as the general practice in
5 the late 1980s, the early 1990s as to describing the
6 risk of neurological complications in operations such as
7 those to remedy coarctation?
8 DR HOUSTON: I think for all operations people would be told
9 there were risks. Of course death is the one that
10 parents are most worried about and then it would be
11 pointed out there is a possibility of damage to other
12 organs, particularly the brain or the kidneys.
13 I do not know that one would necessarily give
14 a percentage figure for it because, as Dr Joffe said, it
15 is difficult to know exactly, but you would point out
16 there is a risk of that.
17 Do you want me to be more specific about
18 instances?
19 MR LANGSTAFF: I think in general, unless there is anything
20 Dr Joffe wants to confirm with you in evidence.
21 In the evidence of Mrs Maria Shortis dealing with
22 the life of her daughter Jacinta, what she has told us
23 is the news that she got shortly after Jacinta's birth
24 of problems affecting her heart and how, when she came
25 in to the Children's Hospital --
0016
1 A. I beg your pardon, I have the note of the letter that
2 I asked you if I could read overnight, which is where
3 you ended the session last night, so I may need to ask
4 you to put up some of the notes on Maria if we need to.
5 Q. Certainly. What she has told us, again, this is
6 essentially dealing with communications with parents to
7 see if there are particular instances we have been told
8 about which you can confirm or deny from your own
9 evidence of the general, to which you have already given
10 evidence.
11 A. Yes.
12 Q. What she has told us is that when she spoke to you in
13 respect of Jacinta when she first met you --
14 A. Yes.
15 Q. -- and consulted you about her daughter's condition, you
16 told her that you had spoken to Mr Dhasmana, the
17 consultant paediatric cardiac surgeon, and that she had
18 been listed for surgery the following afternoon.
19 A. Yes.
20 Q. Her recollection is that you told her that she would
21 have details of the operation from Mr Dhasmana later
22 on --
23 A. Yes.
24 Q. -- at a further meeting and that you said to her that
25 they were "lucky to be at a centre of excellence". The
0017
1 effect of that was to make her feel very relieved.
2 Again, is that something you would say: that "this
3 is a centre of excellence", "You are lucky to be at
4 a centre of excellence", something along those lines?
5 A. Most certainly not. I would have regarded the top two
6 or three units in this country as being centres of
7 excellence in the true sense of the word. I would have
8 certainly pointed out that we were one of nine
9 supra-regional centres in the country and that the nine
10 units were undertaking surgery for complex children,
11 particularly under 1 year olds, and I do not believe
12 I would have suggested that we were among the best
13 which, to me, "a centre of excellence" should mean.
14 Q. If you say (as was the fact) that Bristol is one of nine
15 supra-regional centres specially designated for the
16 purpose of neonatal and infant cardiac surgery, I expect
17 that might be seen by those who hear it and who do not
18 know the details of the system, as being some warranty
19 of quality?
20 A. That is possible.
21 Q. So they may read into what is said in those terms that
22 this is as it were a certificate of, if not excellence,
23 at least high quality?
24 A. Yes.
25 Q. The purpose of mentioning that Bristol was one of the
0018
1 nine centres would be, would it, to convey something of
2 that flavour to the parent who might need reassurance?
3 A. Yes, I think that is correct. I do not recall if
4 Mrs Shortis raises the question herself, it is not one
5 I would have volunteered, but if raised I would have
6 talked along those lines.
7 Q. Her recollection is that it was volunteered to her by
8 you.
9 A. I do not believe I would have done that off-the-cuff.
10 Q. What she told us she found distressing was that when she
11 went to see Mr Dhasmana, she was told by him that her
12 daughter, Jacinta was inoperable.
13 A. Yes.
14 Q. And indicated to her that he had cancelled the operation
15 that she was to have.
16 A. Yes, can I make that clear, I cannot speak for
17 Mr Dhasmana, but I presume what he was meaning is that
18 a full repair, a reparative, corrective operation was
19 not possible. In that sense she was inoperable.
20 In terms of carrying out a palliative initial
21 procedure, that statement is not true, she was operable
22 in terms of putting a shunt in, which was the one that
23 was recommended. So I just wanted to clarify that
24 aspect; she was not completely inoperable, she was
25 operable with regard to a palliative operation, but at
0019
1 that point in time there was no clear way of seeing that
2 she was operable for the totality of her condition, and
3 I might need to amplify that later if necessary.
4 Q. The problem is, is it, that Jacinta was a very sick
5 baby, her mother was, as mothers are bound to be,
6 distressed and upset by that knowledge?
7 A. Certainly.
8 Q. But as she sees it, she is given hope by the way in
9 which you deal with her, reassurance and hope. Then she
10 sees Mr Dhasmana without your being there and he, in an
11 instant, dashes that hope. Her expression to us is
12 along the lines that that was a cruel failure of
13 communication between the way in which you were putting
14 the case of Jacinta to her and the way in which
15 Mr Dhasmana dealt with it when --
16 A. Yes, unfortunately I was not present at that discussion,
17 so I cannot speak for Mr Dhasmana.
18 Q. No, you cannot say what he said to her and what she said
19 to him because you were not there. What she does
20 recollect is that a few days later you spoke to her and
21 apologised for the incident there had been with
22 Mr Dhasmana. That you may have a recollection of?
23 A. Yes, I do, because I was likewise upset that she was
24 receiving two messages, or at least that was what she
25 said and I accepted that at the time from her.
0020
1 Q. At the time she did get two messages?
2 A. Yes, it seems she did.
3 Q. One was one -- if I can describe it in these terms --
4 essentially of reassurance?
5 A. Well, reassurance up to the point of being able to do
6 a palliative operation for a short term in which case
7 Jacinta would survive for a few unknown number of years,
8 but that there was no complete corrective operation
9 available in the offing at that time.
10 Q. The other was a statement as to the inevitable future
11 for Jacinta?
12 A. Yes, I believe what Mr Dhasmana was getting at was --
13 and I am trying to translate second-hand what he might
14 have said -- that given there is no corrective operation
15 long-term and she is ill, if we leave her unoperated at
16 the moment she is likely not to survive for very long,
17 and by that I would have thought weeks, two months
18 probably.
19 Q. The problem she identifies is one thus of different
20 messages being given by two senior clinicians, both of
21 them dealing within a short space of time with her
22 daughter's case?
23 A. Yes.
24 Q. What attempts (if any) were made between cardiologist
25 and surgeon to ensure that the same message, one would
0021
1 hope an accurate one, was given to parents?
2 A. This is a very, very unusual occurrence. I do not
3 remember this ever happening to me, certainly not in
4 Bristol, that we apparently seemed to be talking at odds
5 with each other. We certainly had a meeting before
6 coming to a conclusion about what we should together
7 offer Mrs Shortis in terms of Jacinta and although at
8 the beginning of our meeting there was a difference of
9 opinion in terms of emphasis, we talked through the
10 particular details of the baby's condition and, by the
11 end of our discussion it was my belief that we had
12 reached a conclusion that we should offer Jacinta
13 a shunt at this stage and that that is what would be put
14 to the parents.
15 As far as I was concerned that followed our normal
16 line of approach and I believed we had come to
17 a conclusion after a very amicable discussion about her,
18 although we did have differences of opinion to begin
19 with, and eventually I thought we had come to a common
20 course.
21 Q. The answer is: you did speak to Mr Dhasmana about the
22 case before he saw Mrs Shortis?
23 A. Unquestionably, yes, a surgeon would not have taken on
24 any case at all unless there had been a full discussion
25 and review of the echocardiography and the catheter
0022
1 features before moving on to the surgery itself.
2 Q. In the course of that discussion you started, you say,
3 with disagreement. That disagreement was resolved
4 between the two of you, the two clinicians?
5 A. Yes.
6 Q. Inevitably in that process there may from time to time,
7 might there, because that cannot be an unusual process,
8 that you have a slightly different approach to a case
9 than the surgeon does?
10 A. Yes, but it would be very rare for us to remain of
11 different resolve at the end of our discussion.
12 Q. What it might imply is that what you have told the
13 parent, because obviously you had already seen the
14 parent and spoken to the parent, may need to be modified
15 in the light of what you know the surgeon is going to
16 say because you and he have discussed it and come to
17 a common view?
18 A. Yes.
19 Q. How do you deal with that?
20 A. I think once one comes to a common view, there should
21 really be no problem from there on, we should both be
22 talking the same language, as far as is possible
23 although no two doctors are going to put things in
24 exactly the same way and inevitably I think parents
25 being particularly sensitive to the nature of how the
0023
1 doctor is putting things at that time, and in particular
2 with very ill children, they may well pick up
3 differences in emphasis, I think that is almost
4 inevitable that there will be a different overall feel
5 of what any two people are saying about the same
6 operation and the same intention.
7 So to that degree there will be a difference. But
8 in terms of the gist of the matter, as to either doing
9 an operation or not and if so the specific type of
10 operation should be crystal clear on both individuals'
11 parts --
12 Q. I think what I am addressing is what is said to the
13 parent. Inevitably you are right, there must be
14 a difference of approach by different people because
15 they are different?
16 A. Yes.
17 Q. But the information that is given by you, the
18 cardiologist, to a parent may be along particular lines
19 which, having discussed the matter with the surgeon, you
20 say to yourself "Actually that is not quite right, we
21 are going to do it differently", or "what I have told
22 the parent about the risks", for instance, "may need to
23 be modified. I may have said the risks are 25 per cent
24 where in fact they are 40 per cent or 10 per cent",
25 having discussed it with the surgeon you realise this is
0024
1 probably the case and you reach a common position with
2 him or her.
3 How do you deal with the change of information
4 with a parent who inevitably is going to feel very
5 keenly the situation of their child at that time; do you
6 go back to the parent and say "I want to change my
7 position" or do you say at the first consultation "What
8 I am telling you is provisional, I need to discuss it
9 with the surgeon, this may be subject to change, you
10 have to understand I am giving you the best view that
11 I can at the moment, it is actually quite difficult and
12 I do need to discuss it", something along those lines?
13 A. Yes, if I saw the patient (as often happens) before
14 gathering the sum of information that is necessary to
15 make a decision but have not yet spoken to the surgeon
16 about it, then I would use precisely that approach and
17 indicate that this is my opinion at the moment,
18 I believe that in this instance a palliative operation
19 is feasible given the circumstances even of later not
20 being able to foresee the next step and would then put
21 it to the parent, and I do not think I could put it
22 better than you, that "We need to have a discussion with
23 the surgeon and go through the case and then decide
24 whether he agrees with me that this is the best approach
25 or not and if not, what other approach we should adopt".
0025
1 Q. I do not know if you have ever had the situation of
2 yourself thinking quite strongly "This is what needs to
3 be done" because it is your province as a cardiologist
4 to draw those conclusions, to have those opinions.
5 Going to a surgeon who takes a different view and
6 ultimately finding that the two of you disagree, or at
7 least unwillingly agree in the sense that you as
8 a cardiologist say "If he is going to do the operation,
9 then we have ultimately to do it his way; all right, it
10 is a possible way but I think my way is better", if you
11 were in that position --
12 A. Yes, I would hope we would very rarely be in that
13 position.
14 Q. Are you sometimes?
15 A. I cannot recollect. I do not think we were in this
16 case.
17 Q. No, but in general?
18 A. After you have had a discussion at a joint meeting, let
19 us say, usually with a whole team present, you may have
20 I suppose the human response that "Well, I think maybe
21 may way is better, but I understand the arguments put
22 forward by a surgeon and that ultimately the surgeon is
23 going to be doing the job and I do not disagree with his
24 particular approach. I might think mine is better, but
25 on balance I accept that his is equally good and that he
0026
1 ought to proceed with that". We would not be left at
2 that point with a real difference of opinion about
3 approach. So I do not think there is any conflict
4 necessarily there.
5 THE CHAIRMAN: You might, Dr Joffe, be left with a problem
6 if it was your view that there ought to be surgery and
7 the surgeon was not wanting to carry it out; what would
8 you do in that situation, do you think? Here we are
9 looking for advice and your view.
10 A. I believe this case is just such a one. As I say,
11 I believed that we had reconciled our differences by the
12 end of the discussion. I do not know what Mr Dhasmana's
13 emotional state was after that or what had happened that
14 morning prior to his meeting, this is guesswork, but it
15 seems that he took a different line.
16 I think Mr Dhasmana sometimes, in order to
17 emphasise the seriousness of the outcome may sometimes
18 overstate the danger and the validity of proceeding, he
19 is that kind of man I think who tends to come out with
20 a curt statement and so I think in this case that might
21 explain it.
22 In addition to the discussion we had before the
23 meeting he had with Mrs Shortis, I had a discussion with
24 him again because I became aware of this conflict
25 through Mrs Shortis and I apologised to her for it
0027
1 because I did not think that was correct, and
2 Mr Dhasmana said, as I think he did to Mrs Shortis at
3 the end of their discussion "We will go ahead with the
4 operation, but you do realise this is likely to be
5 short-term and we do not know if there is anything more
6 we can do for your baby".
7 Q. As it happens, in this particular case -- I have really
8 been asking you about general propositions that emerge
9 from the particular -- Jacinta had a shunt I think?
10 A. She did, yes.
11 Q. That was successful. Some time after that she came back
12 into hospital because of difficulties?
13 A. Yes.
14 Q. Mrs Shortis recalls that, following investigations in
15 the Bristol Children's Hospital the second time that she
16 had been there, there was an occasion when you came from
17 behind her in the corridor and said in a loud voice --
18 she describes it as shouting -- that you had good news
19 for her and indicated Jacinta would live until she
20 was 7.
21 A. Sometimes I wish I had that kind of forthright
22 personality. In fact that is totally untrue, I would
23 not be capable of making that sort of comment, shouting
24 down a corridor about any news whatsoever, let alone
25 giving a precise definition of a length of life-span,
0028
1 which is just totally, may I say the word, ridiculous.
2 Q. You would agree that if it is right that that is what
3 happened, that would be a completely inappropriate place
4 to give information of that sort?
5 A. Unquestionably.
6 Q. And you would agree that information of any personal
7 nature ought not to be given in public but in some
8 private and quiet conversation?
9 A. Absolutely.
10 Q. Dealing with the same case because it is a case which
11 I understand you particularly want to deal with.
12 A. Yes, I am very happy to deal with it in as much detail
13 as you wish to put forward.
14 Perhaps I could come back to an issue about the
15 shunt, you mentioned Jacinta did not do as well as we
16 expected and I think Mrs Shortis at some point in your
17 notes will say that I guaranteed that this child would
18 live for about 2 years, or words to that effect. Again,
19 nothing that I would put to a parent of this nature
20 would be a guarantee, particularly in this field of
21 work.
22 Secondly, the general outcome following
23 Blalock-Taussig shunts is very very good, the immediate
24 results are good, and the longer term, that is up to a
25 few years, one would expect a baby of this nature with
0029
1 this condition to do very well, to remain blue to
2 a degree, but to thrive, perhaps less than normal but
3 not far behind but to be able to take part in normal
4 growth and activities for a number of years and
5 unfortunately in this baby Mr Dhasmana wished to make
6 sure that the shunt was of an adequate size that would
7 enable sufficient pulmonary blood flow to pass through
8 the lungs so that the oxygen saturation would be
9 satisfactory. He used a 5mm Goretex graft which is
10 ample in a newborn baby, usually just ample and no more,
11 but in her case it proved to be big enough to allow an
12 excessive pulmonary blood flow and therefore she went
13 into heart failure soon after the procedure and, indeed,
14 she returned into hospital some weeks after her
15 discharge because she was ill and in heart failure still
16 despite medication, anti-failure treatment with
17 diuretics and I believe -- I cannot remember the
18 details, but that could be looked up.
19 She was still not controlled when she returned,
20 I think her readmission was precipitated by a pulmonary
21 infection at the time and I was still relatively
22 optimistic and felt that with increased anti-failure
23 treatment we would be able to hold her until, so to say,
24 she grew into her shunt and she got bigger and the shunt
25 would become relatively smaller and then she would
0030
1 progress better.
2 That clearly did not happen and unfortunately (and
3 I say that for two reasons) I did not see Jacinta again
4 for the next 7 weeks while I believe she was not doing
5 well at home, failing to thrive, becoming more
6 breathless, deteriorating and I am very sorry that I did
7 not see her again because, (a) I think we could have
8 managed to treat her perhaps and, (b) not long
9 thereafter we began to change our approach to the Fontan
10 operation from the original Fontan, right atrial to
11 pulmonary artery direct connection to the total
12 cavopulmonary connection whereby the superior vena cava
13 and the inferior cava are separately joined to the
14 pulmonary artery thus bypassing the right side of the
15 heart completely with the venous return of blue blood to
16 the lungs. That became, and is now, the accepted
17 mechanism or method for approaching babies with complex
18 heart defects.
19 I should add in for clarification for
20 cardiologists perhaps and others, that her condition
21 involved a dextrocardia, complete AVSD, the
22 transposition and pulmonary atresia and that doing
23 a right atrial to pulmonary artery connection in that
24 situation is not possible because you have a common AV
25 valve and you therefore have to do something to prevent
0031
1 flow from the right atrium into the right ventricle and
2 that would mean putting a diaphragm or sheet of tissue
3 across the right side of the AV valve and it is really
4 not tenable. That can be done in other situations where
5 you do not have an atrioventricular canal defect and
6 that is the reason why initially she was considered to
7 be inoperable.
8 I have said a lot of clinical technical stuff
9 there and Dr Houston may want to come in, either to
10 contradict or support, but that gives the background to
11 the situation which I felt I needed to explain.
12 Q. What I am focusing on in this part of my questions is
13 not so much the clinical details, we will have a look at
14 some cases and explore the lessons that might be learned
15 from them in a few minutes, but the communication you
16 had with parents and the approach and lessons we may
17 learn generally from particular cases in which
18 communication has taken place or may seem to have
19 failed.
20 One of the pictures that you are painting,
21 I think, is that as between yourself and Mr Dhasmana,
22 perhaps reflections of different personalities, you
23 tended to express optimism where he might tend to
24 express pessimism in terms of outcome. Is that --
25 A. I think by and large that is so in terms of our
0032
1 personality types, yes.
2 Q. So that a parent coming to you as a cardiologist might
3 get as it were the best view painted?
4 A. I would hope it would be a very realistic view, but one
5 does not want to dash the hopes of parents. Part of the
6 therapeutic process is to keep hope alive and if you
7 cannot do that, then you are not practising medicine
8 appropriately.
9 Q. It is something that may be thought to be reflected in
10 the note that I showed you yesterday of the meeting that
11 you had on 21st April with Mrs Maria Shortis, go to
12 PAR 1 at page 1/432. 433. Go down to the bottom of the page:
13 "We talked about how much parents should be told
14 about the risks to their children when facing life
15 threatening surgery. Dr Joffe said that if parents were
16 always told the whole truth, then no one would hand over
17 their children for surgery." Then there is a discussion
18 of a particular case.
19 You said yesterday that you do not think you said
20 that.
21 A. Yes, not that way, no.
22 Q. Not that way. What way do you think you might have said
23 or given the same sort of message?
24 A. I note this is in 1995, so this is 7 years since
25 Jacinta's presentation. I think I would have not talked
0033
1 in terms of "truth" or "non-truth", but I would have
2 been more likely to have talked in terms of, if we gave
3 every detail of what might happen to the child, then if
4 every complication was pointed out in a very calculated
5 fashion, then it is possible that parents would find it
6 very difficult to hand over their children for even an
7 acute appendicitis, let alone a complex cardiac
8 operation.
9 Q. In other words if one were to substitute the words,
10 going back to the bottom of the previous page, if
11 parents were always told "the whole truth", if we
12 substituted "the full facts" for "the whole truth", in
13 other words take out the pejorative, that would
14 correspond with what you may well have said?
15 A. That would be closer, yes. Again I was unaware of these
16 minutes of our meeting until yesterday. Mrs Shortis
17 certainly was not taking notes during the meeting. It
18 is dated the 21st, which is the day after the meeting so
19 I presume she made those notes the following day --
20 I cannot recollect --
21 Q. Can I ask you to pause there. If we go to the top of
22 the page, the way in which it is described in her own
23 note is "this meeting took place on April 21st", and so
24 it would appear to be a note made after the 21st and
25 that confirms your account of that?
0034
1 A. Yes. I was going to go on to say that I really cannot
2 recollect the precise terminology that I used. But the
3 sense of what you are saying is more or less correct.
4 Q. Do you still have that view, that one of the
5 difficulties with the present modern approach is that it
6 may put off parents or distress them in a way that the,
7 if I can call it, old fashioned approach did not?
8 A. Yes, I am still concerned about that, but as I mentioned
9 yesterday I think the understanding of the lay public
10 (and that includes parents as well as other patients)
11 has evolved, has changed, has opened up, has become more
12 desirous of knowing the full facts and I believe now
13 (and I am using my usual kind of non-direct approach, if
14 you like) probably best to give the full facts but put
15 them in perspective as far as one can and somehow retain
16 the sense of hope in the patient.
17 But I still believe there is an element of
18 judgment and selectivity involved and that there are
19 some patients or parents, and I believe there are one or
20 two among those that you have mentioned, and I would be
21 prepared to say which, where I think I might have been
22 a little tardy about telling them absolutely everything
23 in a stark fashion because of my judgment, not that they
24 would not want their child to be operated upon, but
25 because it might -- destroy is too strong a word, but
0035
1 might be too tough for them to cope with at that time.
2 I would rather, under those circumstances, perhaps
3 break up the information into what I believed at the
4 time they would cope with, with a view to seeing them
5 again once or twice before an operation and try and
6 convey additional risks thereafter; it is a very
7 difficult subject. I believe it comes with experience
8 of being with people and unfortunately I have had to be
9 part of the process, not only of informing people of the
10 total picture but also of being present at bereavement
11 situations and inevitably there will be a difference of
12 opinion about how that should be handled. But I think
13 one does one's best in one's own perception of the
14 requirement.
15 THE CHAIRMAN: Dr Joffe, you talk of keeping alive some
16 sense of hope. We have heard some evidence in which
17 parents have talked of false hope, indeed the word
18 "cruel", applied in that context. Can you help us
19 a little bit as to when keeping alive hope is in fact
20 misleading and unhelpful?
21 A. It is a balance. I think the primary or the overriding
22 risks I think should be stated and I do not think that
23 under any circumstances one should shy away from that.
24 By that I mean that if an operation has a risk of 1 in 3
25 or 1 in 4, and quite frankly at that time I do not think
0036
1 there is a difference in a parent's mind about what 33
2 mortality rate is versus 35 mortality rate, it is a real
3 mortality rate, their child could die is the point and
4 I think that is as far as one needs to go, frankly, at
5 that stage but one cannot hold back on that, that is
6 reality.
7 But in terms of some of the less common
8 complications, I believe that can be introduced in
9 a gentler way in the case of cerebral haemorrhage or as
10 Dr Houston mentioned, renal failure and other sorts of
11 complications that would be far rarer.
12 THE CHAIRMAN: It is quite a central point of distinction
13 that you may be making, the difference between whether
14 you pass on this information and how you pass it on.
15 I take what you have just said to as it were be prepared
16 to concede the idea that one does pass on, but one does
17 it in a particular way?
18 A. Yes, I think that is correct.
19 MR LANGSTAFF: One of the points to which Mrs Shortis turns
20 in her note of the conversation, and therefore suggests
21 that the conversation ended on this note, was
22 a discussion between you and her as to the need in
23 general terms for communication skills in the clinician
24 to be developed, maintained, improved. Did you, in the
25 course of your training -- it was in South Africa, was
0037
1 it?
2 A. Yes.
3 Q. Did you have any training in communication skills?
4 A. No, not at all.
5 Q. You have picked up the skills that you have by practice?
6 A. Yes, correct.
7 Q. And you have no means of judging, save by the apparent
8 reactions of those to whom you are talking at the time,
9 of how effective those skills may be?
10 A. Yes, I believe that is right.
11 Q. You mentioned the question of bereavement and what one
12 says in respect of bereavement which puts the clinician
13 dealing with bereavement in a very difficult position
14 because you do not know really how to deal with the
15 news, I suspect, except by having done it in a number of
16 distressing circumstances over a period of years?
17 A. Yes.
18 Q. The fact of death must, I suspect, be distressing to the
19 clinician even if not as distressing as it is to the
20 parent?
21 A. Undoubtedly, yes.
22 Q. One of the things we are told in Mrs Shortis's
23 statement, again going back to that for the sake of
24 example, is that when her daughter died at home she
25 telephoned you the next day to tell you of the death and
0038
1 your reaction to her, having just heard the news, was
2 "She should not have died, that surprises me, but,
3 Mrs Shortis, you always thought that she would die
4 early".
5 A. Yes, I could have said those words. I do not think they
6 would have been my instantaneous response, I do believe
7 I would have offered condolences and said how sorry
8 I was. I recall Mrs Shortis putting in her statement
9 that I did not, which I find hard to believe. But I may
10 well have gone on saying that I did not expect her to
11 die so soon because, as I pointed out earlier, when she
12 was discharged from hospital 7 weeks earlier she had
13 improved considerably with increased treatment and I had
14 no knowledge for the next 7 weeks that she in fact was
15 deteriorating.
16 So I was surprised, I thought that she would have
17 been controlled with regard to her excessive shunt and
18 that she would have gone on hopefully for two or three
19 years. So, yes, I think I probably did say that.
20 Q. You were expressing that as a human reaction to the
21 information you had because you were in fact surprised?
22 A. Yes.
23 Q. Without perhaps thinking twice, because of the situation
24 you were in, of the effect that it might have upon
25 a parent who was newly bereaved and still no doubt
0039
1 coming to terms with everything that had happened?
2 A. This is one of the instances where one makes a judgment
3 and I believed -- through my previous encounters with
4 Mrs Shortis, that she was highly intelligent, she had
5 a good grasp of what was going on -- having given my
6 emotions of sorrow, that that was the sort of statement
7 I could make to her, possibly not to other people.
8 Q. Dr Houston, we have been touching on a general issue:
9 communication with parents, both of the nature of the
10 operation, the seriousness of a child's condition, the
11 risks to the child and communication, if there is
12 mortality, to the bereaved parent and how one handles
13 that. Has there been in clinical circles any general
14 training as to how one as a doctor should deal with
15 this?
16 DR HOUSTON: I think nowadays the students get some training
17 in this, but certainly when I qualified we did not, we
18 worked with our colleagues and you would know how
19 various colleagues put things and you would learn from
20 that and decide how you did it yourself.
21 I think a point to make, though it perhaps already
22 has been made, is: there are two people in any
23 communication situation, there is not just the doctor,
24 there is also the parent and usually we are talking to
25 them when they are very emotionally upset. Sometimes
0040
1 when you speak to them subsequently their perception of
2 what was said is not what was said, and I think there is
3 no doubt about that.
4 I can certainly recollect a parent coming back and
5 asking her "what were you told about this?", and I said
6 "who on earth told you that?", looked up the notes and
7 it was myself and I have a pretty standard way of
8 putting things, so people do perceive things
9 differently. I was very interested in this 7 years and
10 this 2 years, people come back and say "yes, I was told
11 that this would be done when the child was 7, 6, 8" and
12 I do not believe anyone actually said that. Sometimes
13 they may say "when would it be" and we might say "we
14 have to wait and see", and whether they might have said
15 at that time "about 8?", and someone might have said "it
16 might be the case I am not even sure of that", but
17 people do come with this idea of set times when things
18 would be done, and I see you are nodding when I am
19 saying that.
20 DR JOFFE: Yes, I absolutely agree with that.
21 DR HOUSTON: They have this perception, and again how things
22 are put by different people are taken up differently.
23 MR LANGSTAFF: What that would seem to call for is, if
24 treatment is continuing, some form of written treatment
25 plan.
0041
1 DR HOUSTON: Perhaps, yes, or seeing them again after the
2 emotional time, but often if we see them before the
3 operation they are very upset and after that perhaps we
4 should be going over things again. I am sure we all
5 offer to see them again and go over it again if they
6 want, but patients do not very often come back and ask,
7 I think they do not like perhaps to ask us and it is
8 only when we say "do you want me to go over it again"
9 some will say, "no it is all right" and some will say
10 "yes, could you".
11 MR LANGSTAFF: The common ground between, I think, almost
12 everyone who has given evidence is that the
13 conversations which take place very often take place at
14 times of high emotion. Might it be the case, then, that
15 there is a case for a system which reviews the
16 information which is given at a time when the emotion is
17 less likely to be heightened.
18 DR HOUSTON: That may be the case, yes.
19 DR JOFFE: There has been another suggestion, and I know it
20 has not been taken up very widely in this country but it
21 is to some extent in the United States, and that is to
22 have a video or an audio tape running at the time of,
23 particularly the communication between the surgeon and
24 the parents prior to surgery in terms of risks and
25 consent. That may be a road that we should perhaps at
0042
1 least explore.
2 I think it sounds like an artificial intrusion,
3 and I dare say one would feel it is to begin with, but
4 it is possible that as you get used to the system that
5 would become an acceptable way in situations where you
6 are facing -- having to convey very high risks.
7 DR HOUSTON: I think the other thing that assists nowadays
8 is the liaison nurse, someone whose job is not actually
9 to nurse the patient but to be there to talk to parents
10 and go over things and I think most units now would have
11 someone like that, someone they can go and talk to after
12 and sometimes, although we think of ourselves as being
13 quite approachable and no problem in telling people to
14 telephone they tend not to, they tend not to want to do
15 it and they are more likely to go to their liaison nurse
16 and I think that is improving things nowadays.
17 MR LANGSTAFF: The difficulty with that is that the surgeon
18 or the consultant cardiologist are seen as the person
19 who knows and the person who actually makes the
20 decisions (as indeed is the case), and the liaison nurse
21 is seen simply as somebody who does his or her best to
22 interpret that which the great man or woman has said.
23 Is it not always likely to be the case that the
24 parent will come back and say "well, the doctor
25 said ..."
0043
1 A. Yes, that is true up to a point but I think if the
2 liaison person was (herself usually) au fait with the
3 field of work and the particular specialty and has
4 either been a theatre sister or one of the leading
5 nurses in the Intensive Care Unit, and perhaps there
6 should be an additional training course for people in
7 this very position so that there would be a confidence
8 between parents and such an individual, liaison person,
9 from the first time they begin talking to each other
10 because it should become apparent that that liaison
11 person -- be it a nurse or other background -- does have
12 virtually the full information or most of it to be able
13 to answer those queries. I think it is possible to
14 train someone to do that job.
15 Q. Can I pick up another theme which emerged when I was
16 talking to you about the case of Jacinta Shortis, it is
17 the question of optimism and pessimism: Dr Houston, is
18 it known within a unit that some clinicians tend to
19 express risks, chances, futures in a more optimistic
20 manner than others?
21 DR HOUSTON: I am not sure that I can answer that exactly,
22 but there are certainly different ways of putting things
23 and there are some clinicians who will take a lot more
24 time explaining things than others. As to whether they
25 will put it more optimistically or more pessimistically,
0044
1 I think there has to be -- no one can in fact possibly
2 do it exactly the same way unless you just write it out
3 on a piece of paper without putting any of yourself into
4 it, but I do not think, as far as I know, that there
5 would be major differences. The surgeon of course is
6 the man who is going to be responsible if something goes
7 wrong and I would think he is more likely to be
8 pessimistic.
9 MR LANGSTAFF: The case we have heard of, Dr Joffe, that of
10 Jessica Hill, a little girl suffering from VSD who
11 develops problems with pulmonary hypertension. What
12 Mrs Hill recollects and told us of is that following
13 a catheterisation at the age of about 7 months she was
14 spoken to by you and you were encouraging to her; she
15 speaks to Mr Dhasmana who is discouraging, the same
16 difference of approach really that we identified with
17 Mrs Shortis.
18 So she goes to see Mr Dhasmana and he says, in
19 a quiet voice, "There is nothing that I can do for
20 her". The effect on her was devastating because when
21 you had spoken to her -- I think actually before the
22 catheter, I think I was wrong to say after the catheter
23 -- before the catheter she had no inclination from you
24 that things might be as serious as they turned out to
25 be.
0045
1 First of all, is that your recollection of what
2 happened or may have happened?
3 DR JOFFE: Up to a point. I certainly would not have
4 minimised the seriousness of her having a ventricular
5 septal defect with a very large left to right shunt
6 again, and I would need to amplify I am afraid by just
7 going over some details --
8 Q. Can I pick that up if we look at one of the clinical
9 cases from the Clinical Case Note Review because we will
10 deal there I think with the significance of the VSD and
11 the changes?
12 A. The point I want to make very briefly is that she
13 presented in heart failure with dyspnoea and failure to
14 thrive, and the chest X-ray showed a huge heart and
15 plethoric lung field. So, although she had a serious
16 condition it was VSD which is normally not serious, but
17 in her case there was a large shunt. She was an ill
18 baby and it was something of a surprise to me when we
19 did the catheterisation that she had very significant
20 pulmonary vascular hypertension. The pulmonary artery
21 pressures were at equal levels and she had a pulmonary
22 vascular resistance ratio of 7.1 units per metre
23 squared; we can go into the details perhaps later, as
24 you say.
25 But even at that stage the chest X-ray showed the
0046
1 same features, so she was unusual in that the clinical
2 picture suggested one set of haemodynamics, the cardiac
3 catheterisation indicated another and when we had the
4 joint meeting -- this is perhaps going ahead now beyond
5 your question -- it was acknowledged and realised that
6 it was a very significant degree of pulmonary vascular
7 obstruction and it was by no means sure that this was
8 (or would be) reversible, but the reasoning at the
9 meeting was that she was 7 months old then and that it
10 is very unusual for a child with VSD -- and I stress it
11 is not atrio ventricular septal defect -- for a seven
12 month old to be in the position of having irreversible
13 pulmonary vascular disease. So it was felt that this
14 was a very high risk case but we would take it on.
15 I am not sure at which point Mr Dhasmana spoke to
16 her. If and when I spoke to her after the catheter
17 procedure, I would have certainly been very concerned
18 about her outlook and would have emphasised the
19 haemodynamic position.
20 Q. What Mrs Hill has told us is that when she saw
21 Mr Dhasmana for a discussion following the catheter he
22 indicated to her that Jessica was inoperable, there was
23 nothing that he could do for her?
24 A. I think that is another illustration of the way he
25 approaches patients, to make no bones about the fact
0047
1 that they are very high risk. It is not my approach,
2 but here are two cases in which he has taken the same
3 line on both.
4 Q. In fact she recollects him saying during the
5 conversation, and I appreciate you would not be at that
6 conversation --
7 A. No.
8 Q. -- that he was surprised they did not realise how
9 serious Jessica's condition was and commented something
10 like: "We surgeons" or "the surgeons always get the
11 worst job", that is telling a parent that their child's
12 condition is really very serious when they had not
13 expected anything of the sort to be told to them?
14 A. I think we have certainly a tough job ourselves in
15 conveying risks, but I accept what he says, that the
16 surgeons are probably in a worst position.
17 Q. He, it is said, gave the risks for the operation as
18 50/50, that subsequently when you went through with
19 Mrs Hill the operation, you quoted risks -- that 7 out
20 of 8 [7 or 8 out of 10] cases may be successful --
21 A. Yes.
22 Q. -- which again is a difference of approach. Both of
23 course indicate a serious risk, but they put it very
24 differently; is that a question of optimism and
25 pessimism?
0048
1 A. I think by now you have had enough exposure to
2 Mr Dhasmana and myself to make that decision.
3 THE CHAIRMAN: Dr Joffe, I do not think the point
4 Mr Langstaff is pursuing is that there are differences
5 between you per se, so much as when the parent is
6 greeted with information there is a system which allows
7 mixed communication or different messages to be given.
8 That is what I think is being addressed, it is not that
9 you were different from him, but that that creates
10 a situation where the parent is (if you will) confused?
11 A. Yes, I accept that. I do not know the way out of that
12 other than that perhaps the cardiologist and the cardiac
13 surgeon should be together when they discuss the
14 immediate preoperative session, that might possibly help
15 to give a more appropriate commonality in the response.
16 MR LANGSTAFF: One of the difficulties --
17 MRS MACLEAN: Just to make sure that I am absolutely clear:
18 I understand that the cardiologist will be the first
19 person to talk with the parent who must then be in
20 a very distressed state and clearly it is a time for as
21 much reassurance as possible and a lot of avenues are
22 open. Then the child is seen by the surgeon. What I am
23 not absolutely clear about is at what point that
24 cardiologist and surgeon make their joint plan of
25 action, have their joint meeting; is it between the
0049
1 interview between parent and cardiologist and parent and
2 surgeon, or do cardiologist and surgeon meet after both
3 doctors have seen the child?
4 A. To answer from the end: no, they do not see or meet
5 together after the surgeon has seen the child; that is
6 usually the final stage, pre-op.
7 The joint meeting takes place at a time when all
8 the information has been gathered and, depending on the
9 urgency of the case, that would be done quickly or it
10 would be done over a matter of months including the echo
11 and the catheter and so on.
12 Usually soon after the catheter, within a couple
13 of weeks usually, the details are discussed. So it may
14 be (depending again on the urgency of the case), quite
15 a long time, six, nine months maybe from that point
16 before the surgeon actually has his final preoperative
17 discussion. So there is a lapse of time and I suppose
18 that in itself may be a factor that may not result in
19 the two approaches being as close as they would have
20 been at the time of the joint meeting.
21 MRS MACLEAN: That is very helpful. So a joint position
22 reached after your meeting --
23 A. That is the point.
24 MRS MACLEAN: -- might result in a decision which would be
25 altered by a surgeon when he sees the patient himself
0050
1 after --
2 A. I do not think it would be altered particularly because
3 then I think he would come back to the cardiologist to
4 discuss a change in the nature of the operation he is
5 going to do, but ultimately I think the surgeon has the
6 final say. I mean if he opens the chest and he sees
7 a heart with circumstances that are different from what
8 the cardiologist told him, or even if it is not, if he
9 sees some way in which the diagnosis is correct but an
10 approach that is slightly different should be taken, let
11 us say the pulmonary arteries are too small for a shunt
12 on the one side, he will do it on the other side or
13 whatever, then of course he makes that decision without
14 consulting the cardiologist again.
15 So in that sense ultimately the surgeon does take
16 the final decision, but as far as possible it is a joint
17 venture concluded at the joint meeting.
18 MR LANGSTAFF: Coming back for a moment just on this topic
19 to your suggestion that one of the ways of resolving the
20 situation might be to have a joint discussion of
21 cardiologist/surgeon with parent or patient. That would
22 certainly resolve the difficulties of different
23 percentage rates being quoted by the two clinicians and
24 I used the example of Mrs Hill earlier. I think I may
25 have misquoted what she told us the rate was that you
0051
1 said. I think I may have said "7 out of 8", I meant to
2 say "7 or 8 out of 10". So let me correct that.
3 One of the problems of clinicians quoting
4 different percentage rates, although each may believe
5 what they are saying, it may give either false optimism,
6 it may dash hopes or it may give to the parent or the
7 patient a sense that nobody knows what they are doing
8 because you have dissention, disagreement at the top as
9 they see it. It is obviously important to avoid that,
10 is it not?
11 A. As far as possible, yes.
12 Q. Is it feasible to have a system in which the
13 cardiologist and the surgeon meet together with
14 a patient for a discussion?
15 A. It is feasible, but it would take a lot of organisation
16 and it would depend on a whole range of timetabling
17 issues, of whether that could be fitted in.
18 I must say, when I first started in Bristol and
19 the workload at that point was not as exhausting as it
20 became subsequently, we had our outpatient meetings
21 (that is, the surgeon and cardiologist) at the same time
22 on a Wednesday afternoon and there would be two clinic
23 rooms running together, one the surgeon who would be
24 seeing follow-up cases largely and the cardiologist who
25 would be seeing patients pre-operatively or later,
0052
1 post-op follow-ups.
2 There were times then that either the surgeon or
3 I would call each other to possibly explain something
4 that either the surgeon wished to have more input in or
5 the parent perhaps asked a question that was more
6 appropriate for the cardiologist to respond to it. So
7 I think it is feasible, but it of course would take
8 a lot of organisation of theatre lists, anaesthetists'
9 times to free up surgeons for those particular sessions,
10 but it could be done.
11 I would be interested in Dr Houston's view about
12 this because I think we are in fresh territory now.
13 MR LANGSTAFF: Let me give you the last word before a break.
14 DR HOUSTON: I am not sure that it is necessary to see them
15 together. It sounds to me as if there has certainly
16 been a great difference between the way the two of you
17 put things if what we have been told is correct. But
18 when you work in teams you generally know pretty well
19 what your colleague is like and what he is likely to
20 say. I think perhaps as a physician you do not need to
21 be actually quoting risks in percentage terms, but if
22 you want to do that, fine, you could do that, you could
23 all decide at the meeting when you sit down and discuss
24 it what risks are going to be given.
25 How we do it, we have our catheters and every
0053
1 Thursday we go over all the catheters as a group and
2 make our decision together and then the physician writes
3 down the decision of the meeting.
4 At that time you could say, if you think the
5 actual percentage risks are important to give to people,
6 you could write down the risk that you want to give. Is
7 this the point you are trying to get over, that we
8 should be giving precise percentages of risks?
9 MR LANGSTAFF: I think the point is wider than that, the
10 question is: consistency on information and approach
11 coupled with an honesty of information and approach and
12 a fullness of information and approach; it is those
13 three factors and how one delivers that.
14 DR HOUSTON: I think that is just a matter of working
15 together and agreeing what you are going to say, or one
16 putting the diagnosis and what the procedure is about
17 (which is our job) and then a surgeon to tell him his
18 aspects of it, what he thinks of the risks rather than
19 us, I think our remit is to give them general
20 information related to that.
21 DR JOFFE: I think you would be asked though, would you not,
22 by parents?
23 DR HOUSTON: Yes, and I tend to say "there is a definite
24 risk" or "the risk is low but I cannot be sure about it,
25 but if you want to get the exact figures speak to the
0054
1 surgeon".
2 THE CHAIRMAN: Mr Langstaff, thank you for that summation at
3 the end of the issues we have been exploring, that was
4 very helpful I think to all and it puts in context what
5 we have been talking about, so we are grateful to you
6 and to you, Dr Houston. Let us now take a break for 15
7 minutes and come back --
8 MR LANGSTAFF: 11.30 or just after.
9 (11.20 pm)
10 (A short break)
11 (11.35 am)
12 MR LANGSTAFF: Dr Joffe, before I turn to ask you some
13 questions about the cases which arise from the Clinical
14 Case Note Review, two further aspects of communication
15 which I need to pick up with you following this
16 morning's discussion.
17 It is important, I take it, that when a patient is
18 discharged from hospital -- particularly, one thinks of
19 the little baby Shortis, for instance -- that the parent
20 has appropriate information about what signs there may
21 be that may justify concern, return to hospital and so
22 on, because communication, as Dr Houston was saying, is
23 a two-way process, but it is all very well to say it is
24 a two-way process unless the doctor knows what to say;
25 the parent may not, because they may not know what signs
0055
1 to spot, what information to give, what is a matter of
2 importance.
3 What steps should be taken, do you think, as
4 a matter of general principle, to keep a parent in that
5 sort of situation informed as to the need to refer the
6 baby back to hospital for further investigations or
7 whatever?
8 A. I think it is very necessary and appropriate for
9 sufficient information to be given to the patient at the
10 time of discharge, or the parent, and that would depend
11 on the particular case. If it is a baby like Jacinta,
12 who required ongoing medication, and it was explained
13 that it was necessary to persevere with and to give
14 details of the dosages, as you correctly say, it would
15 be important to indicate the kind of features that
16 should be looked for which might reflect deterioration,
17 and of course, an appointment would normally be made for
18 a follow-up visit at a particular time and the parent
19 would be given an indication of when that would be, and
20 told that an appointment card -- the normal hospital
21 information would be sent to them in addition in due
22 course, usually a week or two before the date of the
23 appointment.
24 Then anything different would depend on the
25 particular child involved, whether or not the child may
0056
1 continue or not to look cyanosed, for instance, and in
2 addition, if the child in hospital was not thriving,
3 ways and means of trying to ensure that the parents were
4 aware of steps to be taken to remedy that, or try and
5 ensure that that did not happen, the failure to thrive.
6 Those are particular sorts of information one
7 would give.
8 Q. Listeners may have been struck by your comment:
9 "If I had known some of the features of Jacinta's
10 presentation over the period after she left hospital,
11 then I might have been able to do something about it",
12 I think was the implication?
13 A. Yes.
14 Q. You did not know, the parent cannot be expected to know
15 unless the parent has information or support in order to
16 help her or him to recognise the signs, and I suppose
17 that the same might be said for a case such as Jessica
18 Hill, where she is looked at at an early stage, VSD is
19 recognised --
20 A. Can I take them one by one? You are relating them to
21 specific cases and there are allegations that are
22 possibly critical.
23 Q. What I am exploring, I hope, in this passage, is not the
24 allegations so much as what communication is
25 desirable; --
0057
1 A. Yes.
2 Q. -- what communication should, in a general sense, be
3 given; and then I shall ask you what you can say about
4 the communication that was in fact given, if anything.
5 In general, you are accepting I think the
6 proposition that parents need to know what to look for?
7 A. Yes.
8 Q. That unless they do, the parent cannot be expected to
9 tell the clinician of the particular signs that may be
10 of importance to the clinician if he knew?
11 A. That is a roundabout way of putting it, but ...
12 Q. The issue is, how do you tell the parent? Whose job is
13 it? In the case of somebody who has been discharged
14 there is a role, is there, for the GP and the health
15 visitor?
16 A. Yes.
17 Q. What measures, historically, were taken by Bristol to
18 co-ordinate with the health visitor service or the GPs
19 in order to ensure that a parent, who may not recognise
20 important signs, is supported and helped to do so?
21 A. Yes, with regard to the general practitioner, the parent
22 is given a brief note at the time of discharge,
23 something of the diagnosis noted, the major elements of
24 treatment provided during the admission, and with a list
25 of the drugs which he or she should continue to take,
0058
1 and the doses. That information is given to the parent
2 who is asked to take a copy to the general practitioner
3 as soon as reasonable.
4 In addition a more detailed summary of the
5 patient's admission is sent, usually within two or three
6 weeks, with more detail of what took place during the
7 admission and with information, incidentally, the first
8 form would have information about the next expected
9 visit to outpatients, and the nature of the condition
10 and the treatment would be expanded in the case summary,
11 which would be sent to the general practitioner.
12 Occasionally, if the health visitor has been involved
13 previously, and is known, a copy of that summary could
14 be sent to her, and was sometimes done.
15 In patients where there are community elements
16 involved, social services, et cetera, a communication is
17 normally sent from the senior nursing staff or the
18 cardiology counsellor to these various services, to
19 inform them of the patient's status at the time and,
20 again, their medication that they would be taking.
21 Does that answer your question?
22 Q. I think it helps. Dealing with the situation of
23 a patient before discharge -- this is now looking at the
24 sort of case, and I stress "the sort of" case that
25 Jessica Hill represents, where a child comes in, is
0059
1 examined, VSD is recognised, and what is then important,
2 presumably, is whether the child thrives or fails to
3 thrive, because that may indicate a need for more urgent
4 intervention?
5 A. There are a variety of reasons why there may be a need
6 for urgent intervention. Again, I think it is very
7 difficult to talk in the broad, because in Jessica
8 Hill's case, the problem was one of pulmonary
9 hypertension and the need to get on with that at that
10 point, as I recollect -- I do not have her notes here --
11 I do not believe failure to thrive was a particular
12 problem, so it is essentially pulmonary hypertension.
13 Jacinta would be another problem, and other cases would
14 be separate problems. I cannot answer that in detail in
15 a general sense.
16 Q. But is it the case that in general terms, trying to
17 distill, if I can, the general proposition from the
18 specific evidence, in general terms a child patient who
19 first comes in and has a congenital heart problem
20 identified, needs to be given -- or at least, the
21 parents need to be given -- case specific advice as to
22 what to look for in order to help the clinicians to do
23 their job?
24 A. That is correct.
25 Q. And a system of follow-up appointments may be, I am
0060
1 asking, insufficient to enable that to be done?
2 A. Insufficient in which terms?
3 Q. If there is a follow-up set for six months time, let us
4 suppose, the six months of a child's life which may go
5 past during which events may happen which may be of
6 importance. If you are a clinician you recognise the
7 importance, if you are a parent you might not. One has
8 to help the parent to recognise the potential importance
9 of events in that period?
10 A. In general, if you advise a patient to return to
11 outpatients in six months time, that is, with very few
12 exceptions, I think a completely asymptomatic patient,
13 so there may not be any particular information that you
14 need give. For instance, a child with a secundum atrial
15 defect who does not need to be seen very often is not
16 going to be symptomatic, they will be perfectly normal
17 during that period. Whereas, if you were to see
18 a patient in one month, two months or six weeks,
19 generally speaking that will be a patient who is
20 symptomatic, who needs closer follow-up, and therefore
21 needs usually to be on medication.
22 In that kind of situation you would, of course, at
23 each occasion, whether it is an admission or at each
24 following follow-up outpatient visit, you would give the
25 information appropriate for the following period.
0061
1 Q. With parents, just asking about the practice
2 historically, between 1984 and 1995, was that
3 information given orally at the outpatient clinic or
4 consultation, or was it given in writing, or was it
5 both?
6 A. Verbally, to the patient. A letter would be written to
7 the general practitioner with the same information in
8 terms of, as I say, medication and other aspects to look
9 out for.
10 Q. And then that would depend upon the degree to which the
11 parent felt it important or appropriate to contact the
12 local surgery?
13 A. Yes.
14 Q. Practices as to that, presumably, would differ, but it
15 is not your concern directly?
16 A. Yes.
17 MR LANGSTAFF: Dr Houston, does that differ at all from the
18 practices with which you are familiar?
19 DR HOUSTON: Very little. You made comments about health
20 visitors. We have a liaison health visitor who goes
21 round and communicates with our colleagues out in the
22 community, where it is important. But I think
23 essentially what has been said is correct.
24 MR LANGSTAFF: So there is a system where you are which
25 maintains contact where it is important to do so by
0062
1 actually going to seek out the relevant information?
2 DR HOUSTON: I am sorry?
3 MR LANGSTAFF: The liaison health visitor?
4 DR HOUSTON: She would pass the information out to her
5 colleague in the community.
6 MR LANGSTAFF: To health visitors.
7 DR HOUSTON: Yes.
8 MR LANGSTAFF: But not to the parent directly.
9 DR HOUSTON: No, we would talk to the parents and explain
10 to the parents what to look out for and what to do.
11 MR LANGSTAFF: For how long has there been such a post?
12 DR HOUSTON: The health visitor?
13 MR LANGSTAFF: The liaison health visitor.
14 DR HOUSTON: A very long time, so far as I can remember.
15 I do not remember her not being there.
16 THE CHAIRMAN: I think the distinction Mr Langstaff was
17 trying to draw was whether you had some reactive
18 mechanism and proactive mechanism and I take it you are
19 describing the role of the health visitor being
20 proactive once having been briefed by your liaison
21 officer. Is that accurate?
22 DR HOUSTON: I would have thought so, yes, but the
23 information is given by ourselves.
24 MR LANGSTAFF: Can we turn away from the question of
25 communication, and have a look at some of the cases
0063
1 which arise from the Clinical Case Note Review. I tell
2 you, as I have told each of the clinicians who have
3 looked at such cases, that the purpose is not to
4 attribute blame in the sense that we are not a tribunal
5 hearing a medical compensation claim; it is to identify
6 what happened and to learn what lessons there may be
7 from what happened, as exemplars, because these are
8 chosen statistically as representative of the 2,000 or
9 thereabouts cases of children who were operated on
10 between 1984 and 1995.
11 Those which we have to deal with -- you have,
12 I hope, with you the notes of Sam Sollars?
13 DR JOFFE: Yes.
14 Q. In each of these cases we have the full consent of the
15 parent to deal with the case of his, her or their child
16 and that includes full authority to deal with the
17 medical notes.
18 Can I say that the way in which I am going to deal
19 with the cases are that the Panel may conclude at the
20 end, possibly, that we will look essentially
21 pre-operatively, moving in the last of the cases we will
22 deal with the factors which are more operative and
23 post-operative.
24 The case of Sam Sollars, if I may take fairly
25 quickly matters I expect there will be agreement on, but
0064
1 if there is anything you want me to stop on I shall do
2 so. If you want the medical record called up, if we
3 have the medical record we will call it up on the
4 screen.
5 Sam was born on 23rd August 1989, and was
6 diagnosed as suffering from Down's syndrome, with
7 a complete atrioventricular septal defect. That,
8 I think, is common ground.
9 A. Yes.
10 Q. He was admitted to the Special Care Baby Unit because of
11 cyanosis, and his colour improved in air, and came for
12 an echocardiogram on 23rd August 1989, which is the date
13 of his birth. The diagnosis was made then; he still had
14 a ductus which was patent.
15 For the next two weeks he remained in the Special
16 Care Baby Unit. He was seen by you on 22nd September
17 1989, therefore at the age of 1 month, bar a day. You
18 found him, I think, to be dyspnoeic, with a soft
19 systolic murmur and a loud second sound.
20 Just stopping there, that would indicate that
21 there was pulmonary hypertension?
22 A. Yes, if it is the second component of the second heart
23 sound, namely the pulmonary component, then that would
24 indicate pulmonary hypertension, that is correct. At
25 that age, the pulmonary hypertension could be
0065
1 a carry-over from the neonatal period, where all babies
2 are pulmonary hypertensive. What one would be more
3 concerned about is if it was beginning to show evidence
4 of pulmonary hypertension as early as that as
5 a progressive situation, which I must say would be very
6 unusual at that very early age.
7 Q. Dealing with pulmonary hypertension in general terms,
8 when children, babies, are born, their lungs are
9 naturally hypertensive, are they?
10 A. The pulmonary arteries are naturally hypertensive. That
11 is due to the persistence of the foetal state of the
12 circulation, where, because the lungs are deflated
13 in utero, the right ventricle has to pump at a certain
14 pressure against that resistance, in order to pass blood
15 in the foetal circuit from the right ventricle into the
16 pulmonary artery and via one of the essential
17 communications, the ductus, into the aorta.
18 The resistance in the body read by the aorta is
19 also high, so throughout pregnancy, throughout the
20 intra-uterine life of the foetus, the pressure in the
21 right ventricle will be at systemic level, in other
22 words, the same as the normal aortic pressure. So that
23 is correct. The right ventricle is dominant in the
24 new-born baby and pulmonary hypertension persists or at
25 least in the form of the changes within the small
0066
1 pulmonary arterioles inside the lungs, the muscular
2 hypertrophy would persist for quite a long period of
3 weeks or months. The actual pressure does tend to come
4 down fairly rapidly in the early days of life.
5 Q. So in the first few weeks of life the pulmonary
6 hypertension reduces in the ordinary child?
7 A. Yes.
8 Q. Where there is a heart defect, such as an AVSD or a VSD,
9 then on occasions pulmonary hypertension may not reduce
10 but may remain and if it does so, there are eventually
11 inevitable changes which take place in the lungs, we
12 have heard?
13 A. Yes.
14 Q. Those changes may, up to a certain extent, be
15 reversible, so that there will be no long-term
16 ill-effect, but if they go beyond that stage, they
17 become irreversible?
18 A. Yes, that is correct.
19 Q. And that inevitably shortens life?
20 A. Yes.
21 Q. So there is an importance inevitably in timing any
22 operation in which it is thought that there is pulmonary
23 hypertension?
24 A. Yes.
25 Q. One would want to do it sooner rather than later as
0067
1 a general proposition?
2 A. Yes.
3 Q. Again, if I am right, that would involve looking at any
4 child in which it was thought there was a risk of
5 pulmonary hypertension developing, or being present or
6 developing, at regular intervals to make sure that there
7 were no such changes as to make an operation futile?
8 A. Yes.
9 Q. In Sam's case, I think he continued in the Special Care
10 Baby Unit. By the time he got to the age of five weeks
11 or so, feeding was worse, he became sweaty, breathless
12 and his liver was beginning to enlarge. Those would all
13 be signs, would they, of heart failure?
14 A. They would.
15 MR LANGSTAFF: By "heart failure", so it is not
16 misunderstood, I think Dr Houston, you might want to
17 comment on the meaning of heart failure?
18 DR HOUSTON: Well, as I mentioned to you before, it is
19 a point, when you talk to parents and say "heart
20 failure", they have the concept of people having a heart
21 attack and their heart stopping and dying from that.
22 "Heart failure" just means it is under strain and you
23 get certain symptoms, as you know, related to that, but
24 the heart is not going to suddenly stop; it is just
25 under strain.
0068
1 DR JOFFE: Could I add that the symptom you have described
2 is because the volume of blood going through the lungs
3 in these situations where there is a communication is
4 excessive. That excessive volume returns from the lungs
5 to the left side of the heart into the left atrium and
6 then the left ventricle. So it is the left ventricle
7 that is specifically put under strain, due to
8 over-volume loading, and that means that there is
9 a passive pressure rise back into the veins of the
10 lungs, and increased volume in the lungs, so it is the
11 excess fluid essentially that overloads the left
12 ventricle and makes it therefore fail or be put under
13 strain, as you heard.
14 In addition, the excess congestion in the lungs
15 through the back pressure makes the lungs stiff and the
16 baby becomes breathless. Similarly, the back pressure
17 results if other organs becoming swollen, for instance
18 the liver, so that the essential signs of so-called
19 heart failure is breathlessness and enlarged liver,
20 difficulty to feed because of the breathlessness, and
21 therefore failure to thrive. Those are all the features
22 which I believe were present in Sam Sollars' case round
23 about this time.
24 Q. Indeed, entirely appropriately described as being in
25 persistent congested cardiac failure?
0069
1 A. Yes.
2 Q. On 10th December 1989 -- so he is now 3 and a half
3 months of age, there is a routine admission for
4 a cardiac catheter. The cardiac catheterisation showed,
5 did it, a complete AVSD; showed some AV valve
6 regurgitation, and it demonstrated a small left
7 ventricle compared with the right, with a large VSD
8 component.
9 I think you concluded -- you performed the report
10 on the catheterisation?
11 A. Yes, except for the angiography, which was reported on
12 by Dr Wilde, normally.
13 Q. There was a conclusion at the end of that that there was
14 pulmonary hypertension with increased pulmonary vascular
15 resistance, and there was a ratio of pulmonary flow to
16 systemic flow, RP over RS, which was recorded as being
17 0.49, was there?
18 A. Yes.
19 Q. And just --
20 DR HOUSTON: I am sorry, that is resistance, not flow.
21 MR LANGSTAFF: I am sorry, I should have said resistance,
22 I beg your pardon. There was a ratio of pulmonary flow
23 to systemic flow of 2P over QS?
24 A. Yes.
25 Q. The ratio of pulmonary resistance to the systemic
0070
1 resistance of 0.49 was quite high, was it?
2 A. Yes.
3 Q. That would be inevitably worrying?
4 A. Yes.
5 Q. So there was a need, was there, to operate really as
6 soon as an operation could be performed?
7 A. Yes. As soon as could reasonably be performed.
8 Q. There was a joint cardiac surgical meeting within seven
9 days, or seven days after the catheterisation which is
10 relatively prompt. It is on 18th December 1989.
11 Let us look at your letter, 2042/104 --
12 THE CHAIRMAN: We may need to take that address out.
13 MR LANGSTAFF: I am sorry, I think I have the wrong letter.
14 If you will forgive me, can we look at the BRI notes at
15 1565, page 184?
16 THE CHAIRMAN: I am being told there is no --
17 MR LANGSTAFF: You will have to forgive me. You, in any
18 event, I think, wrote on 20th December 1989 to
19 Mr Wisheart, saying that it appeared that there was
20 a considerable increase in the pulmonary blood flow
21 following hyperoxygenation, suggesting dynamic and
22 probably reversible pulmonary hypertension. You added
23 a "PS" to Mr Wisheart saying would he be prepared to
24 put him on the surgical waiting list in the relatively
25 near future?
0071
1 A. Yes.
2 Q. The operation did not take place for what was
3 effectively a further six and a half months, on 2nd July
4 1990, when he was then 10 months of age. What do you
5 say about the length of time that it took between the
6 catheterisation in December 1989 and the timing of the
7 repair?
8 A. I would have wished it to have been done earlier. As
9 I mentioned, I think yesterday, at the time of the joint
10 meeting, and soon after, two days later in fact, after
11 the hyperoxia test, and as you recorded in my letter,
12 there was a note of urgency in the "PS", but the system
13 was such that the surgeons, generally speaking, would
14 wish to discuss the operation in detail, in outpatients,
15 in order to explain to them what the operation was all
16 about, and also to talk to them about risks. That
17 consultation took place with Mr Wisheart at seven
18 months, on 28th March 1990, and the child was put on the
19 waiting list. Because of the pressures that we
20 discussed yesterday, between adults, I presume, and
21 children, the anticipation was that the actual operation
22 would be performed in May or June.
23 Indeed, the operation was performed, as you say,
24 at 10 months on 2nd July 1990.
25 Our role firstly, as paediatric cardiologists, is
0072
1 to provide the surgeons with all the information, as
2 much as possible, and the system being as it was with
3 a split site and the combined adult/children service for
4 open-heart surgery at the BRI meant that the waiting
5 list control was in the hands of the surgeons.
6 Q. Can I just ask you to pause there? By all means we will
7 come back to what you are saying but I now have the
8 reference I wanted to show you. It is 2402/184.
9 THE CHAIRMAN: I am grateful to those behind you, thank
10 you.
11 MR LANGSTAFF: So am I! Can we scroll down? There is
12 a copy to Mr Wisheart, a letter to the general
13 practitioner. If we go down to see what the "PS" says,
14 can we highlight that and enlarge it?
15 That is the "PS".
16 A. Yes.
17 Q. "The improvement in oxygen suggests that Sam has
18 essentially reversible pulmonary hypertension. Would
19 you be prepared to put him on your surgical waiting list
20 for complete correction in the relatively near future?
21 For further discussion, query for outpatient appointment
22 for discussion of operation with parents."
23 So there is a note of urgency in your approach, is
24 there not?
25 A. Yes.
0073
1 Q. If we pick up what then happens, at page 182, this is
2 the letter to you from Mr Wisheart:
3 "Could we please discuss Sam fully again at an
4 early opportunity. Thank you for your letter of
5 20th December."
6 By now three weeks has gone past.
7 DR JOFFE: It is not on my screen yet.
8 THE CHAIRMAN: Just to explain what is happening, Dr Joffe,
9 when that happens it is because we are anxious to remove
10 an address or some other identifying quality. Sometimes
11 that will happen, forgive me if it does, but it will
12 come back when we have edited it.
13 DR JOFFE: Thank you, sir.
14 MR LANGSTAFF: So three weeks have now passed and
15 Mr Wisheart is asking to discuss Sam fully again.
16 A. Could I point out the note on the top right-hand corner.
17 Q. "For Mon. am discussion".
18 A. Yes. I do not know if there was a letter about that,
19 but it was discussed the following Monday.
20 Q. What we have at 2042/181 is a letter from the consultant
21 paediatrician to Dr Rice. The second paragraph:
22 "No major problems recently. As you know, he was
23 seen in Dr Joffe's clinic before Christmas and Dr Joffe
24 wrote to Mr Wisheart with a view to possibly arranging
25 for Sam to be admitted for complete correction of his
0074
1 AV canal defect at some stage in the not too distant
2 future. Since that time Mr and Mrs Sollars have not had
3 any further communication from Dr Joffe or Mr Wisheart
4 and are very anxious to know what the plans for Sam's
5 future cardiac care will be. By a copy of this letter
6 I will ask Dr Joffe if he would mind making contact with
7 Mr and Mrs Sollars in the next week or two to let them
8 know his plans for Sam's future care."
9 So the parents were getting a bit anxious about
10 progress. In this case, where you had obviously had
11 a certain idea of urgency in December, where Mr Wisheart
12 has asked to discuss the matter with you in January,
13 when the parents are getting anxious, ideally the
14 operation should have happened very shortly thereafter?
15 A. Yes, ideally that is so, given those haemodynamic
16 findings. At that time, although there was, if I can
17 add, some move towards operating earlier, in infancy
18 with children or babies with AVSDs, this particular case
19 was seen in 1989/90 and as we discussed yesterday, it
20 was the effect of the Frimley Park meetings which took
21 place in 1991, I believe, which particularly highlighted
22 the need to operate on babies early, for this very
23 reason, among others.
24 So on the one hand, yes, I was concerned, as you
25 have pointed out, that given these haemodynamics we
0075
1 should get a move on. At the same time, there was
2 a view around at the time, in most centres, I dare say,
3 where patients with this condition were still being
4 operated at the latter end of the first year, or maybe
5 even after.
6 I just point that out to give the background to
7 the situation, but my own feeling was that this patient
8 needed to be done soon.
9 Q. Suffering from pulmonary hypertension in the way that
10 these notes describe, the child obviously was not going
11 to get better spontaneously?
12 A. Not from the point of view of pulmonary hypertension,
13 no.
14 Q. The child was not well and needed medical treatment, so
15 whatever the general view may have been as to age of
16 operation, this child needed to be operated on promptly?
17 A. Yes.
18 Q. And was not; and you have explained in your evidence
19 yesterday that that was outwith your control?
20 A. Yes.
21 Q. But Dr Houston, what do you say about the timing of the
22 operation relative to the catheterisation and the delays
23 in this case?
24 DR HOUSTON: I agree, I think, with what you have both
25 said. It would have been ideal to operate fairly soon
0076
1 after the catheter. One of the points I would say is
2 that the catheterisation is done only when you are
3 thinking that the child should be -- not always, but in
4 this case you are doing it with a view to surgery, and
5 if the surgery was not going to be carried out for
6 several months, perhaps a catheter could have been done
7 nearer the time, so you knew the situation just at the
8 time of surgery. Am I making myself clear?
9 MR LANGSTAFF: You are. You are saying there are two
10 points: the timing of the operation and the timing of
11 the operation relative to the catheterisation?
12 DR HOUSTON: Yes. I think to catheterise and leave a child
13 like this for seven months is rather long, as Dr Joffe
14 has said.
15 MR LANGSTAFF: So I think there is general agreement between
16 those who have looked at this case that the delay was
17 regrettable; to the extent of being unacceptable, you
18 say, or not?
19 DR HOUSTON: I do not think I would go as far as to say
20 "unacceptable". The child had the operation, the
21 pressure came down.
22 MR LANGSTAFF: The child, in fact, as we know, survived.
23 DR JOFFE: The child is alive and well, is now aged ten
24 years, and has obviously had reversible pulmonary
25 hypertension, and that is confirmed by the -- I beg your
0077
1 pardon. The post-operative course was prolonged by
2 septicaemia, but certainly the clinical course confirmed
3 this child survived without progress of pulmonary
4 hypertension. There is no indication that there is
5 a persistence of pulmonary vascular disease.
6 Q. If you like, what was risked by the fact of delay in
7 this case, delay which we agree was regrettable, was the
8 prospect that the pulmonary vascular changes might get
9 worse, and such changes are often associated, are they
10 not, as it happens, with Down's syndrome children?
11 A. They are more common in Down's children. The other
12 problem, of course, is the immediate post-operative
13 phase where pulmonary hypertensive crisis, so-called,
14 also complicates the course. To that extent, it is
15 believed in latter years that the earlier operation
16 might avoid some of those problems occurring as well.
17 THE CHAIRMAN: Mr Langstaff, just for clarification, the
18 acceptability or otherwise does not necessarily relate
19 to the outcome but running the risk as to what the
20 outcome might be. I think that is more to the point
21 than the fact that the child may or may not have
22 survived. Can I ask you to respond to that?
23 DR HOUSTON: Yes. Again, I think one of the questions is,
24 was there a definite intention to leave the child to
25 that age? If that was the case, I think the catheter
0078
1 should have been done later. I think if the catheter
2 was done and there was a decision to go ahead and
3 operate, it should have been done sooner. The word was
4 "unacceptable" --
5 MR LANGSTAFF: That is what I asked.
6 DR HOUSTON: -- I did not answer "unacceptable". I think it
7 was too long and I think it was inappropriate.
8 THE CHAIRMAN: Forgive me, it is my usual elliptical way.
9 In response to the question whether it was unacceptable
10 or not, you seemed to say that the child is alive and
11 well, on your understanding, and I was putting to you
12 that the acceptability or otherwise may not go to that
13 but to the risk run by delaying or not doing the
14 surgery.
15 DR HOUSTON: I was sort of failing to answer the question.
16 If you have to say "acceptable" or "unacceptable",
17 I would choose "unacceptable".
18 DR JOFFE: But I do believe your definition in your review,
19 among your experts, gave a score of 1. If whatever
20 fault there may have been was unacceptable and would
21 have caused permanent disability or damage -- I forget
22 the precise words -- this patient survived and did well,
23 so did not suffer permanent disability as a result of
24 this operation. I think I am correct in those
25 definitions.
0079
1 DR HOUSTON: I would agree with that. I do not think it
2 should have been graded 1.
3 MR LANGSTAFF: It would have made a difference to outcome,
4 I think, is the difficulty -- you were not a member of
5 the Panel, Dr Houston?
6 DR HOUSTON: No.
7 MR LANGSTAFF: It is difficult to know what the Panel had in
8 mind in terms of outcome, whether a longer stay in ITU
9 as a possibility, in that sense, but certainly, with
10 reversible changes in the lungs, as I asked you earlier,
11 in the long-term the delay in fact has caused no
12 difference to outcome.
13 DR JOFFE: Ipso facto, this was an acceptable omission.
14 THE CHAIRMAN: With respect, that is not an ipso facto.
15 It could be well described as fortuitous analytically,
16 and that is quite an important distinction to draw.
17 MR LANGSTAFF: I think if one looks at it in overall and
18 theoretical terms, Dr Joffe, one may learn quite a lot
19 from what one might call near misses or cases where
20 something has gone wrong but in the end it did not
21 actually cause a problem, may one not?
22 DR JOFFE: Yes. If I might answer the point made by
23 Dr Houston, I agree with him that the catheter should be
24 done as soon as possible before the operation under
25 these circumstances. That was the intention, that the
0080
1 operation should follow hard upon.
2 MR LANGSTAFF: May I again make it clear that the criticism
3 here is the system. It is the delay; it is not directed
4 at you personally.
5 DR JOFFE: No, I would hope not, in this case.
6 MR LANGSTAFF: Because personally, you were saying "Let us
7 get ahead and do the operation", and you were
8 disappointed it does not happen?
9 A. That is right.
10 Q. But the reasons, we learn from this what might have gone
11 wrong might have been the consequence of delay, because
12 the delay might actually have put this child at serious
13 risk?
14 A. Yes, I agree with that.
15 Q. That delay, you would ascribe to the reasons you gave us
16 yesterday, for the split site, the adult theatre, the
17 difficulty of operating lists being under the control of
18 surgeons who were mixed adult and paediatric?
19 A. Yes.
20 Q. And the probability is that if such a case arose today,
21 under the system that you now have, it would be dealt
22 with very soon after the catheter?
23 A. Within two or three weeks.
24 Q. Which is how it should have been?
25 A. Yes.
0081
1 Q. Before I leave this general area -- that, I think, was
2 the message that we might have learned from this, and
3 I think we are at one on that.
4 A. Yes.
5 Q. If I can just ask a little about the development of
6 pulmonary hypertension, Dr Houston: children are born
7 with naturally hypertensive lungs. Does that mean that
8 they are suffering any degree of damage to their lungs?
9 DR HOUSTON: The normal child, no. It is normal, and the
10 pressure is high, as Dr Joffe says, in utero when the
11 lungs are collapsed and very little blood goes through
12 them in the normal way. With the first breath, their
13 lungs are opening up and the flow increases through them
14 and their resistance increases over the next couple of
15 weeks.
16 MR LANGSTAFF: We see, in this case, a catheterisation
17 showing there was a high degree of hypertension -- I say
18 a high degree -- there was a hypertension present which
19 needed fairly speedy operation, and nothing in fact
20 happens for six and a half months.
21 Within that period of time there has been an
22 involvement plainly of the paediatrician, Dr Fleming.
23 There has been a discussion between Mr Wisheart and
24 yourself, Dr Joffe. But what degree of follow-up is, do
25 you think, necessary in a period of delay like that to
0082
1 make sure that the child who is at risk of the changes
2 which are taking place becoming irreversible, does not
3 actually get to that stage and if necessary, even within
4 a system where the operation is not likely to be done
5 for six months, it can be brought forward as an
6 emergency if necessary?
7 What system should exist for that?
8 DR JOFFE: I would have said probably monthly visits to keep
9 an eye on the child, but in effect, in this kind of
10 situation, and I believe Dr Houston is likely to agree,
11 there is unlikely to be any change in the clinical
12 status of the patient over the next few months. It is
13 the knowledge that the pulmonary vascular resistance at
14 this kind of level does tend to progress. The rate of
15 progression is unknown. It varies from case to case.
16 In this case, as you have seen, fortuitously, the rate
17 was relatively slow, although I believe it is quite
18 unusual to have this degree of pulmonary vascular
19 resistance in a child of 3 and a half months when we
20 catheterised the child.
21 So the follow-up visits, even though of course one
22 wants to keep an eye on the child, is not going to,
23 I believe, reveal any deterioration. That is happening
24 inexorably in the small pulmonary arteries of the lungs,
25 and will only really become apparent 15 or 20 years
0083
1 later.
2 DR HOUSTON: Indeed, as resistance goes up, the child
3 might improve, so I think seeing the child over that
4 period, I agree entirely, you are not going to have any
5 signs to see that things are getting worse.
6 MR LANGSTAFF: So the important thing for any child who
7 is at risk of pulmonary hypertension developing is to
8 identify that it is there, or it is a serious risk and
9 to operate as soon as one can.
10 DR HOUSTON: Not as soon as one can. One has to have
11 a balance. In theory, you could say you could operate
12 in a fortnight, but you would not do that. Years ago we
13 had the concept that if you operated before the age
14 of 2, the changes were likely to be reversible. I think
15 now we would always operate much earlier than that,
16 because it is not always the case that they will return
17 to normal and in particular in Down's syndrome, they
18 tend to get changes earlier, so we would be particularly
19 keen to operate on them at an early age, six months or
20 so.
21 MR LANGSTAFF: How common is the case, as for instance the
22 case of Jessica Hill we looked at or talked about this
23 morning, in which the changes are so advanced at such an
24 early stage?
25 DR HOUSTON: That would not be common. She was about
0084
1 six months. I do not have all the information on her,
2 but there are people who will get changes similar, who
3 have what is known as primary pulmonary hypertension,
4 where they do not have a heart problem and those changes
5 occur. So there are a variety of different reasons for
6 this occurring. For someone with VSD to have high
7 resistance that does not come down at seven months, it
8 would be uncommon.
9 Q. In fact, Jessica was just over seven months, but that
10 does not make much of a difference, or does it, to the
11 point you are making?
12 DR HOUSTON: No, I would not have thought so. Seven months,
13 six months, five months, it is very similar, but I do
14 not know the exact figures for her. I do not know the
15 details.
16 MR LANGSTAFF: No, but in terms of general principle, if
17 a child is identified as being at risk of hypertension,
18 what you are saying is that such is the general
19 approach, that it is thought that operating at six
20 months or seven months is acceptable, and indeed, you
21 are saying that earlier, some years ago, it was thought
22 that within two years was acceptable, because of the
23 general experience of how often those changes became
24 irreversible.
25 Can I ask, if the changes in fact biologically
0085
1 become irreversible at some stage and you do not know
2 how fast it is happening in a particular child's case,
3 why wait at all?
4 DR HOUSTON: Nowadays, one would tend to go ahead with --
5 you mean why wait at all? You are not going to operate
6 in the first month or two, wait until the child is a bit
7 larger and you know the child is definitely going to
8 need the operation.
9 Q. Because ...
10 DR HOUSTON: Because of heart failure or pulmonary
11 hypertension. VSDs can close, so you would not operate
12 when you diagnose them in a baby of a week or two. An
13 appropriate size would be about six months. I think the
14 ages come down because of modern surgery and it is now
15 relatively straightforward to operate on infants,
16 neonates, so four, five, six months would be an
17 appropriate age, now.
18 DR JOFFE: There is a difference between ventricular septal
19 defect and complete AVSD in a Down's child; would you
20 agree?
21 DR HOUSTON: Yes.
22 MR LANGSTAFF: This is because the VSD will in many cases
23 close naturally.
24 DR JOFFE: And also because the rate of progress of
25 pulmonary vascular disease seems to be particularly
0086
1 rapid over a range in children with AVSDs and Down's,
2 and even non-Down's, AVSDs.
3 MR LANGSTAFF: If there is a risk of hypertension in some
4 children becoming irreversible, which you cannot predict
5 from simply observing a child in daily life, how
6 important is it to carry out tests which might
7 demonstrate this to ensure that the child is not one of
8 those who is particularly at risk?
9 DR JOFFE: The only way would be, as Dr Houston mentioned,
10 to either do the catheter immediately prior to surgery
11 or to repeat the catheter at that time. There is no
12 other way, I believe, even echocardiographically, that
13 can differentiate or define what degree of pulmonary
14 vascular disease there is. You can measure the
15 pressure, the right-sided pressure if there is
16 a tricuspid reflux or pulmonary incompetence. The
17 Doppler system will allow you to make a measure which is
18 not direct but indirect, but that pressure will always
19 be at systemic level. Once the pressure has reached
20 that level, it stays there. It is the additional factor
21 associated with pulmonary hypertension, namely the
22 resistance, due to the pathology in the lungs, that
23 progressively increases, whereas the pressure remains
24 the same.
25 MR LANGSTAFF: Dr Houston, we are talking generally here,
0087
1 having gone on really from Sam's case, to talk generally
2 about the management of such conditions as VSDs in young
3 babies. One option is to leave the VSD to close, as you
4 have said. How important is an apparent failure to
5 thrive in the child?
6 DR HOUSTON: Rather than just answering that
7 straightforwardly, when a baby is born with a VSD, this
8 is the sort of thing you would tell the parents: first
9 of all, that the baby might have a relatively small VSD
10 which will make a noise and not affect the child in any
11 way.
12 Secondly, because of the high flow to the lungs
13 that has been mentioned, there may be heart failure and
14 the baby will not gain weight. That would be an
15 indication over a period of the closure of the VSD
16 surgically. But not at the age of six weeks or two
17 months, usually. If a child is in heart failure you
18 will usually treat it medically; it will need extra
19 calories in the feed, and often tube-fed, to see if they
20 will make some progress.
21 So generally, you would try and treat the heart
22 failure medically but if that failed to work, any time
23 from three, four months, it would be appropriate to go
24 ahead and close it, I would have said.
25 So it would be an indication with heart failure
0088
1 that you are not controlling, but you would tend, rather
2 than saying, "The baby is in heart failure, let us close
3 the VSD now", you would tend to treat it medically and
4 try to get the child to grow a little.
5 MR LANGSTAFF: If the baby does not appear to be in heart
6 failure and appears to be all right so far as the
7 mother, the parents can tell and the health visitor and
8 GP and so on, what then.
9 DR HOUSTON: You would want to ascertain that the child did
10 not have pulmonary hypertension, so you would follow the
11 child up and it is relatively straightforward, as
12 Dr Joffe said, to assess the pulmonary pressure with
13 Doppler ultrasound. So I would suggest that the child
14 would be followed up and assessed about five, six
15 months. If there is pulmonary hypertension, then you
16 have to consider closing it because of the problem of
17 heart failure occurring.
18 MR LANGSTAFF: So the timing of that condition, it really is
19 the first identification of the condition, the
20 consultation, being aware that there is a failure to
21 thrive and one may need an operation some time between
22 three to four months, and any time thereafter.
23 DR HOUSTON: Yes.
24 MR LANGSTAFF: If there is apparent thriving, one would
25 leave it for six months and then investigate to make
0089
1 sure that everything was satisfactory?
2 DR HOUSTON: Round about that, five or six months, yes.
3 MR LANGSTAFF: Do you agree with what Dr Houston has been
4 saying?
5 DR JOFFE: Yes, I do indeed.
6 MR LANGSTAFF: Before we leave Sam's case, I described him
7 in observation to you as "alive and well". We know,
8 I think, that he suffers from damaged lungs, and becomes
9 breathless easily and has similar problems, so he
10 continues to have problems, I think, associated with the
11 heart condition for which he was operated upon.
12 DR JOFFE: I would need to check that. It is not my
13 information.
14 Q. We can leave that, and if necessary that can be
15 clarified later.
16 A. Fine.
17 Q. In the same way, you have seen, I think, the comments of
18 a Mrs Harris about her child, and what I invite you to
19 do, because you have not had a chance to look at the
20 medical records in detail, is if you would please
21 consider what is said and respond to us in detail about
22 that case in writing. I need not trouble you with it
23 today.
24 DR JOFFE: Thank you.
25 DR HOUSTON: Can I comment on Sam Sollars? I would raise
0090
1 the question as to whether there is any lung problem.
2 There is a figure after the operation suggesting that
3 pulmonary artery pressure had come down. There is
4 a figure of 35 to 40 quoted following operation, when
5 the systemic pressure was 70 to 75. That is 2042 --
6 MR LANGSTAFF: We may be in danger here of focusing too much
7 upon individual cases. The purpose is as to exemplars.
8 What I am attempting to do is make sure what I say is
9 accurate and does not cause unnecessary distress.
10 DR JOFFE: I agree with Dr Houston, you did suggest that
11 this child had some element of pulmonary vascular
12 disease and was breathless later on in life, and the
13 usual procedure that happens biologically is that either
14 the pulmonary vascular resistance progresses and
15 continues to do so, or it reverses, and usually,
16 ultimately normalises. The pulmonary artery pressure
17 may stay up slightly from the normal of 25 to, let us
18 say 40, but that does not produce any symptoms, and
19 generally speaking the child can go on and have a full
20 life for a Down's patient, so I think it is
21 a distinction to make.
22 Q. Can we move on to the case of Ross Hukku.
23 Again, let me take you through some of the areas
24 likely to be uncontroversial fairly quickly. Ross was
25 born on 31st January 1988 and first seen by you,
0091
1 I think, on 24th June 1988, where it was said that he
2 had not thrived from about six weeks of age. There was
3 no cyanosis but the clinical features favoured the
4 diagnosis of AVSD with a left to right shunt and marked
5 pulmonary hypertension.
6 You, I think, suggested that there should be
7 2-dimensional echo as soon as possible with a follow-on
8 cardiac catheterisation?
9 A. Yes, normally speaking there would be an echo machine at
10 the peripheral clinic. This was in Exeter. Either they
11 were changing machines or for whatever reason there was
12 not one available, I presume, so I asked that one be
13 done at the Children's Hospital as soon as possible,
14 given the late presentation of this patient, that came
15 to our attention only at five months of age.
16 Q. So we are looking essentially at the same condition in
17 general terms as we have been discussing in Sam's case?
18 But the cardiac catheterisation is carried out,
19 if we look, MR 726/25. If we scroll down, please, if
20 one picks up just underneath 15, where it deals with
21 pressures, we have "RFA", right femoral artery
22 "needled", and then we go across and the comment is
23 "damped", with a gradient of 20. Can we have that
24 highlighted, please?
25 The echocardiogram that you have done had
0092
1 confirmed the diagnosis of the complete AVSD with
2 a large atrial ventricle component and with a small
3 aorta. The gradient of 20 would demonstrate, would it,
4 that there was some coarctation in the aorta?
5 A. Yes. And I would have graded it as mild. The impact of
6 the word "damped" is that the femoral artery fracture
7 may not be as high as it normally should be, in other
8 words, the peak will be lower, which means it would
9 accentuate the gradient. That is why that was put in.
10 Two lines further down, when slightly better pressure
11 wave was obtained in the femoral artery, the gradient is
12 16. A gradient of 16 at catheter, purely based on
13 pressures, I would rate as mild. Others may rate it
14 higher.
15 Q. I was quite interested in the different descriptions you
16 used yourself. If we go to page 27, where you deal with
17 the report, under the heading "Aortogram", the sending
18 out of the arch of the aorta, it appears normal, but
19 there is a moderate coarctation of the arch of the
20 aorta. Catheter indicates mild with a gradient of 10.
21 You conclude at the bottom of the page:
22 "Mild coarctation with maximal gradient of 20 mm",
23 and you point out that is damped. But in the text there
24 is first of all a description of moderate coarctation
25 and then you say, well, it is mild. Was there some
0093
1 uncertainty about it?
2 A. No. As I mentioned earlier, the angiography is
3 interpreted by Dr Wilde. The comments on the
4 angiography are his. He put in the word "moderate" for
5 his interpretation of the aorta in its appearance on
6 angiography, but taking that as I perceived, together
7 with a gradient which, at the time of the catheter, we
8 thought was just 10, he has come to a conclusion that
9 this is mild.
10 My conclusion, at the bottom of the page, if we
11 may return, is a combination of the impact of pressures
12 and angios together, and it states there is mild
13 coarctation of the aorta with maximal gradient of 20 --
14 that is putting it at its worst -- damp pressure.
15 Q. Where there is a coarctation of the aorta, if it is
16 anything other than mild, in terms of the desirable
17 surgical procedure, one would want to remedy the
18 coarctation first before one attempted to rectify the
19 AVSD?
20 A. Yes.
21 Q. And so there would be effectively two operations or
22 a two-stage repair of the problem?
23 A. Yes, that is correct.
24 Q. And the reason for that?
25 A. The reason is that the left ventricle, after
0094
1 cardiopulmonary bypass, is going to be under strain and
2 stress anyway and that to have a significant degree of
3 obstruction to outflow from the left side of the heart
4 would put an additional strain on the left ventricle,
5 which could be avoided if the coarctation was corrected
6 first.
7 Q. There was a discussion as to how one should approach
8 this particular case, and we can pick that up at page 24
9 in the medical notes. It is the paragraph which begins:
10 "After some discussion, it was agreed that the
11 coarctation was mild and probably not influencing his
12 present condition significantly, and therefore unlikely
13 to be a significant post-operative factor", and the
14 agreement is to do the AVSD as a first procedure.
15 So a decision taken upon the basis of a view as to
16 the extent of the coarctation, whether it was mild or
17 whether it may have been larger, concern, and an
18 approach taken therefore, in the view that it was mild,
19 to go ahead with the operation and operate as one stage?
20 A. That is correct. May I take this note down to the
21 bottom to ensure the signatory is evident?
22 Q. Yes. (Pause). As it happens, at postmortem -- we may
23 be able to look at this; it is page 15 to 17. We will
24 start at page 15. If we go over to page 16, we see
25 Dr Berry's report as to the size of the coarctation. It
0095
1 is just above the first horizontal line across the page:
2 "There is a coarctation of the aorta 2.5 mm in
3 diameter opposite the ligamentum arteriosum.
4 That, as measured at postmortem, is actually
5 a very severe coarctation, is it not?
6 A. If that is a correct interpretation of what the
7 situation is in a patient who is alive and not in
8 a specimen which has become formalinised and therefore
9 very often constricted, I would agree with you.
10 Q. If it had been appreciated in life that the aorta may
11 have been coarctated to that extent, then the operation
12 would have been a two-stage operation and not
13 a one-stage?
14 A. Yes.
15 MR LANGSTAFF: Given the importance of knowing the size of
16 the coarctation, what, Dr Houston, would you say about
17 the decision to go ahead as a one-stage operation?
18 DR HOUSTON: Given the postmortem information? Given the
19 postmortem information, the coarctation should have been
20 attended to, but it is difficult to tie that postmortem
21 with the findings at catheterisation, with the pressure
22 gradient and the comment on the angiography.
23 DR JOFFE: May I ask, if I may, if the review group had the
24 benefit of seeing the angiography?
25 DR HOUSTON: They should have. The review group should have
0096
1 the angios, unless they were missing. I do not know if
2 they were or not.
3 DR JOFFE: Thank you.
4 THE CHAIRMAN: Mrs Howard has a question.
5 MRS HOWARD: Can I go back to the point you have made?
6 I think you said at 95/17:
7 "If that is a correct interpretation of what the
8 situation is in a patient who is alive and not in
9 a specimen which has become formalinised and therefore
10 very often constricted, I would agree with you."
11 Are you suggesting by that statement that one
12 cannot comment on the severity of coarctation by
13 postmortem alone.
14 DR JOFFE: Yes, I am commenting that one cannot obtain an
15 accurate assessment. It is small, I do not think there
16 is any doubt about that. There is coarctation, I am not
17 debating that.
18 MRS HOWARD: So you are not going as far as to say one
19 cannot comment on the coarctation.
20 DR JOFFE: By no means. This patient has coarctation.
21 I would refer to another point. Going right back to my
22 first note of this patient, that is MR 0726/0032, there
23 is a drawing there under "Pulse", about halfway down
24 that page, those plusses -- they look like noughts and
25 crosses with no noughts. Either my clinical acumen has
0097
1 fallen off in my over 30 years of experience, or what
2 I have put down there represents what I actually did
3 find, and that is that the femoral pulses are present.
4 This cannot in any way be a severe coarctation. In
5 children I think that invariably the pulses would be
6 small and in severe cases usually absent. When the
7 patient was admitted, I did note then for the first
8 time, and that is on MR 726/0008. I think that is the
9 right one.
10 MR LANGSTAFF: I think you are looking at the end of the
11 first line --
12 THE CHAIRMAN: Not yet; we are just taking something out.
13 DR JOFFE: In the top line, the pulse is down and the echo
14 as you pointed out earlier, "small aorta". In the
15 summary, I think I made the comment that the femorals
16 were present but not as obvious, so we were very aware
17 that there was a coarctation.
18 MR LANGSTAFF: Can I just ask you to pause there, because
19 there is something else you may want to comment on;
20 that is at page 7, under "CVS". This is not your note,
21 but it is obviously the note of the admitting clinician,
22 where it looks at the pulses and the note is "femorals",
23 and below, "are difficult to palpate"?
24 A. Yes. I think it is important to know who wrote that
25 note.
0098
1 Q. Can you help with the writing?
2 A. I cannot, I am afraid, in which case, I do not believe
3 it was Dr Jordan or Dr Martin, who had just started that
4 year, so it could only have been one of the SHOs. Given
5 the date and the structure of the report, I would think
6 it is an SHO who is putting down those notes on
7 admission, presumably for the catheter.
8 As I mentioned earlier, I think with experience
9 one improves one's facility with detecting the femoral
10 pulses and whether they are absent or not. I hope I am
11 not maligning this SHO, but it is not an easy sign.
12 Q. Is the picture then one of a femoral pulse which is
13 perhaps difficult for a more junior doctor to detect,
14 one which you, having more experience, practising in the
15 field, detect although you notice as "depressed", back
16 to page 8? How does that relate, on 29th June, if we go
17 back to page 31 -- we have not been to page 31 yet, but
18 it is the start of the diagram you showed us earlier,
19 24th June in your writing. If we just scroll down, is
20 that the first page of what we saw at page 32?
21 A. Yes.
22 Q. Can we go back to page 32, then, overleaf? There the
23 pulses seem to be all right.
24 A. Yes.
25 Q. So do we have the picture that on 24th June, five days
0099
1 before the admission, the pulses seem to be patent, to
2 you, on examination?
3 A. Yes.
4 Q. But on admission, there is some difficulty in detecting
5 them?
6 A. Yes.
7 Q. Or detecting them as clearly as they might be?
8 A. Yes.
9 Q. Does that summary help at all with whether one might
10 learn from that that there was a coarctation or not, and
11 if so, to what degree?
12 A. Yes. I think there is no argument about the fact that
13 there was a coarctation; it is a matter of degree.
14 There is, I think, a written letter that goes along with
15 this diagram, if I can pick it up --
16 Q. I think we have that at page 29.
17 A. Yes.
18 Q. It is not very clearly photocopied, I am afraid. Which
19 part do you want to take us to?
20 A. I wanted to see what I said about femoral pulses.
21 THE CHAIRMAN: We are just taking out some addresses and
22 there is a telephone number higher up. (Pause).
23 MR LANGSTAFF: It is the bottom of that page:
24 "On examination", and the fourth line down, "liver
25 is 1 centimetre palpable and pulses are all present and
0100
1 equal in sinus rhythm."
2 DR JOFFE: That is correct, yes, which augments my comment
3 or figure on the written note.
4 MR LANGSTAFF: So given this level of information,
5 Dr Houston, given the importance of the coarctation and
6 needing to know what, as a matter of degree, it was in
7 terms of mild, moderate, and so on, what do you suggest
8 was an appropriate approach?
9 DR HOUSTON: I think the critical thing is in fact whether
10 the pulses were reduced clinically, which I think it
11 would seem to be the case from the second note, and
12 given that, I must say I would have been inclined to
13 deal with the coarctation first and then the AVSD.
14 MR LANGSTAFF: Is there any way of getting a better
15 measurement of the coarctation?
16 DR HOUSTON: Not really. The measurement was made in the
17 femoral artery. You could have said, perhaps a catheter
18 should have been put across the coarctation and measure
19 it, and a pull back -- I presume, was put in -- it was
20 just a needle in the femoral artery to preserve the
21 femoral artery rather than putting in a catheter.
22 DR JOFFE: That is correct.
23 DR HOUSTON: The measurement was there, and there is no
24 reason to doubt that the measurement was not high. It
25 is quite difficult to tie everything together with the
0101
1 postmortem finding here.
2 DR JOFFE: Yes.
3 DR HOUSTON: But I think the pulses were reduced and that
4 indicates there is coarctation, no doubt.
5 DR JOFFE: May I venture to ask for some attention to be
6 given to the comments in the experts' page 3:
7 "Post-operative care and assessment; pulmonary
8 vascular disease unlikely. Pulmonary hypertension,
9 probably due to increased LA pressure, secondary to left
10 ventricular failure, coarctation."
11 MR LANGSTAFF: I think that is "secondary to coarctation".
12 DR JOFFE: Yes. In other words the coarctation is stated
13 implicitly to be the cause of left heart failure, which
14 in turn is taken to be the cause of death. I entirely
15 accept that this baby had left ventricular failure on
16 the evidence of pressures and indeed, the postmortem
17 statement, but to jump from there to the cause of death
18 being due to left ventricular failure due to coarctation
19 I think is a jump too far. There are other possible
20 causes of death in this situation which must at least be
21 considered as alternative causes of left ventricular
22 failure.
23 After a long bypass case, left ventricular
24 function is a very important measure and indeed, that is
25 why there has been the drive in recent years to have
0102
1 echocardiograms performed soon after operation virtually
2 as a routine, which we do do now, in Bristol, which we
3 were unable to do at this time in 1988.
4 Secondly, a very well known complication of
5 post-surgical failure of AVSD is severe mitral
6 regurgitation.
7 Thirdly, a potential cause for left ventricular
8 failure would be obstruction of the left ventricular
9 outflow tract, and in some patients, whether on echo or
10 angiography, that left ventricular outflow tract
11 narrowing cannot be established or identified until the
12 patch is actually put in place and it presents itself
13 after the operation.
14 There are three possible alternative causes. All
15 of them would have been demonstrable by
16 echocardiography. Unfortunately, I was unable to find
17 that that was done immediately post surgery, so I would
18 refute the conclusion that has been arrived at by the
19 expert.
20 MR LANGSTAFF: May I say at once, in response, that you have
21 every right to ask that this case be reviewed by another
22 expert reviewing team, who can form their own
23 independent conclusions on the case, if you would wish
24 that. This is not the time or the place to review the
25 case, as I said to you earlier, as though it were
0103
1 a trial in respect of compensation claims for something
2 which happened in the course of medical treatment.
3 A. Yes, but with respect, if it is going to be used as an
4 exemplar, it needs to be accurate, sir.
5 Q. Absolutely, I agree with you. It is in that light
6 I mention that to you, which is why I do not propose to
7 deal with it further today.
8 A. Thank you.
9 Q. We have heard what you say, it is on the transcript and
10 it deserves to be treated seriously and with respect.
11 A. Thank you.
12 Q. It throws up a question which I do want to explore with
13 you, which is the issue of the echocardiogram after the
14 operation. In the event that it may have been one or
15 other of the various causes to which you draw attention,
16 which ultimately led to the death of Ross, would the
17 identification of the problem by an echocardiogram on
18 the Intensive Care Unit, do you think, have made
19 a difference to the course of treatment and possible
20 outcome?
21 A. Yes, I believe it may have. I think if, indeed, it was
22 a coarctation severe enough to produce left heart
23 failure, that child could have been taken back to
24 theatre and the coarctation excised, or resected.
25 Q. So again, what one is looking at here is a combination
0104
1 of factors giving rise to the particular case that we
2 have, but the combination of factors, amongst them is
3 the issue that we have spent most of our time exploring,
4 the question of the decision to operate in the
5 particular way and the basis for that.
6 A. Yes.
7 Q. The second point to which you draw attention is your
8 complaint that you did not have post-operative echo?
9 A. Yes.
10 Q. Which, let us suppose, if the original approach by the
11 surgeon had been less than adequate, would have picked
12 up a potential inadequacy and might have given a chance
13 to remedy that, in the interests of the child?
14 A. Yes, indeed.
15 Q. And that is the consequence of the features we discussed
16 yesterday, is it: the split site?
17 A. Yes.
18 Q. The inability to have a regular routine echocardiogram
19 following operation, as you do now?
20 A. Yes.
21 Q. So this situation would not happen today?
22 A. No.
23 Q. Thank you very much. I am going to leave the case of
24 Ross Hukku, unless there is anything else you want to
25 draw specific attention to?
0105
1 A. No, I believe I have said enough about it.
2 MR LANGSTAFF: Sir, this would be an appropriate moment,
3 perhaps, for a lunch break.
4 THE CHAIRMAN: We will take 45 minutes, then, until 1.55.
5 (1.10 pm)
6 (Adjourned until 1.55 pm)
7 (2.00 pm)
8 MR LANGSTAFF: Sir, this morning when we had the note, the
9 typed note of Mrs Shortis's meeting with Dr Joffe on the
10 screen in the hearing chamber, it was evident that our
11 copy, the copy we were displaying had been annotated
12 with the four-letter word in the margin of the second
13 page. It needs to be said this was not an expression of
14 view by anyone of the Inquiry staff as to the contents
15 against which the word was written, it simply is the way
16 in which the document came to us. Of course, except
17 where medical confidentiality is concerned, we do not
18 redact documents.
19 In case it should be thought to be a reflection on
20 any particular person, it needs also to be pointed out
21 and emphasised that we do actually have a number of
22 copies of this particular document. They have come to
23 us from different sources and this is, as it happens,
24 the only one which does have the four-letter word in the
25 margin. So if there is a responsibility for
0106
1 inappropriate selection of the document to display,
2 I accept it and any rebuke that may necessarily follow.
3 Those who look at the document from afar need take no
4 particular significance from that comment, unless of
5 course somebody in the course of commenting upon the
6 evidence generally wants to draw a conclusion from it as
7 to the views of one particular person or group or
8 whatever.
9 THE CHAIRMAN: No apology from you required, but it is
10 important for us always to notice the sensitivity that
11 attaches to everything, or virtually everything we see
12 and look at. So we regret it. I take responsibility
13 ultimately for anything which appears on screens and
14 therefore it is I who apologise. It is unfortunate.
15 MR LANGSTAFF: Dr Joffe, may we turn to the case of Gareth
16 Eccleshare?
17 A. Yes.
18 Q. In the same way as we have done earlier, if I run
19 through what is likely to be common ground between us:
20 Gareth was born on 25th July 1975. He is, as it
21 happens, one of the earliest births with which we have
22 to deal. The diagnosis was dextrocardia with single
23 ventricle, probable tricuspid atresia and pulmonary
24 stenosis, was it not?
25 A. Yes, in addition to transposed great arteries.
0107
1 Q. He had, on 19th November 1975, a right Blalock-Taussig
2 shunt?
3 A. Yes.
4 Q. He was followed up over several years with mild cyanosis
5 seen both in Cardiff and Bristol, there was a Cardiff
6 catheterisation in 1979. I shall not ask any more about
7 that, save to say the aortic oxygen saturation was then
8 73 per cent. He continued to be reviewed both in
9 Cardiff and in Bristol and gradually got slightly bluer?
10 A. Yes. May I point out that I was not yet in Bristol
11 myself, the first five years of his life he was under
12 the care of Dr Jordan and I came into the picture in
13 1980, which you are about to reach.
14 Q. I can go, I think, to early 1984 where, on 29th April
15 1984 he was admitted, was he, for a cardiac
16 catheterisation?
17 A. Yes.
18 Q. Following that catheterisation, just looking ahead,
19 there was an operation in December 1984. This was the
20 catheter which was the last such investigation prior to
21 that operation.
22 A. Yes.
23 Q. At the time of the catheter -- perhaps we ought to have
24 a look at it -- MR 1538/35. These are the clinical
25 notes made in respect of the admission of the catheter.
0108
1 If we go to page 62, there is the catheterisation report
2 itself. This I think is your report on the catheter
3 examination?
4 A. Yes.
5 Q. The thought was, was it, that he was a potential
6 candidate for the Fontan's procedure?
7 A. Yes.
8 Q. In order to perform a Fontan or to decide that a Fontan
9 was appropriate one would need to fulfil Fontan's "ten
10 commandments"?
11 A. At that time probably so, although with the passage of
12 time those commandments have fallen by the wayside one
13 by one, so that it depends on the timing through that
14 period. Fontan's "commandments" I think were given
15 probably in the late 1970s --
16 Q. April 1977, I think.
17 A. Yes.
18 Q. Amongst those was the need to have a pulmonary artery
19 pressure less than or equal to 15 millimetres of
20 mercury?
21 A. Yes.
22 Q. One would need to have a pulmonary resistance of less
23 than 4 units per metre squared?
24 A. Yes.
25 Q. And to have a normal function of the ventricle?
0109
1 A. Left ventricle, yes. Certainly when he started the
2 operation was for tricuspid atresia only and
3 subsequently the indications enlarged to include
4 a variety of single ventricle conditions, not
5 necessarily just tricuspid atresia.
6 Q. A further one of the "ten commandments", as they have
7 been called, is that the pulmonary artery and ratio to
8 the aortic diameter would be greater than or equal
9 to .75?
10 A. Yes.
11 Q. In the catheter examination there is no evidence on
12 paper of the pulmonary artery pressure having been
13 measured, is there?
14 A. No, I believe that is correct.
15 Q. One does have a left atrial pressure?
16 A. Yes.
17 Q. The pulmonary artery pressure could not, could it, be
18 lower than the left atrial pressure?
19 A. That is correct.
20 Q. If one looks at the examination that was conducted, can
21 you tell us why it was that there was not a measurement
22 at the catheterisation of the pulmonary artery pressure?
23 A. Yes. Firstly I would emphasise what I have said before,
24 that is that the so-called commandments were falling off
25 as the operation became more successful and I do not
0110
1 know if it was at that time or just before or just
2 after, but the issue of pulmonary pressure became less
3 critical and pressures at a higher level than mean
4 pressures of 15 were acceptable.
5 Secondly, this patient, as you have said, had
6 extreme pulmonary stenosis which evolved to pulmonary
7 atresia, a total blockage of the outlet to the lungs,
8 and under circumstances like that it would be very, very
9 uncommon indeed for the pulmonary artery pressure to be
10 high unless there was a previous palliative shunt
11 operation which either was connected directly to the
12 aorta, in other words with a window placed between the
13 two, a procedure that has been called "Waterston" by
14 some, and under those circumstances the pressure from
15 the aorta becomes transferred, so to say, to the
16 pressure in the pulmonary artery and the pulmonary
17 artery pressure is usually elevated.
18 There is another type of shunt called a Potts
19 shunt, which is a connection between the descending
20 aorta and the pulmonary artery and, likewise, that is
21 usually a direct communication between the two great
22 arteries and that also results in a high pressure in the
23 pulmonary artery.
24 But if you put a shunt in that has a length to it
25 and a relatively small circumference or diameter, then
0111
1 that imposes a restriction to flow from the aorta into
2 the pulmonary artery and therefore usually, and in the
3 vast majority, I would say, of patients the pulmonary
4 artery pressure would be low even without measuring it.
5 Thirdly, in this patient because of the particular
6 diagnosis of pulmonary atresia the only access into the
7 pulmonary artery is to put a catheter through the shunt
8 into the pulmonary artery and at that time, 1984, there
9 was still a feeling that that was not a very sensible
10 thing to do because of the possibility of trauma to the
11 shunt itself, the tubal connection made out of plastic
12 material called Goretex, and therefore in some centres
13 indeed it was frowned upon, in other centres there was
14 greater confidence and it was actually done.
15 I am not quite sure of my own response at that
16 time in this case, looking back some 15 years, but
17 either it was caution on my part given the presence of
18 pulmonary atresia and knowing that the PA pressure was
19 likely to be low or it may have been a technical
20 difficulty in traversing the Goretex shunt in order to
21 get into the pulmonary artery, I cannot recollect, it is
22 not stated in the actual report.
23 Q. You mean you may have tried but failed?
24 A. Yes.
25 Q. Dr Houston, how important would you say, in the light of
0112
1 what Dr Joffe has said, would it be in a case such as
2 this to have a pulmonary artery pressure, if one could
3 get one? That is the first question.
4 Secondly, if you would like to comment on what
5 Dr Joffe has said about the difficulties in obtaining
6 such a pressure?
7 DR HOUSTON: Firstly, I think it would be essential that the
8 pressure was measured before one went ahead with
9 a Fontan. I accept that in some situations,
10 particularly in those days -- we now have different
11 wires and different catheters which I think make it
12 easier -- it was not always possible to get the
13 pressure, though I think having said that if you could
14 not measure it, it may be correct that the surgeon would
15 measure it at the time of operation before proceeding
16 with the operation.
17 I think the pressure certainly has to be measured,
18 if not by the cardiologist, then by the surgeon.
19 MR LANGSTAFF: Can I stop you there? I caught you
20 nodding there, I do not know if you meant to. The point
21 was about the timing really of the taking of the
22 pressure; if the cardiologist cannot do it for one
23 reason or another must the surgeon in effect do it.
24 DR JOFFE: It would, if possible, be advisable for the
25 surgeon to do so.
0113
1 I would go back to the point that in 1984 there
2 would have been, in my view, certainly a body of opinion
3 that would have been reluctant to go through a shunt.
4 Secondly, I think it must be very rare indeed that
5 I have measured the pulmonary artery pressure in
6 a patient with pulmonary atresia without those types of
7 shunts that I was talking about, where the pressure was
8 not of the order of 15, 18 millimetres of mercury.
9 DR HOUSTON: I do not dispute that, the pressure is -- it
10 is unlikely to be high, but I think it is correct that
11 it should be measured.
12 MR LANGSTAFF: Because it might be high?
13 DR HOUSTON: Yes. I think the risks involved are to some
14 extent related to the pressure. If the pressure is at
15 the high level, the risk perhaps is a little greater
16 than that if it is lower. I am not sure if I could give
17 an absolute reference for that, but there is a general
18 feeling that that would be the case.
19 MR LANGSTAFF: Obviously for some reason those advising or
20 talking about the Fontan's procedure and devising the
21 ten commandments had thought one should draw a line, an
22 upper limit at 15 rather than anything higher.
23 DR HOUSTON: Everyone would not necessarily accept that
24 15 is the figure. I trained in Toronto in the late
25 1970s, 1979 and 19 was the figure that was taken then.
0114
1 My surgeon was trained in Toronto too and that is the
2 figure we tended to take.
3 MR LANGSTAFF: Dr Houston, you might like to comment on what
4 Dr Joffe was saying earlier about the level having risen
5 over the years, the commandments dropping away with
6 time?
7 DR HOUSTON: I do not know if I could speak specifically
8 about changes with time, but I would accept a higher
9 level than 15 would have been accepted in the mid-1980s.
10 DR JOFFE: There were other commandments, if I might enlarge
11 on that, such as the need for sinus rhythm and, in other
12 words, not to proceed if a patient was in atrial
13 fibrillation because of the concept at that time, that
14 when you were using, or believing you were using a right
15 atrium to be the driving pump for forward pressure into
16 the pulmonary artery, that was a commandment that was
17 dropped even when the original Fontan, direct right
18 atrium to pulmonary artery connection was in vogue.
19 Certainly it becomes far less important when the
20 modified Fontan, namely the cavopulmonary connection,
21 came into being or into the priority operation.
22 MR LANGSTAFF: Dr Houston, you were saying the pressure
23 should be measured either by the cardiologist or by the
24 surgeon. What about the difficulties there were in this
25 case in taking the measurement?
0115
1 DR HOUSTON: Again we are not sure how much effort was put
2 into it. I do not think an arterial catheter was used
3 and it might have been possible to get down from an
4 arterial approach.
5 Having said that, I think looking at what we do
6 with the different wires we have, it is much easier to
7 get down those shunts. I am not sure how much effort
8 was made.
9 MR LANGSTAFF: That I think is probably lost in history.
10 Is it the sort of thing you would put in your note of
11 the catheter examination or not?
12 DR JOFFE: I would normally do so, but I might not have in
13 this case, I do not know.
14 MR LANGSTAFF: You were postulating, Dr Houston, that in
15 those days you might have taken an approach, what, from
16 the femoral artery.
17 DR HOUSTON: Nowadays we would tend to go from the femoral
18 artery up to the subclavian artery and down through the
19 shunt.
20 MR LANGSTAFF: What about the theoretical risk that Dr Joffe
21 was adverting to of causing some additional damage to
22 the shunt or to the patient because one was going
23 through the shunt?
24 DR HOUSTON: I can certainly remember a surgeon saying to me
25 in 1980 that I was very brave going down through
0116
1 a shunt. Perhaps I had not thought about any problem
2 with it and I do not know what evidence there was that
3 there was a problem with these. Certainly some people
4 were wary of doing it, yes.
5 MR LANGSTAFF: You yourself were regularly -- I say
6 "regularly", you did it?
7 DR HOUSTON: Yes.
8 MR LANGSTAFF: The left ventricular pressure measured at the
9 catheterisation if we look back at what is on the
10 screen, shows a diastolic of 10 to 25, it is the second
11 of the findings, the aorta to left ventricle, line 3; is
12 that a sign that the ventricle is failing?
13 A. Yes, I would agree with that.
14 Q. What one has here is a case where one has not got
15 a measurement of the arterial pressure but it is not
16 going to be less than 18 which is the left atrial
17 pressure. There is a heart ventricle which is failing.
18 Can we then follow on to what was discussed
19 subsequently before the decision to operate was taken?
20 If we look at 988/29.
21 THE CHAIRMAN: There is a telephone number on the right-hand
22 side.
23 MR LANGSTAFF: This is a letter to you from Mr Wisheart.
24 A. Yes.
25 Q. The last paragraph:
0117
1 "I discussed things fully with mother who was
2 well-informed about the options. The only realistic
3 alternative is of course a shunt, but I think its
4 limited long-term benefit makes its a less desirable
5 option than the Fontan."
6 Those are the two alternatives for operative
7 treatment, are they?
8 A. Yes.
9 Q. "Its only attraction is that the immediate risk is of
10 course lower than the risk of the Fontan."
11 Pausing there, you would both agree with that,
12 would you.
13 DR HOUSTON: Yes.
14 A. Yes.
15 MR LANGSTAFF: "Mother and I had a frank discussion about
16 these things, we have agreed that a Fontan procedure is
17 right. I had hoped to carry it out in the autumn and
18 planned to see Gareth in the first two weeks of
19 September in order to decide the precise timing."
20 The second paragraph in that letter says in the
21 last sentence:
22 "It is clear however that he is suitable for
23 a Fontan operation and I think there can be no doubt
24 that his pulmonary artery pressure will be low."
25 Here is a decision to operate being made in the
0118
1 absence of the pulmonary artery pressure which you have
2 said has to be measured before the operation proceeds at
3 any rate even if --
4 DR HOUSTON: I would stick by that, yes.
5 MR LANGSTAFF: You would query it because --
6 DR JOFFE: Yes, I do not think it is essential -- well, it
7 would be desirable but not essential.
8 Q. Is there a compromise at highly desirable. I do not
9 invite you to change your view, if it is your view.
10 A. I think desirable probably covers the area that I am
11 thinking of.
12 Q. The decision then made by Mr Wisheart, and no doubt in
13 consultation with the others in the team to proceed to
14 the operation, he comes to operation on -- admitted on
15 6th December 1984, the operation is on 10th December
16 1984 and we can pick that up at page 13 in 988.
17 Bottom of the page we see the procedure which is
18 adopted. Can we scroll right down, please? We can then
19 turn over. Stopping at this stage, there does not seem
20 to be any record in the operation note of the pulmonary
21 arterial pressure actually having been measured?
22 A. No, that is correct and I think that would follow on the
23 comment made by Mr Wisheart in which he stated that he
24 felt -- I forget the words -- that it was most unlikely
25 that the PA pressure would not be low --
0119
1 Q. It would be low --
2 A. Would not be --
3 Q. Too high?
4 A. -- too high. Yes, sorry.
5 Q. Because if one were to stop at this stage, we have
6 a case in which the pulmonary arterial pressure, had one
7 been aware of the left atrial pressure would be 18 or
8 more, that must be so. There is no measurement I think
9 of the pulmonary arteries so as to compare them with the
10 diameter of the aorta, although that may be a matter of
11 impression on the table for the surgeon?
12 A. Yes.
13 Q. The ventricle does not have normal function?
14 A. No, that would weigh more heavily with me frankly than
15 the PA pressure.
16 Q. If one takes those aspects in those three respects, one
17 cannot fulfil those commandments anyway of Fontan?
18 A. No, that is correct. I would not argue about the fact
19 that this was not an ideal case for a Fontan operation
20 with the left ventricular performance as you have
21 stated. But I would like to put this case into
22 perspective: firstly, if I might return to the experts'
23 notes. I have great difficulty in understanding what
24 the meaning is of "appropriateness of initial treatment
25 strategy". On the one hand I think the sentence above
0120
1 states that it would appear to be correct that a Fontan
2 operation should be done as long as the preoperative
3 haemodynamic assessment was adequate.
4 The next sentence says the Fontan operation should
5 not have been attempted, even considering the limited
6 knowledge of preoperative haemodynamics. I am not quite
7 sure what it means and what the complaint is about doing
8 the Fontan operation at that stage.
9 MR LANGSTAFF: Can I perhaps help with that? Dr Houston,
10 were you a member of the team here.
11 DR HOUSTON: No I was not.
12 MR LANGSTAFF: The points I would wish to raise for
13 discussion are: why it was, given the fact there was not
14 a measurement of pressure, given the fact the ventricle
15 was in failure, given the absence -- it is the third
16 point perhaps, subsidiary of measurements of the
17 relevant vessels, whether the Fontan operation should
18 have been attempted rather than a shunt. I think that
19 is probably what the reviewers have in mind; this is
20 a case where, if the information had been available and
21 if it had been considered, then a shunt would have been
22 appropriate and not the full Fontan.
23 DR JOFFE: Yes, if I may go on to the timing of planned
24 treatment. The implication there is that -- considering
25 the child's general status, and certainly it was
0121
1 advanced -- the operation could have been offered at an
2 earlier date. One of Fontan's criteria was that the
3 Fontan operation should be performed between 3 and 15
4 years, so according to that commandment, 9 years of age
5 would be acceptable.
6 However, there is no question that this patient
7 was done late, and I take that to be the impact of that
8 sentence.
9 MR LANGSTAFF: Can I ask you to pause there? Do you
10 suggest, Dr Houston, that this patient was done late?
11 DR HOUSTON: He could have been operated on earlier, and
12 I think his haemoglobin was very high and that might
13 have been an indication to operate earlier but I am not
14 sure if it had been measured before the year it is
15 quoted because he was seen elsewhere, was not he? He
16 was not seen here, so we do not --
17 DR JOFFE: He was seen both at Bristol and in Cardiff.
18 DR HOUSTON: -- necessarily have the notes. But given the
19 fact that he had a haemoglobin at one time of 23,
20 I think an earlier operation probably would have been
21 appropriate, but I do not --
22 DR JOFFE: I would like to take that further, if I may?
23 MR LANGSTAFF: Please.
24 DR JOFFE: The difficulty with this patient --
25 THE CHAIRMAN: Mr Langstaff, you will forgive me if
0122
1 I interrupt, but there is a procedural problem here
2 which I would be grateful if I could have your
3 assistance: if Dr Joffe wants these cases to be
4 re-reviewed, which he is perfectly entitled to do so,
5 the procedure we have adopted is that that second review
6 will take place blind of any information. The more that
7 is said about the case by way of one way or the other in
8 this hearing now could, to that extent, interfere with
9 the blind nature of the second review. I would be
10 grateful if you could give me some assistance on that.
11 MR LANGSTAFF: Certainly. Any second review would not,
12 without the full knowledge of Dr Joffe's
13 representatives, have as input anything that he might
14 say about it because otherwise it is not as it were
15 a replica review.
16 Dr Joffe, of course, is here facing comments which
17 may be seen as critical of him and he is (and must be)
18 entitled to defend himself and he is entitled to defend
19 himself as he sees fit. If there is a criticism which
20 he would wish to answer now or address (a potential
21 criticism, it has to be said), then he must be entitled
22 to do so and be given every opportunity to do so and of
23 course he is free to address it, not only orally but
24 also in writing afterwards if he prefers to do it.
25 THE CHAIRMAN: I think we are completely in agreement and
0123
1 I am sure those behind you would agree with that, that
2 both of those propositions might be right. My concern
3 is more of a practical nature if, for example, we could
4 ensure that the transcript of today was not read by
5 those who may engage in the second review or some such
6 mechanism so as to make sure the second review was
7 conducted in a way which was entirely blind of anybody's
8 opinion except those who were doing the review.
9 DR JOFFE: Chairman, may I interrupt?
10 THE CHAIRMAN: Let me have this conversation with
11 Mr Langstaff.
12 MR LANGSTAFF: Sir, I think one of the aspects of the second
13 review is this: the evidence upon which the
14 statisticians rely for such conclusions as they have
15 given the Panel is that which is presented by
16 a statistical sample of the cases. The conclusions
17 drawn may, to a greater or lesser extent, represent
18 the -- if I use the word you will understand why I use
19 it -- 'true view of the situation'; it is after all an
20 opinion. One must appreciate that opinions may vary.
21 The usefulness of the 15 cases thus far explored
22 by way of a second review is to show how far the
23 opinions coincide with the earlier opinions to represent
24 (again I use the word in italics) the 'true view of the
25 situation'; it is not in every case that they do
0124
1 coincide. To the extent that there is a difference you,
2 the Panel, must take that into account in evaluating the
3 results of the first 80 cases in the first review.
4 The function of a second review for a clinician is
5 twofold: first of all the reviewing panel might come to
6 the same conclusion and if so then, so far as the
7 clinician is concerned, there is no difference. So far
8 as the validity of any conclusions to be drawn from the
9 first 80 cases is concerned, you may think as a panel it
10 is all the stronger.
11 If, however, the second review comes to
12 a conclusion which is different from that of the first,
13 two objects are served: first of all the clinician
14 himself may feel (if the conclusion is more favourable)
15 that he has been defended or vindicated or his approach
16 is thought to be entirely appropriate.
17 Secondly, the message for the Panel is perhaps the
18 second, which is: it casts a greater margin of
19 appreciation around the interpretation that has to be
20 placed and the weight that can be placed upon the
21 results drawn from the first 80 cases.
22 What that means in practical terms is that, it
23 does not seem to me -- responding as I am on my feet to
24 the question that you put to me -- that it is a matter
25 of central importance that the second reviewing panel
0125
1 should necessarily be blind, because if they are not
2 blind that fact would be taken into account by the Panel
3 in evaluating the extent to which any further conclusion
4 may cast light upon the validity of the first 80 case
5 reviews.
6 THE CHAIRMAN: I am very grateful to you for that. That was
7 very helpful. I think it might be wise for us to take
8 a five-minute break so we can talk to you, seek your
9 advice further and you can have conversations with those
10 behind you so that we quite understand how we proceed.
11 Would that not be helpful because that is what I am
12 going to do? Shall we break for 5 minutes?
13 MR LANGSTAFF: Before we take that entirely advisable and
14 desirable course, may I mention that it is open to
15 a clinician not only to seek a second review but, quite
16 apart from that or together with it, to put in his own
17 written comments upon any case.
18 THE CHAIRMAN: We will just take five minutes.
19 (2.40 pm)
20 (A short break)
21 (4.00 pm)
22 THE CHAIRMAN: Mr Langstaff, perhaps I should first of all
23 apologise to Dr Joffe. We have been away for a little
24 while. Forgive me, we were talking elsewhere.
25 I thought it might be helpful if I said something
0126
1 about what we were just discussing before we had
2 a break. I recognise what I am going to say is said in
3 the absence of any advice and counsel from
4 Miss O'Rourke, so I recognise that you may be able to
5 help me in due course, and of course I would invite you
6 to do so, not necessarily this afternoon, but in writing
7 or whatever form you should so wish.
8 I make a few points which I hope will help. First
9 of all, I would emphasise that what was engaged in on
10 behalf of the Inquiry was a Clinical Case Note Review
11 and all of those words are important, but perhaps the
12 most important word is the word "Note". It was a review
13 of case notes. It was recognised that there are
14 drawbacks in that source of knowledge, but on the other
15 hand, it was thought that it would throw some light on
16 the picture which the Panel is obliged to draw as to
17 adequacy of care over the period of our terms of
18 reference.
19 That is the first point.
20 The second point is that in that review of case
21 notes -- and it is only a review of case notes and was
22 so declared to be -- it is recognised that if anyone is
23 or feels criticised, he or she would wish to respond to
24 that criticism, as is seen or perceived. That is
25 entirely proper. For the most part, we would expect
0127
1 that that response be in writing. We would receive it.
2 The third point that I would make is that the
3 responses of anyone who feels criticised will form
4 a part of the material which will be in the public
5 domain. It will sit alongside whatever else is in
6 public, as being material made available to the
7 Inquiry.
8 Then I would say that the overall effect --
9 because the Clinical Case Note Review was concerned with
10 an overall picture which we need to test and have tested
11 as to its scientific validity, the overall effect which
12 any such observations, responses to criticism, perceived
13 or real, the overall effect which these observations may
14 have on the conclusions which the Panel is entitled to
15 draw from the Clinical Case Note Review is a matter for
16 the Panel on which, where necessary, it will seek expert
17 advice.
18 The fourth point I will make is that as has been
19 made clear from the outset, and indeed, as you made
20 clear only I think two days ago, Mr Langstaff, this is
21 not a trial. We are not concerned, it is not within our
22 terms of reference and we have declared it to be the
23 case from the outset, with attributing blame.
24 Those observations, I hope, will help us go
25 forward. If there is anything that needs clarification,
0128
1 I am sure in due course it will be clarified, I hope to
2 the satisfaction of all.
3 Mr Langstaff?
4 MR LANGSTAFF: Sir, I think what that implies is that if
5 this case is to be subject to a second review, that
6 administrative steps will be taken to ensure that the
7 comments which Dr Joffe has to make, which he is
8 entitled to make and which go into the public domain,
9 are not heard and observed by those engaged in the
10 review, since they were used for a different purpose,
11 but they will of course be heard and considered by the
12 Panel as part of the evidence, and they will be public,
13 as a public response, to anything which is thought to be
14 an individual criticism.
15 THE CHAIRMAN: Precisely so, because the exercises are
16 entirely different. One is concerned with a review of
17 case notes and a testing of the validity of that
18 review. The other is that the personal comments of any
19 particular individual which they must be entitled to
20 submit, and which will be made public, and as I say,
21 will sit alongside whatever else is in the public
22 domain. We, for our part as a Panel -- it is not within
23 our terms of reference to descend to arbitrate as
24 between the two.
25 DR JOFFE: Thank you.
0129
1 MR LANGSTAFF: Dr Joffe, if we may just complete what
2 lessons we may learn from Gareth's case, and perhaps the
3 best way of doing it is to take you, if you remember,
4 back to the operation note. It is at MR 988/14.
5 Can I take this generally, and tell me if I have
6 it wrong: problems were encountered at operation
7 essentially because the venous return to the left atrium
8 seemed to be poor. And as a result, the child then
9 being off bypass, there was an extracardial conduit put
10 in?
11 A. Yes.
12 Q. That caused further problems and the Fontan operation
13 was then sought to be undone. Post-operatively, there
14 were then further problems of further deterioration.
15 The problem of the venous return may have been due
16 either to the size of the arteries or to some
17 obstruction, presumably.
18 A. Yes. There may have been.
19 Q. And the question which is addressed as you pointed out
20 in looking at the comments in the Clinical Case Note
21 Review was whether, given the information or the lack of
22 information about the pulmonary artery pressures and
23 given the ventricular function, whether, looking back on
24 it, admittedly, as one does, this was an operation which
25 ought to have been performed as it was at that time, or
0130
1 whether it ought to have been the alternative of the
2 shunt.
3 A. Or if I may pose a third alternative, whether this
4 operation should not have been done two or three years
5 earlier, at which stage it may have been the case that
6 the left ventricular and diastolic pressure which was
7 elevated and the elevated left atrial pressure which
8 suggest that had the left ventricle was not coping, that
9 we may have been able to operate at an earlier stage
10 with far better anticipated outcome.
11 So I freely accept that the operation at that
12 time, for a Fontan, was not ideal for that patient; it
13 would have been far better to have done that operation
14 earlier.
15 As I mentioned, we did discuss the alternative of
16 the shunt. We felt that that would have been a very
17 short-term palliation; it would have done no more. We
18 would have faced exactly the same problem a year or two
19 later. The patient would have been less cyanosed, but
20 there is no saying that the left ventricular and
21 diastolic pressure would not still be up, or indeed if
22 the pulmonary artery pressure was elevated then that
23 would still be the case. So it was decided that the
24 best approach, certainly because it was so late, it was
25 a last ditch stand which our surgeons were prepared to
0131
1 undertake.
2 I would like to very briefly, because I realise
3 there has been some delay in considering this case, if
4 I may just point out that the salient reason for not
5 proceeding earlier was entirely the opinion and the
6 views of the parents themselves, particularly the
7 mother. I believe that this issue will intrude on the
8 process of the Inquiry, because it introduces the
9 element of parental responsibility for operations on
10 their children. I would like to quote in support of
11 that comment that on 18th November 1981 -- I do not
12 think it is necessary to put these up; I will read a few
13 off at random and they can be checked -- that is number
14 MR 1538/0077, in my letter I have included the comment:
15 "Parents' view is that there should be
16 non-intervention for this child."
17 On 17th November 1982, 0076:
18 "Mother was advised to have investigation", and
19 I have in quotes, "She put off the investigation".
20 16th November 1983 --
21 MR LANGSTAFF: Again, without wishing to cut you short
22 unduly, you are going to tell me, I think, that there is
23 inevitably, in deciding on the operation of any child,
24 contact with the parents, and any operative decision
25 that is taken and the timing of any operation has
0132
1 necessarily to take their views into account, and
2 indeed, give them the weight that they deserve, which is
3 primary weight, because they are, after all, the people
4 most concerned with the welfare of their child.
5 A. That is right.
6 Q. And you can advise but you cannot decide. The parent
7 decides in the light of advice that you give.
8 A. Yes, and I believe the Inquiry perhaps would have to
9 consider that issue.
10 Q. I am grateful. It is the other side, is it, of the
11 communication coin that we were looking at earlier, when
12 I was asking you questions about what you as a clinician
13 would tell the parents, and of course, you for your part
14 have to listen to what the parents say to you, whatever
15 it may be.
16 A. Yes. We certainly have to take that into account.
17 Q. And so long as you ensure that the parents are fully and
18 properly advised of the risks and chances, in what
19 nowadays will involve giving them the full facts, even
20 though it may not have done in 1990?
21 A. Yes.
22 Q. Therefore all the more so in 1980. That has to be their
23 choice and their decision, and it is not for us to
24 second guess it.
25 A. Yes, and even at that time, given the full facts, which
0133
1 I believe she was, there is a parental responsibility
2 which must be taken into account in deciding whether one
3 should proceed with the operation or not. I would like
4 to give you the additional evidence, but I am happy to
5 do that by written comment afterwards.
6 Q. We are happy to have that in written comment.
7 THE CHAIRMAN: We have the point and I am grateful for it.
8 Please, you said you were concerned about the passage of
9 time. From our point of view, you should not be
10 concerned. We are content to listen to your evidence,
11 take your evidence and we will be helped by your
12 evidence.
13 DR JOFFE: Thank you.
14 THE CHAIRMAN: It is your evidence we are here to listen
15 to, so there is no constraint of time.
16 DR JOFFE: Thank you.
17 MR LANGSTAFF: Now can I then leave the cases which I was
18 picking up from the Clinical Case Note Review, and
19 I shall not ask you for comments on the lessons that we
20 may learn from the fourth of the cases which you have
21 been invited to expect, in part because of the passage
22 of time this afternoon, but I am sure you will
23 understand.
24 I will return, if I may, to some of the themes
25 that you and I were exploring yesterday, where you may
0134
1 remember that I had taken you, in timing, up I think to
2 mid-1992, in terms of the results which the unit was
3 producing.
4 A. Yes.
5 Q. Again, taking an overall view, we have been into the
6 particular; let us now return, if we may, to the
7 general.
8 While I think about it, in the general, if we can
9 just have a look at UBHT 61/126 -- this is taking you
10 back to 1990 -- it is an audit meeting where those
11 present, which included yourself and those others we see
12 at the top of the page, looked amongst other things at
13 VSD. Given our discussion earlier today about VSD and
14 its possible outcomes, I thought it might be helpful to
15 look and see what changes there were in practice, and
16 why, because you mentioned the Frimley conference, which
17 was in 1991, and an idea that earlier intervention may
18 be appropriate.
19 A. Yes, pardon me, but I believe the Frimley conference was
20 specifically AVSDs.
21 Q. AVSDs, yes. Can we look at what was said? Nine
22 patients underwent primary closure of VSD with two
23 deaths. Both deaths related to post-operative pulmonary
24 hypertensive difficulties. You record the pre-operative
25 resistance. The first would be high, would it, seven
0135
1 units?
2 A. Yes.
3 Q. And postmortem examination showing potentially
4 reversible disease in both cases. Neither patient given
5 a 'new' regime of Phenoxybenzamine hyperventilation and
6 minimal handling."
7 That is a reference to a post-operative drug
8 regime?
9 A. Yes, that is correct,.
10 Q. What views as to the management of hypertension and the
11 way of approaching it change at all at about this time?
12 A. I think it began to be understood that even if the
13 pulmonary vascular changes would in the long run reverse
14 and normalise, there was a potential immediately post
15 surgery when a pulmonary artery pressure that had fallen
16 from the systemic level, around 90 or 100, down to
17 perhaps levels of 40 or 50, that intermittently, and
18 often for no obvious reason, could rise dramatically,
19 quickly, and produce problems usually of ventilation,
20 but also a fall in blood pressure. What was needed was
21 some way of reducing the pulmonary vascular resistance,
22 or in other words, relaxing the medial muscle layer
23 within the pulmonary arterioles. These were approaches
24 to handling or treating that problem which was, as
25 suggested there, fairly new, but appeared to be helpful:
0136
1 Phenoxybenzamine being a vasodilator of both the
2 systemic and pulmonary arteries, but which had a greater
3 effect on pulmonary arteries than many other
4 vasodilators, hypoventilation being a factor that
5 assisted firstly the level of oxygen in the pulmonary
6 arteries, which permitted vasodilatation, and secondly,
7 raising the ventilation itself and minimal handling.
8 I believe that those were schemes that were in the
9 literature and were being tried, and which we intended
10 to follow after these deaths.
11 Q. The results for VSD during the 1990s were, I think, very
12 much improved over those that there were before 1990?
13 A. Yes.
14 Q. I do not propose to take you to it, but if one were to
15 look back to 1989, for instance, one might see
16 Mr Dhasmana's results for VSD and AVSD were not very
17 good, but after 1990, there seems to have been a bit of
18 a change.
19 A. Yes.
20 Q. To what would you attribute that change?
21 A. I think this method of immediate post-operative
22 treatment was certainly a factor, and again, the notion
23 of trying to operate on babies at a younger age wherever
24 possible, were two factors that influenced the
25 outcomes.
0137
1 Q. Would you see anything else, apart from age and use of
2 Phenoxybenzamine?
3 A. Not that I can think of offhand, at the moment.
4 MR LANGSTAFF: Dr Houston, do you want to comment? This was
5 a change, was it, that took place generally throughout
6 the United Kingdom, or were other places ahead of
7 Bristol?
8 DR HOUSTON: I do not think I can speak with any clear
9 knowledge of that. I am not really aware of any great
10 change at that time. It may be the case, though. I do
11 not know what the national results show at that time,
12 I am sorry.
13 MR LANGSTAFF: In the 1990s the results of VSD repairs were
14 generally good, were they?
15 DR HOUSTON: Things have been improving over the years,
16 yes.
17 Q. And before then, and when they were not quite so good,
18 were the problems related to the risks of pulmonary
19 hypertension?
20 DR HOUSTON: Yes, I think that would be correct to say so,
21 but you know, I would reserve my judgment on that. I do
22 not think I can speak with great authority on that. But
23 pulmonary hypertension would be a factor.
24 Q. Let me leave the specific and come back to you in the
25 unit. I have looked at the statistics, the lessons that
0138
1 they tell us up to 1992.
2 One of the matters I wanted to pick up with you:
3 did you know at any stage that an anaesthetist in
4 general, or Steve Bolsin in particular, was collecting
5 data upon the work that surgeons had done?
6 DR JOFFE: No.
7 Q. We know that the Phenoxybenzamine was a regime which in
8 part had been advocated by Mr Mee in Australia?
9 A. Among others, yes.
10 Q. And was the suggestion here, which we see on the screen
11 still, one which was made by those newcomers to the unit
12 who had recent experience of such a regime?
13 A. I really cannot recollect how that came into the arena
14 of our discussions, but it would have happened at either
15 the joint meetings held each week or one of the other
16 meetings. I do not recall who specifically raised it.
17 Q. One thing which the statistics which we looked at thus
18 far do not show is anything in relation to
19 intraoperative management in particular, or for that
20 matter post-operative management in particular. If one
21 looks intraoperatively, for instance, the length of time
22 on bypass or the cross-clamp times.
23 A. Yes.
24 Q. Was it thought generally, at this time in the early
25 1990s, that the length of time on bypass or the time
0139
1 period of circulatory arrest might be important in terms
2 of post-operative survival?
3 A. Yes. There was a general view that patients' hearts
4 would be more effective if bypass times could be kept
5 shorter, in general terms. There is very little, if
6 any, literature to support that thesis, but it is
7 a widely held view and whether it is that factor alone
8 or not, I think if one looks at patients who undergo
9 surgery today -- this is some time after -- that appears
10 to be the case. So I do not think there is really any
11 hard proof about the length of time on bypass, but it is
12 widely held.
13 Q. Perhaps I can ask Dr Houston this. This is the last
14 matter we need to detain Dr Houston with today, if he
15 wishes to take leave of us, given the hour. But
16 Dr Houston, was there a growing view in the 1990s, or
17 had it always been the view, that the length of time on
18 bypass was a matter which was important?
19 DR HOUSTON: I think I would agree with what Dr Joffe said,
20 that there is just a general concept that the less time
21 on bypass the better, yes, but I do not think it
22 changed. Are you implying that there was a change?
23 MR LANGSTAFF: I am asking.
24 DR HOUSTON: No, I do not think so.
25 DR JOFFE: Yes.
0140
1 DR HOUSTON: I think one always had that view, although I am
2 not sure how rigid the evidence is for that.
3 DR JOFFE: Yes.
4 MR LANGSTAFF: So essentially, the quicker an operation
5 could be done, provided it was still done as neatly in
6 surgical terms, the better?
7 DR HOUSTON: Yes.
8 THE CHAIRMAN: May I ask, is it the case that one may get
9 a skewed picture of how long bypass time may be because
10 a patient is taken off bypass for a while and then put
11 back on for whatever reason? Is that something that
12 happened commonly or rarely, or what?
13 DR HOUSTON: That would be, if they go back on it, it is
14 because there has been a problem; they try and come off
15 and then there is a problem and then they put them back
16 on. If the whole thing was just added up you would get
17 as good, but there was one earlier on when they showed
18 the two different periods, it showed the first and the
19 second period.
20 THE CHAIRMAN: I may say, we heard evidence from Mr de Leval
21 that on one operation he went back I think seven times
22 to make sure he had done something proper, and clearly,
23 that would have involved a very, long period of going
24 backwards and forwards.
25 MR LANGSTAFF: Now I am going to turn away from matters
0141
1 which involve an expert, or may involve an expert
2 cardiological input, apart from that which Dr Joffe
3 himself can give us.
4 THE CHAIRMAN: So are you saying that Dr Houston can ...
5 MR LANGSTAFF: He may freely take his release if he wishes
6 to do so. He is very welcome to stay, if he wishes to
7 stay.
8 DR HOUSTON: How long will this be going on for?
9 THE CHAIRMAN: I think the only answer is as long as it
10 needs to give proper respect to the evidence.
11 DR HOUSTON: If this is an appropriate time to go, I would
12 take my leave.
13 THE CHAIRMAN: I only ask so I may thank you on behalf of
14 the Panel should you wish to leave. We are grateful, as
15 ever, should you wish to leave.
16 DR HOUSTON: Thank you all for looking after me.
17 (Dr Houston withdraws)
18 MR LANGSTAFF: Dr Joffe, when Professor Vann Jones came to
19 give his evidence before us, what he told us was that
20 there was a picture of general debate between November
21 1993, when he was first seen by Dr Bolsin, and April
22 1994, when he wrote a particular letter to Mr Durie, the
23 Chairman of the Trust.
24 He was asked how widely spread the debate was
25 amongst those involved in cardiac surgery and paediatric
0142
1 cardiac surgery specifically.
2 What he said was:
3 "This debate was everywhere by that stage. By
4 April 1994", so you appreciate we have moved from 1992
5 through 1993 to 1994, "in the course of the ensuing year
6 or two it was a major topic of conversation by everybody
7 in cardiac circles.
8 Question: So if I mention specific names, did you
9 have any conversations firstly with Mr Dhasmana about
10 the subject?
11 Answer: I am absolutely certain we must have
12 talked about it, but no formal interview.
13 Question: What about Dr Hyam Joffe? Can you
14 recollect any discussion with him?
15 Answer: I saw Hyam quite regularly because he was
16 Clinical Director for Children's Services. I am equally
17 certain that I must have expressed my concerns to him.
18 It was almost impossible not to discuss it, rather than
19 specifically going to find people and if you bumped into
20 someone, it was the topic of conversation, 'What is
21 happening?', et cetera, so it was not a question of
22 having to go and see people, it was quite the reverse.
23 It was sometimes the question of not discussing it when
24 you met somebody.
25 Question: Nevertheless, you say I must have
0143
1 spoken to him about it, which is the language of
2 assumption rather than definite recollection?
3 Answer: This is 6 years down the line and as
4 I say, just about everyone you spoke to would have had
5 a discussion about the subject. It would have been
6 remarkable, let us put it that way. I have seen
7 Hyam Joffe at the clinical directors' meetings monthly
8 for four years -- well, it was not four years, it was
9 towards the end then, but certainly at the clinical
10 directors' meetings for a year or two, it would have
11 been remarkable if we had not discussed it."
12 That is his evidence. No specific recollection of
13 talking to you on a specific occasion about the concerns
14 of Dr Bolsin, but he says it was a general topic of
15 conversation and it would have been remarkable if he had
16 not mentioned it and this would be talking some time
17 after November 1993, and I suspect relating to 1994
18 generally?
19 A. Yes.
20 Q. Did he, during 1994, discuss matters with you?
21 A. Not at all.
22 Q. Did you, in 1994, pick up the conversation which he says
23 was everywhere?
24 A. No, I am afraid not. I think we were very much split
25 ad infinitum, as has been mentioned, between the two
0144
1 sites. We were in the Children's Hospital for the vast
2 majority of the time, unless we were aware at peripheral
3 clinics. There was not the free interchange and
4 communication between staff in one place, as happens in
5 either institution when considering the two meeting
6 together -- the BRI and the BCH, or staff from them.
7 Those meetings that took place on a monthly basis were
8 very much administrative, managerial meetings. The
9 issue was never raised formally in that forum, to my
10 knowledge, certainly while I was there. While I may
11 have talked to Professor Vann Jones on occasions, at
12 those meetings, either early on or at the end, it was
13 usually at a time in the late afternoon when one firstly
14 had difficulty getting to them, and secondly, wanted to
15 rush away immediately afterwards. So there was not that
16 much opportunity to hold discussions.
17 But in any case, I never did speak to him about
18 this matter. I say that categorically.
19 Q. Dr Hayes joined the unit in October 1993?
20 A. Correct.
21 Q. Did she work at the Children's Hospital?
22 A. Since then, yes.
23 Q. At the Children's Hospital, did she have regular contact
24 with you?
25 A. Oh, yes, very much so.
0145
1 Q. So did you see each other daily?
2 A. Yes.
3 Q. Did you talk?
4 A. Well, inevitably, yes.
5 Q. She was asked by Dr Bolsin, and agreed, to categorise
6 certain information for him to give him a classification
7 of operations so that he might code the data that he
8 had.
9 A. Yes.
10 Q. Her recollection of being asked to do and agreeing to do
11 that was shortly after she began her work in October
12 1993 --
13 A. Can I come in there?
14 Q. Yes, please.
15 A. She was appointed, I think the interview was in May.
16 When she started in October 1993, that was the first
17 time that she officially took on the role of consultant
18 paediatric cardiologist.
19 In some of the papers through this Inquiry
20 Dr Bolsin, I believe, has said that a consultant
21 paediatric cardiologist had reviewed his figures early
22 in 1993, so if she had been the person she was not at
23 that time a consultant.
24 Secondly, my knowledge of Dr Hayes' involvement
25 came to me for the first time when reading the
0146
1 transcripts of the GMC proceedings -- not all of it, but
2 certainly I read her contribution. That was the first
3 time I knew that she had been involved in that
4 particular process.
5 At the same time, I must say that early on after
6 her -- I believe it was after she had been appointed,
7 because she was in Toronto after that time, she did
8 speak to me about my thoughts about her undertaking some
9 research, as she put it, with Dr Bolsin, to do with
10 patient data and outcomes in groups of patients, but
11 that was the only conversation I had with her that had
12 anything remotely to do with this possible so-called
13 confidential audit.
14 Q. And you knew, I take it, that Dr Bolsin had an interest
15 in audit generally, and indeed, had sought the
16 assistance of the surgeons to audit adult data?
17 A. Very vaguely. I really had very little, as I mentioned
18 earlier, communication with Dr Bolsin, not because of
19 any reason that I wished not to, or that he wished not
20 to, but our paths moved in different orbits and mine was
21 at the Children's Hospital, his was at the BRI. In the
22 same way, I had very little to do with any of the
23 anaesthetists involved in cardiac intensive care at the
24 BRI, apart from those who came down or up to the
25 meetings at the Children's Hospital, which essentially
0147
1 was Dr Masey and once or twice, other individuals.
2 Q. When I asked you yesterday if you spoke to Dr Bolsin,
3 you said "No", but I think the point you wanted to make,
4 at least in respect of this period of time, was that he
5 did not come to the Children's Hospital where you were,
6 so the opportunity for doing so was non-existent, or
7 severely limited?
8 A. Yes, correct.
9 Q. So far as Dr Hayes is concerned, having read the GMC
10 transcript, you will have seen that she said to the GMC
11 that having worked at the Brompton, she had some idea of
12 what one might expect in terms of results and outcomes,
13 and had the feeling that the results, the outcomes for
14 the under 1s, were less good than she had expected, or
15 would have expected at the Brompton?
16 A. Yes.
17 Q. Was that a feeling that she ever expressed to you?
18 A. Not directly, no.
19 Q. Indirectly?
20 A. Well, she expressed it in terms of her concern about the
21 results under 1 in general terms. I cannot recall her
22 relating it to the Brompton, or for that matter, to
23 Toronto or any other centre.
24 Q. What was it she was concerned about, as you remember it?
25 A. We were all concerned to improve our results. It was
0148
1 a general statement in the under 1s in particular.
2 Q. So it was not only the general concern that all
3 clinicians have to improve results, but focused upon
4 a particular group?
5 A. The under 1s, yes.
6 Q. There must have been then some sense that the under 1s
7 were a group in which the unit was less than successful?
8 A. As we have already discussed, the neonatal switches and
9 AVSDs, although, as we have already seen again, in the
10 letter that the paediatric cardiologists wrote to the
11 paediatricians, one of reassurance, that the results for
12 Mr Dhasmana were very good for AVSDs and that the other
13 results, on the whole, were really very good. There
14 were many other operations that were being done with
15 very acceptable results.
16 Q. What she told the GMC, as you will recollect having read
17 the transcript --
18 A. Yes, but I do not recollect all that well.
19 Q. She said that patients, she thought, did rather
20 better -- I think she was talking about the
21 under 1 category -- with Mr Dhasmana than they did with
22 Mr Wisheart.
23 A. Well, that applied to AVSDs, certainly.
24 Q. That was the general recognition, was it, amongst the
25 cardiologists?
0149
1 A. At that time, yes. But there were other conditions
2 where Mr Wisheart's results were better than
3 Mr Dhasmana's, i.e. the Senning operations for
4 transposition of the great arteries.
5 Q. Was there a difference in the referral of complex work
6 so that the more difficult work might go to one surgeon
7 rather than the other?
8 A. Yes, there was a trend, most of it unspoken and not
9 formally decided upon, to send the AVSDs to
10 Mr Dhasmana. He was already doing the arterial switches
11 by decision. In terms of other complex operations, I do
12 not recollect that there was a specific difference in
13 referral pattern. But overall, he was tending to do
14 more of the under 1s and part of the reason for that,
15 I believe, was that Mr Wisheart was becoming more
16 involved in the managerial side.
17 Q. Another comment which she made was that she had a sense
18 that the lapse of time between the identification of
19 a condition and surgery seemed to be rather longer at
20 Bristol than it had been at the Brompton.
21 From what we have been exploring over the last day
22 or so, that would probably be right, would it, because
23 of the split site?
24 A. By comparison with the Brompton, if she says so, yes.
25 We really had no information about that aspect with
0150
1 regard to the other centres.
2 Q. She, being a paediatric cardiologist -- because she was
3 a paediatric cardiologist, was she not?
4 A. Yes.
5 Q. If she was helping with any collection of data, must
6 have been presumably collecting data on paediatric
7 cases?
8 A. She evidently was.
9 Q. She could only have been, because that was her realm of
10 expertise?
11 A. I do not know if that is the reason, but in fact, that
12 is what she was doing.
13 Q. So if you had thought about the research that she might
14 be involved in at the behest of whoever it was, you
15 would have realised it would probably have been into
16 paediatric cases?
17 A. I would have assumed so, yes.
18 Q. Did you ever ask her what the results were and what it
19 was about?
20 A. Not specifically, no, because what I did not go on to
21 say earlier was when she asked if I thought she should
22 continue or do some work at the BRI and I emphasise
23 again, I had no knowledge of what that entailed, she
24 said it was going to be work with Dr Bolsin, and she
25 asked for my opinion. I said that I did not know him
0151
1 very well and my information is second-hand, but
2 I understand from a variety of opinions that were
3 floating about -- and it was as soft as that -- that he
4 was not someone who ought to be linked with in doing
5 research. I emphasise, this was very soft and more an
6 opinion that was gleaned from what little I did hear
7 about what was going on at the BRI.
8 Q. What category of person was talking to you to give you
9 that soft idea of Dr Bolsin?
10 A. I really cannot recollect. It could have come either
11 from senior or junior anaesthetic colleagues of
12 Dr Bolsin, or from senior or junior surgical staff who
13 worked on Ward 5 of the BRI. I do not recollect who
14 conveyed that.
15 Q. Were there individuals in either group whom you happened
16 to see regularly as a matter of either course or social
17 choice?
18 A. Only the cardiac surgeons, amongst that group. They
19 would have been people whom we frequently met with, but
20 I do not believe one can extract from that consequential
21 decision that they were the individuals who conveyed the
22 information.
23 Q. The way you put it, it sounds as though it was more than
24 one person who was expressing this "soft" view to you.
25 A. I cannot even recall that, I am afraid; it could have
0152
1 been one; it could have been several. I do not know.
2 Q. You passed it on to Dr Hayes for her information?
3 A. Exactly, for her information, without wanting to
4 influence her unduly. It was clearly her decision as to
5 what she wanted to do with that information.
6 Q. How was the information relevant, if it was, to the
7 ability of Dr Hayes and Dr Bolsin to conduct research
8 together?
9 A. I do not know quite how she posed the question, but it
10 would have been in general terms, not specifically to do
11 with the research process, but in terms of working with
12 an individual, "What did you think about that?" I would
13 have commented that I had heard certain things and
14 conveyed that.
15 Q. Can you give me more detail of the nature of the certain
16 things you had heard being said about Dr Bolsin?
17 A. I am afraid I cannot.
18 Q. Was any of it linked to a view that he might have been
19 involved in Private Eye and the disclosures which had
20 hit that magazine a year or so earlier?
21 A. I had no idea about that, his involvement in Private
22 Eye, until later.
23 Q. He denies it.
24 A. Yes. Well, I have no knowledge anyway about any
25 connection until later when I heard that he had
0153
1 communicated with "MD" in Private Eye.
2 Q. It is not so much what you understood; it is what you
3 understood the basis to be of what people were saying to
4 you. Can you help further?
5 A. I do not believe I can, no, I am sorry.
6 THE CHAIRMAN: I think just for clarification, it is his
7 evidence that he communicated with Phil Hammond, who
8 later turned out to be "MD"; just to make sure we
9 respect everybody's evidence.
10 MR LANGSTAFF: Before I leave it, I should ask you whether
11 the comments were about him as a person, his character,
12 or about his abilities.
13 A. Largely about him as a character.
14 Q. When Mr McKinlay came as Chairman of the Trust and took
15 over in the middle of 1994, he has told us that Mr Durie
16 gave him a briefing and he understood that there were
17 concerns about the speed of surgery of Mr Wisheart.
18 First of all, was that a view which had some
19 currency, that he was a slow surgeon?
20 A. I believe it was known that he was very meticulous and
21 careful, and therefore to a degree a slow surgeon.
22 I have mentioned previously how true that was in
23 reviewing the autopsy specimens.
24 Q. Did anyone, in their comments to you, focus upon the
25 length of bypass times or cross-clamp times in
0154
1 operations which he did?
2 A. I am sorry, I did not follow that.
3 Q. Did anyone make specific reference, not only to the
4 overall length of time of an operation, but to the
5 length of time, therefore, that children would be on
6 bypass or circulatory arrest?
7 A. No-one specifically raised that with me.
8 Q. I suppose the general comment about being a slow surgeon
9 would encompass both those elements, would it?
10 A. Being slow in terms of the actual performance of the
11 operation?
12 Q. No, taking one's time?
13 A. I do not think there was a deliberate taking of one's
14 time. It was a matter of taking time to do the job
15 properly.
16 Q. It is not the suggestion, it is the fact of what was
17 said that I am exploring?
18 A. Yes.
19 Q. In 1994, we have heard that in April there was a meeting
20 between Mr Wisheart, Professor Angelini, Dr Monk and
21 Dr Bolsin, at a restaurant, Bistro 21, on either 5th or
22 12th April -- it makes no difference -- 1994?
23 A. It is a very good restaurant and unfortunately it has
24 closed, so it does make a difference.
25 Q. Did you know that a meeting had been arranged in order
0155
1 to discuss concerns that individuals might have?
2 A. No, I did not know that it was arranged prior to its
3 taking place. I did hear about it subsequently.
4 Q. One of the people you saw regularly, as you have already
5 told us, was Mr Wisheart.
6 A. Yes.
7 Q. If there had been such a meeting which related to
8 concerns about results, the outcomes of the unit, you
9 would naturally want to know something of the substance,
10 because you, too, were a Clinical Director?
11 A. I do not think that is the reason, but I would have been
12 interested.
13 Q. And you got on well with Mr Wisheart?
14 A. Indeed.
15 Q. And he spoke to you freely, did he?
16 A. Yes, I believe so. I think we were on very good terms
17 with each other.
18 Q. Did he never mention that there had been some
19 conversation involving, amongst others, Dr Bolsin?
20 A. He mentioned that they had had this dinner together and
21 that he was anticipating that this would give Professor
22 Angelini and Dr Bolsin an opportunity to comment, if
23 they had criticisms which appeared to be the case, so he
24 said, for them to state those criticisms and raise the
25 whole question of data or what they felt was amiss with
0156
1 the performance of cardiac surgery -- in this case
2 paediatric cardiac surgery -- but somehow the evening
3 went by and this did not happen.
4 Q. As Clinical Director of children's services, although
5 your remit did not extend earlier on to the surgical
6 stage -- that later became part of the separate
7 directorate -- you would have had an interest in
8 anything that might affect the outcomes, I take it, for
9 children?
10 A. Of course.
11 Q. And an interest in concerns --
12 A. Yes.
13 Q. -- if they were being expressed by reputable and
14 respectable sources. So having heard from Mr Wisheart
15 that he thought that Professor Angelini and Dr Bolsin
16 had had criticisms about the way in which the unit was
17 being handled, the outcomes, did you not want to know,
18 from them, precisely what their criticisms were and what
19 they might be saying?
20 A. Well, firstly, I think that was the problem that
21 Mr Wisheart had: that he never came to learn directly,
22 I understand, from that source, and secondly, I think
23 the only person who can answer that question in detail
24 is Mr Wisheart.
25 Q. It was a question addressed to you, really, in the light
0157
1 of your knowledge that there might be criticisms,
2 because that is what Mr Wisheart had told you, whether
3 you thought it appropriate to explore the nature of any
4 such criticisms?
5 A. Well, as I have already tried to explain, we had
6 a conversation. I do not know if he told me or I asked
7 him, but we had a conversation about a dinner which they
8 had had together, the four of them, with the view to
9 hoping that they would come forward with criticisms if
10 they had any, because he understood that was happening
11 in the unit, and that in effect no such information was
12 provided. That is the sum total of my information that
13 I gleaned from that discussion.
14 THE CHAIRMAN: I think, Dr Joffe, Mr Langstaff is asking,
15 did you in the light of that conversation with
16 Mr Wisheart, think, "I will go out and try and find
17 something out?" I take that to be the import of your
18 question?
19 A. In answer, I do not think I knew enough about potential
20 concerns to have made a response.
21 MR LANGSTAFF: That in a sense is the point, because if you
22 know that there are criticisms, concerns which you
23 understand to be criticisms, that affect the surgical
24 unit to which you refer your patients and to which those
25 in respect of whom you were Clinical Director refer
0158
1 their patients, by and large, do you not want to know
2 what the criticisms might be in order to assess them for
3 yourself?
4 A. Yes, I would very much like to know. When we discussed
5 it, myself and Mr Wisheart, there was no information
6 that came through from him as to any hard data or
7 information or criticisms that he obtained on that
8 particular occasion, so there was no information about
9 the nature of the criticisms.
10 Q. From him?
11 A. From him.
12 Q. Hence the second part of the question: You knew there
13 were supposedly criticisms. They had not been expressed
14 to him, he told you that, but he alerted you to their
15 existence?
16 A. Yes.
17 Q. He alerted to you the fact that these criticisms
18 appeared to be held, or expressed, to a greater or as it
19 seems lesser extent, by Professor Angelini and
20 Dr Bolsin. What I am asking you is, why did you not go
21 and speak to them, as a result?
22 A. I believe that the reason was that to a degree, to
23 a large degree, possibly, our communication with the
24 unit in the BRI was via the surgeons, both Mr Dhasmana
25 and Mr Wisheart, and I would not, therefore, have made
0159
1 a direct approach to either of those two individuals.
2 At that time, I knew that they were people who
3 were apparently making criticisms, but I did not myself
4 confront them. The only time I talked to Professor
5 Angelini, apart from the one occasion that I have
6 written about in my statement, soon after he took office
7 at the BRI, was the evening after the Daily Telegraph
8 article had come out in April 1995, with the large
9 headline, "Hundreds of babies murdered", and his comment
10 to me, as we met, my coming out of the Children's
11 Hospital and his going towards the University, was that
12 he has to rush to the Senate to ensure that his research
13 would not be influenced by the publicity that was
14 forthcoming at the time.
15 Having started with the Daily Telegraph that
16 morning, and knowing that there was a television
17 programme occurring the following evening, and he needed
18 to do that in a hurry because he was going off on
19 holiday either the next day or the day after -- I think
20 it was a Friday -- and that he is very sorry for
21 Mr Dhasmana, and words to the effect of -- and I do not
22 recall the exact words, but they were not far different
23 from, "I do feel sorry for Janardan. I am afraid he has
24 got caught in the cross-fire. It is Mr Wisheart we need
25 to get" -- either "I" or "we", I cannot recall. That is
0160
1 the only other conversation I had with Professor
2 Angelini in respect of this particular matter.
3 Q. We will come back to that, but the answer you have given
4 me suggests that people other than Mr Wisheart were
5 telling you in about early 1994 that Professor Angelini
6 and Dr Bolsin were expressing criticisms --
7 A. No, I did not hear that from other people.
8 Q. Only from Mr Wisheart?
9 A. Yes.
10 Q. And the question I was going to ask was, given that you
11 did not come into daily contact with them because of the
12 split site, there was no doubt a telephone to which you
13 had access?
14 A. Of course, yes.
15 Q. Why did you not use it and phone them up and say "What
16 is this about?"
17 A. Well, I did not. I think it could have been an opinion
18 that I held about those two individuals, that precluded
19 me from making that call.
20 Q. Then tell me how it was that you had formed your view of
21 Dr Bolsin, and what it was?
22 A. Only by hearsay through other people.
23 Q. That is half the question. That is how you formed it.
24 What was it?
25 A. I think I need to be reassured that if I do make
0161
1 comments here, sir, I am not sure if they are legally --
2 how protected I am. I need to have, I am afraid, some
3 legal assistance.
4 MR LANGSTAFF: I think you should then have some time with
5 your legal representative and we should respect that
6 wish, sir, and I would suggest what I imagine would be
7 a very short adjournment, but if you or Miss O'Rourke
8 can let us know when you are ready?
9 DR JOFFE: Thank you.
10 THE CHAIRMAN: Mr Langstaff, I just saw a communication
11 from Miss O'Rourke which I may have misunderstood.
12 MR LANGSTAFF: I think it will probably be very short, but
13 I think we need to let it take place in private.
14 THE CHAIRMAN: I think that is entirely right. We will just
15 withdraw for five minutes.
16 (5.00 pm)
17 (A short break)
18 (5.10 pm)
19 MR LANGSTAFF: Dr Joffe, what, then, was your view of
20 Dr Bolsin?
21 A. I had heard through essentially the surgeons, but as
22 I say, there were other individuals and I cannot name
23 them, who felt that Dr Bolsin was unreliable in the
24 sense that he tended at times not to do his formal
25 pre-operative examinations; that occasionally he was not
0162
1 available in the immediate post-operative period when
2 issues or patients' conditions were critical, or
3 inevitably after bypass, on ventilation and needing
4 close ventilation; that he frequently was away during
5 theatre time. I understand that is not uncommon with
6 anaesthetists so I do not know if that was any more than
7 the average or not. Essentially, the general opinion
8 that he was unreliable and that, I again say, I know was
9 second-hand only, and more than that, I cannot say.
10 Q. So far as Professor Angelini was concerned, what view
11 did you have of him?
12 A. I did not know him, similar to Dr Bolsin, I did not meet
13 him often, and he of course was working in the adult
14 field, so that our paths crossed very infrequently. But
15 again, purely by repute, there was concern that he
16 wished to influence the management of cardiac surgery at
17 the BRI and that in that sense, there was a feeling, but
18 no more than that, that he, too, could not be trusted.
19 Q. Who, in particular, had a concern that he sought to
20 influence management, cardiac surgery, at the BRI?
21 A. Again, it is very difficult to focus on individuals.
22 I do not believe I heard it from Mr Wisheart; I believe
23 it was from other parties, whoever they were. I am
24 afraid it was rumour and I have to put it forward in
25 that vein.
0163
1 Q. So this is what people were saying generally to you?
2 A. Yes.
3 Q. Is it what you, in turn, would say generally to others
4 about both on the one hand Dr Bolsin and on the other,
5 Professor Angelini?
6 A. I would tend to avoid having to give an opinion of that
7 sort to colleagues or, indeed, anyone else.
8 Q. But this was in the back of your mind, was it, when you
9 spoke to Dr Alison Hayes?
10 A. It was in the back of my mind at that time.
11 Q. And from what you told us, you volunteered a view of
12 Dr Bolsin at that stage?
13 A. Yes.
14 Q. So when the occasion permitted, you did, you think,
15 volunteer a view consistent with the view that you have
16 told us you derived from others?
17 A. That is the only occasion I can recall that I did so.
18 Q. So when others volunteered a view of either Dr Bolsin or
19 Professor Angelini to you, did you respond or did you,
20 as you recollect it, remain silent, or did you nod and
21 say "That is what I have heard from others", or what?
22 A. As you have gathered, I am a very reticent and silent
23 individual, and I would not have wished to, or indeed
24 did talk about others in that way.
25 Q. So what you are saying to us, carefully and advisedly,
0164
1 is that you had formed from the sources you have
2 identified, a view of Professor Angelini and Dr Bolsin
3 which conspired to make you not seek to explore their
4 concerns, as with other individuals you might have
5 done?
6 A. Yes.
7 Q. If you had thought them reliable persons who had
8 a respectable viewpoint, you would, then, have got on
9 the telephone and asked them about it?
10 A. I believe so, yes.
11 Q. Did you ever hear of criticisms which anaesthetists
12 other than Dr Bolsin had either of the paediatric
13 cardiac surgery generally or the arterial switch in
14 particular? Leave aside December 1994 and what happened
15 after that, but before December 1994.
16 A. I believe I did have a discussion once with Dr Monk.
17 I cannot remember, it probably was during 1994.
18 I cannot remember what the purpose of the discussion
19 was, but I think that matter cropped up. I have, I am
20 afraid, not very good recollection of that, but when you
21 mention other anaesthetists, that could have been the
22 only other anaesthetist I would have talked to --
23 indeed, other person.
24 Q. He was, did you understand, at the good meal at the
25 Bistro 21?
0165
1 A. I had forgotten, yes, he was, of course. So there were
2 five people, were there?
3 Q. There were four: Dr Monk, Mr Wisheart, Professor
4 Angelini and Dr Bolsin.
5 A. Right.
6 Q. Did you have a view of Dr Monk which enabled you to
7 treat his views with respect?
8 A. Yes. I had no reason to doubt his integrity.
9 Q. What was the nature of the conversation you had with him
10 about concerns?
11 A. As I said, I do not remember the detail. It was part of
12 a broader discussion. I do not know exactly when it
13 was, so if it was towards the end of 1994, when one had
14 heard rumours about discontent at the surgical ward,
15 then I believe that is what we would have talked about.
16 How specific he was, I really do not recollect.
17 Q. Tell me about the rumours of discontent.
18 A. That is what I meant, that in talking to Dr Monk, I do
19 not remember the specific nature of what he was talking
20 about, but the rumours extended to the fact that some
21 individuals in the cardiac unit were discontent to use
22 that ward again. But we knew, of course, of the
23 anaesthetists' anxiety about the neonatal switch
24 operations, because that had been a matter of discussion
25 earlier, and in October 1993, the neonatal switch was
0166
1 discontinued.
2 I did not have the details. I knew that there was
3 discontent and I presumed it was along similar lines,
4 namely, to do with the switch. I think if Dr Monk did
5 specify anything, that would have been the condition we
6 would have been talking about, at that time.
7 Q. The reason you say that is recollection or retrospect,
8 having read other evidence? Why was it not cardiac
9 surgery generally that he might have had in mind? Can
10 you help us with your recollection?
11 A. It is very difficult. As you have suggested, I have
12 read so much in so many sources that it is very
13 difficult to be clear about what is pure recollection or
14 what has come from one's reading.
15 Q. Tell me about the relationships between the cardiac
16 surgeons as you were told they were, in 1994? You have
17 told us of Professor Angelini and how there was concern
18 that he was not to be trusted because he had an interest
19 in the management of cardiac surgery and from his own
20 perspective. How did the other cardiac surgeons,
21 between themselves, get on?
22 A. You mean among the adult cardiac surgeons and the
23 paediatric cardiac surgeons?
24 Q. You had both Mr Dhasmana and Mr Wisheart being
25 principally adult surgeons --
0167
1 A. Yes.
2 Q. -- doing paediatric work; so they were all surgeons
3 together, were they not?
4 A. They were, yes. As far as I knew, the relations were
5 very good, and again, I did not have firsthand
6 information about that. But relations with Dr Hutter
7 were very good; with Mr Bryan, as far as I knew, were
8 very good. And indeed, with Professor Angelini,
9 I think, was very good.
10 Q. In November 1994, we have been told there was a meeting
11 at which Mr Dhasmana and Professor Angelini came to what
12 one might describe as "verbal blows". Was that
13 a meeting at which you were present?
14 A. No. In fact, I did not know about that.
15 Q. Was it a meeting about which you have heard
16 subsequently?
17 A. No, I have not.
18 Q. We have been told by Mr Dhasmana it was a meeting during
19 which Professor Angelini suggested to Mr Dhasmana that
20 because of the service he, Professor Angelini, had done
21 Mr Dhasmana, he, Mr Dhasmana, should "kiss his boots".
22 A. Yes, I have read about that subsequently. I did not
23 know about it at the time.
24 Q. There was no talk about that at the time?
25 A. Not to me, no.
0168
1 Q. Does it surprise you that an incident like that, which
2 involved strong and intemperate words, spoken by the
3 surgeons to each other in the course of a meeting, did
4 not become a matter of corridor conversation almost
5 immediately afterwards for everyone?
6 A. Well, again, we were entrenched in the Children's
7 Hospital and we were not part of the milieu of the BRI,
8 and it does not surprise me that I did not hear about
9 that at the time.
10 Q. On 8th December 1994, there was a meeting at your house,
11 at which, amongst other things, the progress or the
12 results in respect of the non-neonatal arterial switch
13 were reviewed. What was the purpose of calling the
14 meeting?
15 A. Again, it was one of those regular three or so times
16 a year meetings. As far as I recall, I think it was to
17 discuss the non-neonatal switch operations, among other
18 issues --
19 Q. Are you sure about that? The reason I ask you is
20 because Dr Pryn, when he gave evidence to us,
21 recollected that although that is what the meeting did
22 as part of its discussions, it was not called
23 exclusively for that.
24 A. Yes. Well, there was a meeting, one of those meetings,
25 where the purpose was to discuss non-neonatal switches,
0169
1 and the anaesthetists were asked to attend. But I do
2 not recall if in fact it was that one. But as you say,
3 the issue of non-neonatal switches was discussed that
4 evening.
5 Q. Why was it, as you recollect it, that the anaesthetists
6 were asked to attend that meeting?
7 A. Either that, or another meeting. Again, I think that
8 the feeling was that there was dissatisfaction on the
9 part of anaesthetists about the results of switches
10 generally, in this case, non-neonatal switches, but
11 again, I find myself in difficulty in not knowing
12 precisely how much I knew at the time and how much has
13 come in subsequently from reading, but I do recall we
14 did discuss non-neonatal switches that evening, that is
15 right.
16 Q. Help us as best you can: by 8th December 1994, did you
17 know that Dr Peter Doyle of the Department of Health had
18 been in contact with Dr Roylance? Dr Roylance had
19 responded in respect of what were called "problems", or
20 "a problem" in cardiac surgery?
21 A. No. The first I heard of that was at the Loveday
22 meeting, which no doubt you will come to, where
23 Dr Bolsin, among other comments, said that he was in
24 communication with someone from the Department of
25 Health. I did not, even at that time, know who the
0170
1 individual was. Subsequently it turned out that this
2 was Dr Doyle.
3 THE CHAIRMAN: I do apologise for interrupting,
4 Mr Langstaff, it is just for the transcript. Was the
5 reference to the meeting to discuss "neonatal" switches,
6 or "non-neonatal"?
7 MR LANGSTAFF: Non-neonatal. Do you regard the taking place
8 of cardiac surgery as a team process?
9 A. Yes.
10 Q. Do you regard the cardiologists as an integral, indeed,
11 an important part of the team?
12 A. Yes.
13 Q. Can you help us at all as to why it should be that
14 concerns expressed by somebody from the Department of
15 Health to Professor Angelini, the Professor of Cardiac
16 Surgery, are referred to the Chief Executive and to the
17 Medical Director of the Trust, but you, Clinical
18 Director as you were, senior cardiologist as you were,
19 with a direct interest as part of the team, were never
20 told?
21 A. No, I cannot explain that. Nor can I explain why
22 Dr Bolsin did not make his information known to us at
23 the time of his audits earlier on, but that is besides
24 the point. I would dearly have wished that we were
25 informed, but we were not. I was not.
0171
1 Q. Communications seem to have been poor. Would you wish
2 to comment?
3 A. If that is taken as an example, then, yes. I mean, in
4 general, I have to agree with that.
5 Q. Can I come to the Loveday operation itself? Joshua
6 Loveday was one of Dr Martin's patients?
7 A. Yes.
8 Q. He had been put on the operating list and this had
9 caused, do you understand, some concern because it had
10 been thought amongst some clinicians that no further
11 non-neonatal arterial switches would be performed,
12 pending the arrival then anticipated of Mr Pawade?
13 A. Yes, so I understand, in retrospect. At the time I had
14 no knowledge that that was even being considered by
15 anaesthetists or others, that that in fact was
16 a recommendation.
17 Q. Did you have any idea then that the non-neonatal
18 arterial switches would not be performed or,
19 alternatively, would be performed only after discussion
20 with all the anaesthetists?
21 A. No. So far as I was aware, there had been no decision
22 to discontinue performing non-neonatal switches at that
23 time.
24 Q. Could we have on the screen, please, UBHT 54/11? Your
25 best recollection, please, of the meeting called the
0172
1 night before the operation on Joshua Loveday. You were
2 present?
3 A. Yes.
4 Q. You were not the treating clinician. You had not
5 yourself, I think, examined Joshua Loveday?
6 A. That is right.
7 Q. Did you know when he had last been examined prior to
8 this meeting, at the time?
9 A. No, I did not know.
10 Q. You knew he was on an elective list?
11 A. Well, I did not know it was an elective list, but he
12 clearly was. I did have not in my possession the
13 waiting list.
14 Q. Were you told at the meeting that his surgery was
15 elective?
16 A. Well, we understood that his surgery was in the middle
17 group, as defined by your series of issues, namely,
18 urgent. He was not an emergency; he was not purely
19 elective, by which I would define that to mean that the
20 patient is asymptomatic and requires an operation at
21 some stage in the future; could be fitted in at
22 a convenient and appropriate time thereafter, as a cold
23 elective case.
24 The urgent cases I would define as those who did
25 not have to be dealt with immediately, but within a few
0173
1 weeks or months, if at all possible. That was the
2 category that I understood Joshua Loveday was in: his
3 cyanosis, as I understood at that meeting, was slowly
4 progressing, and getting to a point where something
5 should be done in the reasonably near future.
6 Q. The reasonably near future. So he was a child who, at
7 the time of this meeting, would have been admitted to
8 hospital for an operation the next day, but had not,
9 therefore, been admitted as an emergency case?
10 A. No, not as an emergency. But if I could perhaps
11 amplify, it would have been up to the treating
12 paediatric cardiologist, in this case Dr Martin, to make
13 an assessment at his last outpatient visit that an
14 appropriate time had been reached for him to be put on
15 the semi-urgent or urgent list, to be done soon.
16 Q. We know that he was suffering from a Taussig-Bing
17 syndrome?
18 A. Yes.
19 Q. How important is it, when one comes for an operation for
20 a Taussig-Bing syndrome, to have an up-to-date catheter
21 report?
22 A. I do not think it is urgent to have up-to-date
23 information in that respect, so long as the diagnosis
24 had been clarified clearly and definitively at
25 a previous examination. The important factor in terms
0174
1 of the follow-up was the degree of cyanosis and the
2 rapidity with which the cyanosis had developed or got
3 worse, so that you firstly can see with your naked eye,
4 and secondly, can easily be measured with
5 a transcutaneous oxygen oximeter, so it would not need
6 an up-to-date cardiac catheter at that time.
7 Q. Would you then need some up-to-date measurement by the
8 oximeter, for instance, of oxygen saturations?
9 A. It would not be essential, but it would be a useful
10 guide as to the progress to visit at two, three or four
11 monthly intervals, but it is certainly not done as
12 a routine. One makes an estimate clinically of how
13 severe the cyanosis is and from the history that the
14 parent would give, of increasing fatigue, and dyspnoea
15 on exertion because of the diminishing oxygen saturation
16 level.
17 So it is a clinical assessment more than anything
18 else.
19 Q. The urgent category, as you describe it, not having to
20 be done the next day, but in the near future, would tend
21 to preclude, would it, operation, say, three or four
22 months later?
23 A. It is very difficult to put a time limit on it because
24 each case is slightly different, but I would have
25 thought that "urgent" meant within, say, weeks, or two
0175
1 to three months, preferably.
2 Q. That time-scale would not, then, preclude either seeking
3 a second opinion if a second opinion were thought
4 desirable, or transfer of the patient to another centre,
5 if that were thought desirable?
6 A. No, it would not preclude that.
7 Q. So one may say, with confidence, may one, that there was
8 no good clinical reason which militated against the
9 transfer of Joshua Loveday from Bristol to Birmingham,
10 Great Ormond Street, wherever, if that was a course
11 decided upon?
12 A. No, there would be no reason not to take that course.
13 At the same time, there would not be, in the estimate of
14 clinicians looking after him, any positive reason to
15 take that line given the assessment of the non-neonatal
16 switch operation figures at that point, which were very
17 similar to those experienced throughout the country.
18 There would seem to me not to be a need to refer
19 elsewhere. Or to wait unduly long.
20 Q. Joshua Loveday had last been into the Children's
21 Hospital on 21st November 1994, when he was seen by
22 Dr Martin. Would you have expected, upon such an
23 admission, as a consequence of which he was placed on
24 the operating list of Mr Dhasmana, to have involved an
25 examination of him which would have measured the oxygen
0176
1 saturations?
2 A. No. How old was he at the time? 18 months?
3 Q. He was 18 months when he came to operation, therefore 16
4 months at this stage, thereabouts.
5 A. No, I think it would have been a clinical assessment
6 made in November, in this case, and I think that
7 decision taken then would have been perfectly
8 appropriate to proceed to an operation two months later
9 without any further special investigations.
10 Q. The meeting on 11th January proceeded, as I understand
11 it -- correct me if this is not your recollection -- in
12 two stages: the first stage being to ask, was there any
13 reason, statistically, looking at the figures, why the
14 unit should not do the operation on Joshua Loveday?
15 A. Yes.
16 Q. The second part of the meeting, as I understand it, was
17 then in the light of the views expressed on the first
18 question, whether in fact the operation should go
19 ahead.
20 A. That is within the forum of that meeting?
21 Q. Yes.
22 A. Because there is still a further meeting after that
23 meeting, between Dr Martin and Mr Dhasmana.
24 Q. We have heard that Mr Wisheart, Mr Dhasmana, Dr Martin,
25 went to a side room and there had discussions. We have
0177
1 had the evidence of two of them in respect of that
2 conversation. We are told that at that conversation
3 Mr Wisheart was, in essence, seeking to persuade
4 Dr Martin and Mr Dhasmana that the operation need not go
5 ahead the next day.
6 A. For other than clinical reasons, I believe.
7 Q. What is unclear is whether the meeting as a whole had
8 a report back from the side meeting, or not?
9 A. No, I do not recollect that.
10 Q. So your recollection of the meeting is limited to
11 deciding whether there was any reason not to do the
12 operation?
13 A. Yes.
14 Q. The reasons examined: were they the statistical, and
15 secondly, other considerations, if I can call them that,
16 which arose in particular in discussion as we see in
17 this note if we scroll down to the bottom, the way it is
18 put in Dr Monk's note, discussion on the political
19 position of the Trust; is that right?
20 A. Which, the final paragraph?
21 Q. It is paragraph 3. I was anticipating that you were
22 reading it before you answered.
23 A. Thank you. I was reading the last one. (Pause). Yes,
24 I do not believe I have seen that document before, but
25 essentially, I would have no reason to contradict that.
0178
1 Q. The figures, if I can deal with this fairly quickly,
2 because we have asked a number of witnesses on this, can
3 I have UBHT 126/52, please? You will see that this is
4 a document you may recognise.
5 A. Yes, this one I do.
6 Q. You will notice that there are some figures which have
7 been amended in handwriting.
8 A. Yes.
9 Q. If we scroll down -- they are not very clear on that
10 screen. For that reason, can I take you to UBHT 126/51
11 where the corrections have been made in typescript, this
12 document I think being circulated later than the
13 meeting, but essentially in respect of the questions
14 I have to ask you, I think, in providing the information
15 there was at the meeting.
16 A. Yes.
17 Q. What was reviewed was the mortality rate. The line we
18 have to focus on, I think, if we can scroll down a bit,
19 please, is mortality under JPD, patients only, because
20 he was to perform the operation, is that right?
21 A. Yes.
22 Q. If one looks at the total from 1988 to 1994, there is
23 a mortality rate of 46 per cent, and that, if that were
24 the mortality rate, would argue strongly against having
25 the operation the next day if that were the figure
0179
1 focused upon?
2 A. The 1988 to 1989 figure, yes.
3 Q. If one takes the non-neonates line, if I can have that
4 line highlighted, please, if one takes the total, 1988
5 to 1994, total mortality of 33 per cent, and again, if
6 one were to pick that figure, one would argue, I think,
7 that statistically, the risks were greater than those
8 that might be expected on average elsewhere?
9 A. Yes.
10 Q. If one focuses on the 1990 to 1994 series, one has the
11 risk of 20 per cent in the non-neonates?
12 A. Yes.
13 Q. Can we go down to the bottom of the page, the UK Cardiac
14 Surgical Register data? The relevant comparison line is
15 that for TGA plus VSD. If we go across the total,
16 a declining mortality for that diagnosis across 1990,
17 1991, 1992?
18 A. Yes, that is right.
19 Q. One does not know what operations were being done within
20 that diagnosis, whether it was Sennings or switch?
21 A. No.
22 Q. But I suppose by 1992, most units would be doing the
23 switch, would they?
24 A. Most units would be, but I would also point out that the
25 under 1 year would include neonates and non-neonates, so
0180
1 that if one was making a comparison with non-neonates of
2 Mr Dhasmana's, that comparison is not 100 per cent, as
3 I see it.
4 Q. I follow. If one were to break down the figures
5 further, what we are looking at is, albeit it is
6 specific to TGA and VSD as a diagnosis, it does not help
7 to distinguish between the Taussig-Bing syndrome and
8 those cases where there is no particular anatomy of the
9 Taussig-Bing?
10 A. No, that is true too. Or, indeed, any variety of double
11 outlet right ventricle.
12 Q. The double outlet right ventricle is a rather more
13 difficult surgical proposition?
14 A. Yes.
15 Q. In respect of which the risks are inevitably higher?
16 A. One would expect so, yes.
17 Q. Was the meeting told, did it have any idea of the
18 results, the outcomes, in the few double outlet right
19 ventricle cases that Mr Dhasmana had operated upon?
20 A. I do not recollect that specific issue being discussed.
21 I think the focus was on mortality for switches in
22 non-neonates.
23 Q. One of the problems with looking at data such as this
24 is that inevitably one can only get, I suspect,
25 a general picture, and it does depend how one breaks it
0181
1 down, does it not?
2 A. Yes.
3 Q. It is the old story with statistics. If you break it
4 down in particular groupings, you may get it to give you
5 the answer to the question you first thought of?
6 A. Yes, or the group becomes so small that it becomes
7 unrealistic.
8 Q. What information did the meeting have in respect of
9 results elsewhere in the country, apart from the Cardiac
10 Surgical Register data?
11 A. As far as I know, that was the only data on paper, so to
12 say, of other units in this country, but there were
13 discussions about other papers, mainly from the USA, on
14 the same subject and as I recollect it at that time, the
15 figures were roughly equivalent to those in the UK
16 surgical register.
17 Q. If we go to UBHT 133/20, and look at the second
18 paragraph on the page --
19 A. Can I ask you what the document is?
20 Q. Let us go back to page 18. It is to Dr Martin from
21 Dr Baker, dated 31st July 1995.
22 A. Yes.
23 Q. It is a draft of a paper which he has prepared, and it
24 is the next words which make me ask you about this, he
25 wants comments from Hyam Joffe. That is you, obviously?
0182
1 A. Yes.
2 Q. Let us turn over.
3 A. If I could explain, both Dr Martin and myself were at
4 the meeting with Dr Baker. Dr Baker then drew up
5 a schedule of the information as he understood it, sent
6 it as you see to Dr Martin with a copy to myself.
7 Dr Martin was not around at the time. I think he was on
8 leave. So I had a discussion with Dr Baker in his
9 place, making certain corrections that I felt were
10 necessary, and made the point, I believe, that these
11 overall conclusions would need to be vetted by Dr Martin
12 on his return, to ensure that he found them acceptable
13 as well.
14 Q. 5 to 10 per cent quoted there. As it happens, in
15 a covering letter which Dr Martin subsequently was to
16 write, he thought that might be a bit high for
17 Birmingham.
18 A. Yes.
19 Q. Did you know, in January 1995, at the time of the
20 meeting the night before the operation of Joshua
21 Loveday, that Birmingham's results in this particular
22 operation were actually very good?
23 A. By hearsay, yes. I mean, we knew that they were
24 achieving very good results. I did not, myself, have
25 a percentage, either in mind or that I knew of, but the
0183
1 overall impression was that they were doing very well.
2 Q. Indeed, you knew that was the very reason that
3 Mr Dhasmana had, on two occasions, gone to Birmingham in
4 order to be assisted with his ability to do this
5 particular type of operation?
6 A. Yes, indeed.
7 Q. Albeit in neonates, the technical aspects are not very
8 different?
9 A. Yes.
10 Q. So there would have been no doubt, one would take it,
11 that if Joshua Loveday had been thought suitable or
12 appropriate to transfer him, and if Birmingham would
13 have accepted him, that he could have been transferred
14 to a centre not very far away where there was good
15 reason to think that the operative mortality was lower
16 than that likely to be achieved in the Bristol unit.
17 A. Yes, certainly their results were lower. I agree with
18 that part. But the basis on which I think you asked
19 that question is that if there is a centre reasonably
20 close by that was achieving better results than you were
21 in a particular operation, then you should send that
22 patient to that unit. Which, if one extends the logic,
23 means that each condition should be done in a different
24 place throughout the country, and indeed, why not the
25 world?
0184
1 Q. I follow the logic and understand it. The difference
2 perhaps may be that there never was any other meeting
3 such as this in respect of the operation on Joshua
4 Loveday in respect of any other child, was there?
5 A. No.
6 Q. This was remarkable, and because in part of the history
7 of dissent and disagreement?
8 A. Yes.
9 Q. And the need to go through statistics even before the
10 operation might be considered, or contemplated. One
11 would appreciate that with the best will in the world --
12 and he, let it be said, denies it -- there would
13 inevitably be pressure upon the surgeon which one might
14 think would be at the back of his mind in operating?
15 A. Yes. If one is thinking in non-clinical terms, then
16 with hindsight it may have been far more apposite to
17 have referred this child elsewhere, say Birmingham, but
18 at the time, the clinicians felt that the clinical
19 indications were important and that if the surgeon felt
20 he was not under undue pressure, that that operation,
21 there was no reason why it should not be done there, but
22 with the benefit of hindsight, I think we all now
23 realise that there was a great deal more going on behind
24 the scenes of a purely non-clinical nature about which
25 at least some of us, if not most of us, had no idea, was
0185
1 going on.
2 Q. What do you say to those who might suggest that going
3 ahead with the operation the next day was more an act of
4 stubborn obstinacy than a careful decision which
5 concentrated upon the --
6 A. I do not believe that at all. I think the extent of the
7 clinical discussion was in-depth. The results were
8 discussed considerably, so that I think an appropriate
9 clinical decision was taken.
10 Q. Do you know what view Dr Martin took of Dr Bolsin?
11 A. No.
12 Q. And do you know what view Mr Dhasmana took of
13 Dr Bolsin?
14 A. Well, I think he had a similar view, but I think you
15 must ask Mr Dhasmana, I am afraid I cannot answer for
16 him.
17 Q. There was, was there, some fierce debate and discussion
18 between those at the meeting in respect of Dr Bolsin's
19 contacts with the Department of Health and the
20 involvement in respect of the meeting?
21 A. Yes. Several people were very cross that an
22 individual -- who I might add actually agreed with the
23 clinical decision that there was no reason on that
24 account for the operation not to be done, but said, I do
25 not remember the exact words, something like for
0186
1 political reasons, he would advise that the operation be
2 not done, and then we heard about the connection with
3 the DOH, and there was a lot of anger at the meeting,
4 that this had happened, and I believe it was Dr Masey
5 who asked him directly what he thought he was doing by
6 going directly to the Department of Health.
7 Q. I do not think I need trouble you more with questions
8 about that. We have already dealt earlier in your
9 evidence with events that happened afterwards, and I am
10 not going to ask you about those in any greater detail.
11 I have kept you today, detained you for longer than we
12 might have anticipated. There are just two more
13 questions that I have to ask you. One is in relation to
14 the case which I was going to discuss with you, and time
15 did not permit the opportunity, the case of Bethan
16 Bradley, if you may remember, in which there is
17 a comment about your absence from post-operative care
18 and your failure to offer condolences.
19 First of all, is it right that as a matter of fact
20 you were not present post-operatively after the
21 operation on Bethan Bradley?
22 A. Yes.
23 Q. You want to tell us why that was?
24 A. Yes, I do, thank you. I was on leave from that
25 Saturday. The operation took place on the Thursday.
0187
1 I can look up my diary and check that.
2 Q. No, just tell us.
3 A. That Friday I had a peripheral clinic in Bath. The
4 Thursday, the day of the operation, I did a catheter in
5 the morning and I had an echocardiography session which
6 takes the whole afternoon. Over the weekend, we left
7 for a holiday to Italy and returned three weeks later,
8 so that I was not in fact in Bristol when, sadly,
9 Bethan, who was a dear patient of mine, died.
10 Q. Can you help with the question which it raises, which is
11 that of cardiological cover for other cardiologist
12 patients whilst on the Intensive Care Unit recovering
13 post-operatively?
14 A. There would certainly have been one of my colleagues on
15 duty, on call from the end of that week through to the
16 end of the following week so that individual would then
17 have been available to attend to problems if called
18 upon.
19 Q. "On duty" does not mean "there", it means "if called
20 upon", does it?
21 A. Yes.
22 Q. Does one have again a reflection of the split site in
23 this sense: that if you are working next-door to the
24 ICU, as it were, you will pop in and see, and a cover
25 cardiologist will do the same, no doubt?
0188
1 A. Yes.
2 Q. Whereas, if it is some distance away, maybe only
3 a matter of five minutes down the road, but if it is
4 some distance away, there is not the routine of visiting
5 somebody else's patient in ICU necessarily, unless
6 requested to do so?
7 A. Yes. That is generally correct, as I stated, I think
8 yesterday. Although during the weekdays, as again
9 I mentioned, a cardiologist, either Dr Jordan or Martin,
10 most of the time, would have made an effort to go down
11 to the BRI Intensive Care Unit to assess post-operative
12 cases at least once a day. But it would certainly not
13 be as easy or convenient as it would be in a single
14 centre where one pops in and out virtually all day long.
15 THE CHAIRMAN: Do we also, Dr Joffe, get the picture of how
16 you described as a consultant-led service, where there
17 were not very many others for the consultant to lead,
18 that one person going on holiday begins to stretch
19 resources?
20 A. Yes, it is a one or two cover from them on.
21 MR LANGSTAFF: The second question was this: you told us
22 almost at the beginning of your evidence that you
23 continued to refer some cases to Mr Dhasmana after
24 1st May 1995?
25 A. Yes.
0189
1 Q. Why?
2 A. I could see no reason why not to. He was doing
3 extremely good work in most conditions, apart from the
4 neonatal switch episode, I was happy with his
5 performance and the results he achieved. I could see no
6 reason to change that.
7 Q. The final question which has become routine with us, is
8 to invite you at this stage, having sat there and
9 answered the questions I have had to ask, to volunteer
10 anything you think may have been missed, anything you
11 think may have been needed by way of clarification, or
12 to say anything to the Inquiry which you think needs to
13 be said. This does not, may I say, preclude your adding
14 to your evidence in writing in any respect after today.
15 A. Thank you very much. May I ask my counsel if they have
16 any particular questions to ask? No. Then may I make
17 a brief statement, as follows:
18 Thank you for giving me this opportunity to make
19 this brief statement to the Inquiry. Firstly, as others
20 have done during this Inquiry, I wish to express
21 my sincere regret to the parents who have lost their
22 children through the misfortune of congenital heart
23 disease. That includes both those who have felt the
24 understandable pain and grief of their tragic loss after
25 surgery and have responded by seeking this Inquiry, and
0190
1 also, those many parents who have lost children but have
2 chosen not to become involved with or participate in the
3 Inquiry, wishing to avoid reliving their experience, and
4 going through the mourning process which they had hoped
5 they had put behind them.
6 Secondly, I am concerned, and I believe others
7 are, that the legacy of Bristol should not be a loss of
8 trust and confidence between patients and their doctors,
9 as trust is a key component of the provision of
10 treatment in the NHS.
11 THE CHAIRMAN: Dr Joffe, I know others will read what you
12 have just said, and we heard it and we are grateful to
13 you. Thank you. Thank you also for spending a long day
14 and most of yesterday also with us. We are helped by
15 your evidence. We are very grateful to you. Thank
16 you.
17 MR LANGSTAFF: Sir, we meet again at 10.30 on Monday.
18 MR LANGSTAFF RE NEXT WEEK'S TIMETABLE:
19 MR LANGSTAFF: May I say that next week we shall hear on
20 Monday, Tuesday, Wednesday and perhaps Thursday, from
21 Mr Wisheart. We will hear from him starting at 10.30 on
22 Monday, 9.30 on Tuesday, but on Wednesday we will begin
23 at 9.00 in order to accommodate the evidence of
24 Professor Prys Roberts, which it is anticipated will
25 take about an hour.
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1 It is hoped that the witnesses that we shall hear
2 on Thursday will be announced during the course of next
3 week.
4 THE CHAIRMAN: Mr Langstaff, I am grateful to you and to
5 those behind you. We have gone on longer than we
6 ordinarily do, but I thought it was important to allow
7 Dr Joffe to continue his evidence.
8 So we are all very grateful. Thank you also to
9 the stenographers. They have had a long day. I say
10 good afternoon to all of you.
11 (6.05 pm)
12 (Adjourned until 10.30 am on Monday, 13th December 1999)
13
14
15 I N D E X
16
17 MR LANGSTAFF re investigations into legal
18 position on tissue and organ retention ...... 1
19
20 DR HYAM JOFFE (recalled):
21 Examined by Mr Langstaff (continued) ........ 8
22 [Dr Alan Houston sworn at page 9]
23
24 MR LANGSTAFF re next week's timetable ............. 191
25
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Published by the Bristol Royal Infirmary Inquiry, July 2001
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