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Daily transcripts
Hearing summary
13th May 1999
Today the Inquiry heard evidence from Sir Terence English, former President of the
Royal College of Surgeons of England (RCSE) and member of the Supra Regional Services
Advisory Group (SRSAG) 1990 – 1992. He outlined the role of the Royal College of
Surgeons in the accreditation of hospital training posts for senior house officers (SHO)
through the Hospital Recognition Committee and the higher training of surgeons through the
Specialist Advisory Committee. He described the growing importance of audit of activity
and outcomes during the 1980s and 90s. He said that audit activity in training hospitals
had emerged as a major consideration during accreditation visits. He described the
establishment of the Cardiothoracic Surgeons Register at the end of the 1970s saying that
anonymised information was sent to the Secretary of the Society of Cardio-Thoracic
Surgeons by units in the UK and was distributed to society members. This information was
useful for regional planning and for educational purposes acting as a comparison of
performance. During his time as a member of SRSAG, Sir Terrence confirmed that
de-designation of infant and neonatal cardiac units for supra-regional status was
discussed and that ‘geography’ as well as ‘potential for development’
had been used as criteria for designation. He said that following a SRSAG visit to Bristol
in 1989, which identified problems with the facilities associated with the split site,
both of these criteria were used to justify continued designation of the Bristol unit. He
said RCSE visits to Bristol in the early 1990s reported conflicting findings, suggesting
that SHO training was poor, but that supervision of higher training was exceptionally
high. He said that such information would only be cross-referenced if a particular concern
was expressed about the unit. He said that the low numbers of patients treated at Bristol
remained a concern for SRSAG and that he had formed the opinion that geography alone was
not essential to warrant designation of a unit, and confirmed this in writing to Dr Norman
Halliday, Medical Secretary of SRSAG towards the end of 1991/beginning of 1992. He went on
to say that development of a unit was the responsibility of local management and SRSAG,
that the RCS would only become involved with making recommendations outside those related
to training issues if invited to do so. Sir Terence told the Inquiry that he received a
request from Dr Halliday in July 1991 to arrange a RCS review of the infant and neonatal
cardiac service, asking for recommendations about whether, firstly, some surgical
procedures could be omitted from supra-regional status and secondly if some units should
be de-designated. A report was commissioned and made recommendations for a reduction in
the number of units. Sir Terence said that by July 1992 he felt that Bristol should no
longer be designated.
***************************
Due to the late hour the oral hearings were suspended at this point to resume again on
at 10.00 a.m. on Monday 17th May with evidence from Professor David Baum,
President of the Royal College of Paediatrics and Child Health. Sir Terence English will
continue his evidence on Monday 17th May following Professor Baum’s
evidence.
|
FULL TRANSCRIPT
1 Day 17, 13th May 1999
2 (10.50 am)
3 THE CHAIRMAN: Mr Langstaff, good morning.
4 MR LANGSTAFF: Good morning, sir. Sir, today, as I have
5 I think telegraphed throughout this week, we will have
6 the advantage of hearing from Sir Terence English, the
7 scope of whose evidence has been foreshadowed by others
8 from whom we have heard in the past fortnight.
9 Sir Terence, as is public knowledge, is the master
10 of St Catharine's College, and we think it right to put
11 on the record for all concerned so there is no
12 misunderstanding about it, that Professor Sir Brian
13 Jarman attended St Catharine's College, Cambridge,
14 although this was some time ago, if you will forgive me
15 for saying so, between 1951 and 1954.
16 He met Sir Terence English for the first and only
17 time on Friday 16th April 1999 at a reunion dinner at
18 the College. Sir Terence English told Professor Jarman
19 that he did not know prior to that dinner that Professor
20 Jarman was a member of the Inquiry panel, but this
21 became apparent to him when comment was made by another
22 doctor present.
23 Professor Jarman for his part acknowledged to
24 Sir Terence English that he was on the Inquiry panel,
25 but was scrupulous not to discuss any matters with which
0001
1 this Inquiry is concerned.
2 I should perhaps add that the interested parties
3 wish to consider this potentially significant matter,
4 and that they reserve their position.
5 Sir, with that introduction, making those matters
6 plain before I call Sir Terence, I wonder if Sir Terence
7 would come forward now to take the oath in the usual
8 way?
9 SIR TERENCE ENGLISH (Sworn):
10 Examined by MR LANGSTAFF:
11 Q. Sir Terence, your full name is Terence Alexander
12 Hawthorne English, is it?
13 A. Correct.
14 Q. And as I have already told the gathering, you are the
15 Master of St Catharine's College, Cambridge?
16 A. Yes.
17 Q. You are also, I think, currently the President of the
18 British Cardiac Patients Association?
19 A. Yes.
20 Q. You have, in the past, had the following appointments
21 which I think may be particularly relevant to the
22 subject of our enquiries: first of all, you were
23 a member of the Specialist Advisory Committee in
24 Cardiothoracic Surgery between 1979 and 1987?
25 A. Yes.
0002
1 Q. You were, as I understand it, President of the Royal
2 College of Surgeons of England between 1989 and 1992?
3 A. Yes.
4 Q. You were a representative of the Joint Committee of
5 Higher Surgical Training from 1989 to 1991?
6 A. Yes.
7 Q. You served on the Education Committee of the General
8 Medical Council from 1986 to 1989?
9 A. Yes.
10 Q. You were a member of the Standing Medical Advisory
11 Committee between 1989 and 1992?
12 A. Yes.
13 Q. You were a member of the Joint Consultants Committee
14 from 1989 to 1992?
15 A. Yes.
16 Q. You were a member of the Supra Regional Services
17 Advisory Group from 1990 to 1992?
18 A. Yes.
19 Q. And a member of the Clinical Standards Advisory Group
20 from 1991 to 1994?
21 A. Yes.
22 Q. You were on the editorial board of Current Practice in
23 Surgery from 1988 to 1995?
24 A. Yes.
25 Q. And amongst the various societies of which you have
0003
1 Membership, you are a member of the Society of
2 Cardiothoracic Surgeons, and indeed, have served on
3 their Executive Council?
4 A. Yes.
5 Q. You are a member of the British Cardiac Society?
6 A. Yes.
7 Q. You are also, I think, a member of the Cardiac Surgical
8 Research Panel?
9 A. Yes.
10 Q. I do not wish to embarrass you by reading out in detail
11 the further appointments which you have held, the
12 lectures which you have given and such like, which are
13 contained in your curriculum vitae attached to your
14 statement, because of course that statement will be made
15 freely available for all to see, and they can see for
16 themselves.
17 On 27th March 1996 did you take part in
18 a programme called "Dispatches" which was screened on
19 national TV?
20 A. Yes, I believe so.
21 Q. In the course of that programme, did you say -- this is
22 in reference to something which happened and we will
23 come back to it in detail, in 1992 -- that when you
24 reviewed the results of paediatric cardiac surgery in
25 Bristol, it became apparent to you that mortality was
0004
1 disturbingly high?
2 A. Correct.
3 Q. And when you were asked if you were advising the
4 Department of Health that the service should be
5 de-designated, were you not effectively advising that it
6 should stop, you said you were?
7 A. Yes: that is the service at Bristol.
8 Q. Do I take it that what you said on the "Dispatches"
9 programme was the truth?
10 A. Yes.
11 Q. You made a statement to us, and if I can just have
12 WIT 71/1 up on the screen, that, I think, is the
13 beginning of the statement. If we go through, please,
14 to WIT 71/6, is that your signature at the bottom?
15 A. Yes.
16 Q. Is the statement true?
17 A. The statement above my signature is a direct extract
18 from the Working Party's report. And the whole
19 statement is true, correct.
20 Q. Before I ask you more generally, can I just ask you
21 this: if it were to be suggested -- and I want to
22 explore the circumstances later, but if it were to be
23 suggested that what you did following the receipt, or
24 your understanding, that mortality was disturbingly high
25 at Bristol, was the exact reverse of securing that the
0005
1 surgery stopped, what would your response be?
2 A. One of concern.
3 Q. I will come back to that, because it is a suggestion
4 which you will have, and I think you understand there
5 has been controversy about this matter, and you will
6 have to deal with it for the benefit of the Inquiry at
7 a later stage.
8 A. I think, if I may, there is an important distinction,
9 just going back to your precise words. I do not think
10 I ever suggested that the surgery should be stopped;
11 I suggested that Bristol should be de-designated.
12 I think there is a distinction there.
13 Q. Can I take you away from that for a moment and deal with
14 some broad outline issues of principle.
15 The Royal College of Surgeons, of which you have
16 been a member for a long time, and as you have told us,
17 an important and prominent member, has a number of
18 duties and functions to perform. Amongst those, is it
19 right that the Royal College of Surgeons seeks to
20 maintain and improve education and training standards
21 for surgeons?
22 A. Yes.
23 Q. Does it regard itself as setting or having a role in the
24 setting of standards of good practice and conduct?
25 A. Yes, indeed.
0006
1 Q. Is one of its functions to guide and sponsor research
2 into data collection?
3 A. Yes.
4 Q. Did it in fact have a surgical audit unit in the years
5 at least between 1984 and 1995?
6 A. I believe, if my memory serves me correctly, the audit
7 unit within the College was formally established in
8 1986, with Mr Brendan Devlin at its head, and it then
9 became an important part of the College's activities.
10 Q. So throughout, from 1986 onwards at any rate, the
11 College was centrally concerned with the process of
12 surgical audit?
13 A. Correct.
14 Q. And by "surgical audit", is that in relation to quality
15 or numbers of operations?
16 A. Both, but predominantly quality, but also with regard
17 to -- out of that unit came guidelines, setting
18 standards of care.
19 Q. So it was taking a qualitative rather than
20 a quantitative approach in general?
21 A. Yes.
22 Q. Did the College, in the 1980s, participate in
23 initiatives in data collection and the presentation of
24 evidence?
25 A. Indeed. There was one project which was outwith my own
0007
1 specialty which was established by David Dunn from
2 Cambridge, which established a confidential comparative
3 audit in general surgery, in which the large numbers of
4 general surgeons contributed information on their number
5 of operations and the associated mortality and
6 complications. That helped to take forward the debate
7 on surgical audit, both its pitfalls and its value.
8 Q. I think there was a participation or liaison with the
9 Clinical Outcomes Group of the Department of Health?
10 A. Yes.
11 Q. Just tell me how that would work.
12 A. I believe that when Mr Devlin, who was director of the
13 unit, when Council had decided on a particular area of
14 audit, that he would then have preliminary discussions
15 with the Department of Health and share the proposal
16 with them. I do not know the exact details of how that
17 communication took place.
18 Q. What was your understanding of what the Clinical
19 Outcomes Group of the Department of Health were there to
20 do?
21 A. The Department of Health had funded audit really quite
22 strongly certainly in the late 1980s, early 1990s.
23 Indeed, there were some in the profession that thought
24 that too much money had been put into medical audit as
25 a whole. They needed, obviously within the Department,
0008
1 to have a group who were kept informed of what was going
2 on in audit, in the various Colleges, and so I think it
3 was probably seen as a co-ordinating role rather than an
4 initiating role. That would be my impression.
5 Q. Forgive me, because I am not sure that I have understood
6 from your answer what the Group did with the
7 co-ordinating role. The purpose of co-ordinating
8 information on outcomes with a view to what?
9 A. I think they wanted to know what was going on within the
10 different Colleges, the Royal College of Physicians had
11 an equally important group looking at audit under
12 Dr Hopkins. There were the various national
13 confidential enquiries into operative deaths. There was
14 a change of emphasis in the late 1980s towards a much
15 franker audit, both at a national level and at a local
16 level, so that the College of Surgeons decided, I think
17 in their report on surgical audit in 1989, that in
18 future visitors, College visitors who were going to
19 assess training programmes in hospitals, would
20 specifically enquire whether there was regular open
21 audit conducted in the hospital, and would be able to
22 withdraw recognition if it were not.
23 Q. Certainly our reading in this Inquiry supports the idea
24 that that was 1989, I can tell you.
25 Can you help with this: for several years prior to
0009
1 1989, the cardiothoracic surgeons had themselves
2 established a national register, had they?
3 A. Yes, I can help you with that, because I was largely
4 responsible for it. That was as long ago as 1975. My
5 colleague and I, Mr Milstein wrote a letter to the BMJ
6 suggesting that it would be desirable to have a register
7 of all cardiac operations that were done in the United
8 Kingdom in National Health Service hospitals, and that
9 information ought at the same time to be obtained on
10 30-day mortality for those operations.
11 I then joined the Executive of the Council of the
12 Society and that was one of the objectives which I said
13 during my tenure was to try and establish this register,
14 and the mood was right for it amongst the cardiothoracic
15 surgeons at the time. We conducted a pilot trial in
16 1976 in which we had, I think, about 80 per cent returns
17 from the then 46-odd units who were practising cardiac
18 surgery, and those results, when presented to the annual
19 meeting, were so interesting to the surgeons who were
20 there that they could see the value of such a register
21 and it was agreed and became policy of the Society, that
22 in future every unit should return annually this
23 information, which was sent to the Secretary of the
24 Society from units, not from individual surgeons. It
25 was anonymised. The unit was given a code, and then the
0010
1 data was processed. This was done by a man who worked
2 for BUPA, in fact, Dr Alan Bailey, who was interested in
3 audit, and he was prepared to provide that service for
4 the Society. At the end of the year, after we had got
5 all the information, then the report was published.
6 That was distributed to all the members of the Society.
7 Q. What was the purpose of it?
8 A. The purpose, really, was two-fold: one was for regional
9 planning. I think there was a view amongst many of us
10 that there were too many units in the United Kingdom who
11 had grown up fairly sporadically over the years, and
12 that there was a need probably for fewer centres and
13 that unless one knew where the work was taking place,
14 and the volume of the work in the different units, it
15 would be very difficult to plan regionally. So there
16 was a planning component to it.
17 Of more interest to the surgeons, however, was the
18 educational aspect of the register, because what we had
19 hoped, and I think what in fact was what happened was
20 that at the end of each year the surgeons in the units
21 would get the national report; they would see what the
22 average mortality for aortic valve replacements were
23 that year, a big number of operations, and they could
24 compare it with their own figures. So it, we believed,
25 would act as a stimulus to help surgeons to analyse
0011
1 their own data and compare it with the national data.
2 A similar register had been started in Australia
3 in the mid-1960s, and I had heard about this and the
4 view there was that it had, indeed, contributed to
5 raising standards. I think, if one looks at the, for
6 example, national mortality for aortic valve
7 replacement, the first year we collected information it
8 was somewhere around 8 per cent, just higher than 8 per
9 cent, and within four years it had almost halved. That
10 was shown in some of the other big operations, a big
11 number of operations.
12 Q. You ascribe that to the dissemination of knowledge,
13 rather than the improvements in techniques, equipment
14 and technology through the years?
15 A. It was both, most certainly. This was still a time when
16 the technical aspects of cardiac surgery were improving
17 quite quickly, and generally, the world over, I think,
18 mortality was falling. But one needed a stimulus, and
19 I think this helped to provide that. Obviously not all
20 surgeons saw it in that light, but I think it did quite
21 a lot of good, and indeed, we tried at one stage to not
22 have it as an anonymous register, and some of us shared
23 information across units with each other, but it was
24 never accepted by the Society that we ought to try and
25 force units to be named.
0012
1 What we did do was to get a resolution passed at
2 one meeting that if any unit did not submit its data to
3 the register, then it would be named that year.
4 That only happened one year when two units did not
5 submit their data, and they were named in the report.
6 That was as far as we felt our sanctions could
7 reasonably go at that time.
8 Q. Just a correction to the transcript, which has been
9 pointed out to me -- so you understand, Sir Terence, the
10 transcript is a running transcript, which is taken down
11 at the time. There is an answer which is recorded, it
12 is lines 17 and 18, when you dealt with the sanctions
13 for failure to submit data, and you said "that was as
14 far as we felt our sanctions could reasonably go at that
15 time"?
16 A. Yes.
17 Q. The words "at that time" have been omitted from the
18 answer. Mr McLean tells me that he thinks, and I agree,
19 that it is important that we have that answer as it was
20 given.
21 A. That is how I gave it. Thank you.
22 Q. I imagine that you chose your words with care?
23 A. Yes.
24 Q. I was about to ask you, and you were to tell me, why it
25 was that some units objected to the disclosure of their
0013
1 name, the as it were removal of anonymity?
2 A. This is a difficult question to answer, because I would
3 be answering it on behalf of other surgeons, and I mean,
4 I had no difficulty with sharing our information, and we
5 did, with centres.
6 Q. Simply give me your understanding of their argument, if
7 you please.
8 A. I think in terms first of all, if I might say, that
9 often the difficulties we had with getting returns was
10 due to "lack of secretarial support", "lack of time",
11 "too busy", these sort of things, but we usually
12 managed to get over that, except for the two cases which
13 I have mentioned.
14 The more fundamental objection was based on a view
15 that "I am doing my best with this in the circumstances
16 that I have; I am getting a lot of difficult cases to
17 deal with, which nobody else gets. My mortality may be
18 a bit higher for reasons which are obvious to me, but
19 would not be to others, and I just do not want to share
20 this information and have it known more generally".
21 That may have been the view of some surgeons, and
22 I think there may have been others who were sensitive to
23 the fact that their results were indeed not as good as,
24 say, the average, but that has to be expected anyway,
25 because there will always be a curve and there will be
0014
1 some who have results rather better than the average and
2 some who have rather less than the average. Those with
3 results that were less good would be, understandably
4 perhaps, sensitive about this.
5 Q. The views that you heard expressed were along those
6 lines, were they?
7 A. Yes, largely.
8 Q. So does it follow that on the whole surgeons who it
9 might have been felt "in the trade", as it were, were
10 less successful in terms of outcome were those
11 identified as more reluctant to supply their data
12 without anonymity?
13 A. I could not really go so far as to say that, because
14 I think the decision within the Society not to pursue
15 this, to try and make the register totally open, was one
16 which the Society made; the Executive may have discussed
17 it, and came to a view that it was not worth pursuing
18 without necessarily talking to large numbers of
19 individuals. I certainly did not. I knew that there
20 were a few who had expressed their views to me about
21 this, but I could not have given accurate information on
22 a large number of my colleagues.
23 Q. When the returns came in, did they go to one person?
24 A. They went to the Secretary of the Society who was the
25 one person who knew the identity of all the units. Then
0015
1 he coded them; he gave them the code and they were then
2 sent on in an anonymised form to Dr Bailey at BUPA, who
3 then did the analysis.
4 Q. Was the Secretary himself a medical man?
5 A. Yes. He was a surgeon and he was a senior person on the
6 Executive of the Society, and they tended to serve for
7 four or five years and there were three Secretaries
8 during the time that I was involved with this process.
9 Q. Did you know them well?
10 A. Yes.
11 Q. What, in each case, would his or her view have been as
12 to his or her duty if it had appeared that one of the
13 units sending in returns was very substantially worse
14 than the other? Let me take a "for instance": suppose
15 that the average mortality rate for a particular series
16 of operations is 5 per cent, and a unit doing quite
17 a number produces a return of 50 per cent, to take an
18 obvious case.
19 A. The Secretary did not have that information in terms of
20 percentages. The way the form was constructed, and
21 I have examples of it, I think I sent one in to the
22 Inquiry illustrating the 1984 return from Papworth: you
23 have an operation for a condition, then you have the
24 numbers against it and then you have deaths, and as far
25 as I can recall, the individual returns were not
0016
1 expressed in percentages, because the numbers were often
2 very small.
3 Q. Let me just pick that up with you. Can we have a look,
4 please, on the screen at WIT 71/42? Can we first of all
5 have a look at the distant view, the whole page? We see
6 it is -- do not worry about the print for a moment,
7 because I will have it enlarged, but essentially it is
8 a table which sets out a number of numbers under
9 a couple of headings, and if we can go to the top,
10 please, this is "Miscellaneous operations for acquired
11 heart disease". It is purely an exemplar. "Closed",
12 that is the number of operations, and D is the number of
13 30-day deaths?
14 A. Correct.
15 Q. And "Open", the same. If we go down to the bottom, one
16 can see that in this particular case "Total operations
17 in respect of acquired heart disease" for this
18 particular unit, 6 were done; there were no deaths.
19 100 per cent success rate. That is obvious from the
20 figures.
21 A. Correct.
22 Q. And open, 557, with 26 deaths?
23 A. Correct.
24 Q. And one would not have to be a mathematician, or indeed,
25 to take much more than passing notice of sheets like
0017
1 this to identify quite a disparity between the 5 per
2 cent and the 50 per cent. If, for instance, it was 100
3 operations, 50 deaths, as against 26 with one death,
4 there would be a very obvious difference, would there
5 not?
6 A. There would, indeed, but, I mean, looking at this, you
7 see here, further up, there is heart transplantations,
8 39, 6 deaths. It was a high mortality, but that would
9 not have been included in all but, at that time, two or
10 three of the units in the United Kingdom.
11 The case mix which the units dealt with was, in
12 many instances, quite different. The number of surgeons
13 who were contributing to the unit output varied hugely
14 from two up to six. There were no individual surgeons
15 figures in here; this was the unit's return.
16 If you looked at, for example, the large numbers
17 of coronary artery bypass graft operations, and you
18 looked critically at those, you could see, perhaps, that
19 one unit might have an overall mortality rate of 1.2 per
20 cent and another one of 2.4 per cent, and you could say,
21 "Well, that is 100 per cent higher". But there might
22 be reasons for that which could be explained, and
23 certainly, the Secretary of the Society never saw it as
24 his duty to analyse the individual returns which he
25 received in the way that you are suggesting.
0018
1 Q. The point I was simply asking you about was in response
2 to your observation that the percentages were not shown
3 on the returns?
4 A. Yes.
5 Q. The point of my question was to say that in a number of
6 cases it must be very obvious that there is a disparity
7 in the centre -- leave aside the reason for a moment.
8 But the first step is that it must be obvious to anyone
9 with half an eye for what is being submitted?
10 A. But there would be units which would have, shall we say,
11 the worst results, shall we say, for a particular type
12 of congenital heart operation, which might be quite
13 strong in another field --
14 Q. Forgive me for interrupting, Sir Terence, because there
15 may be a distinction and there may not be much between
16 us, but I just want to establish, as it were, the
17 building blocks.
18 There may be an explanation for disparity of
19 results. What I am asking about is in response to your
20 observation that disparity may not be obvious. My
21 suggestion is that, given this sort of form, disparity,
22 prima facie -- if you do not mind a lawyer's
23 expression -- would be obvious; the explanation may not
24 be?
25 A. The only way I can answer that is to say that I am quite
0019
1 sure that the Secretaries did not see it as their role
2 to look carefully through the 8 or 9 pages of each
3 return that came from the 44 units throughout the
4 country before passing them on for analysis by BUPA.
5 Q. So again taking my hypothetical case, if there were
6 a unit which was producing, obviously on the figures,
7 a very much higher mortality than another unit, it
8 would, to anyone critically looking at the document,
9 obviously suggest a need for some explanation. There
10 may be one. But leave that aside. The question is, is
11 there a need for explanation, is the first step? Are
12 you telling me that the Secretary, although a medical
13 man, would not have conceived it as any part of his duty
14 to say, "Well, this is so startlingly different that
15 someone ought to ask some questions about it and find
16 out why"?
17 A. Yes. I think one would need to ask the Secretaries
18 themselves, but I do not think it ever crossed their
19 mind that there was a startlingly different result from
20 an individual unit in the way that you have described.
21 What we did do, from time to time in the register, was
22 to give, to provide a scattergram linking numbers of
23 operations against mortality, and of course, every year
24 there would be one unit out of the 44 which had a higher
25 mortality for a particular operation than any other
0020
1 unit. There had to be. Those were looked at and
2 analysed from the point of view of whether doing more
3 operations actually reduced the likelihood of having
4 a high mortality in that particular operation, and they
5 were of interest in the early days in coronary artery
6 surgery. But then soon that effect of size became
7 attenuated as surgeons generally got better at the
8 procedure.
9 Q. So I think what you are saying to me, tell me if I have
10 got it right, is that the scattergram would give general
11 information across the service, but not particular
12 information in respect of a unit?
13 A. Correct.
14 Q. Not, at least, without someone knowing that the one with
15 the least operations was X unit?
16 A. Yes.
17 Q. And if it did the latter, if one was able to say that
18 the one with the least operations was X unit, one would
19 be able to have at least the first stage of the building
20 block of saying, "Well, if it is very different or very
21 much better, there may be an explanation"?
22 A. Yes.
23 Q. The accent there being on the "very much" better or
24 worse, because obviously as you point out, it is
25 a matter of logic that in a class of 48 someone must be
0021
1 first and someone must be 48th?
2 A. Yes.
3 Q. The Secretary of the Group, the person who received the
4 returns, it not being conceived as any part of his or
5 her duty to react to the information on the sheet in the
6 way that I have described, would have passed the
7 information on for analysis?
8 A. Yes.
9 Q. Would that information have been passed on anonymised?
10 A. Yes.
11 Q. So by the stage it left the Secretary, the Society of
12 Cardiothoracic Surgeons had no direct means of knowing
13 which unit provided which data?
14 A. Except that the Secretary was an important member of the
15 Society, and he had been delegated by the Executive to
16 undertake this task. So he would have known.
17 Q. Let me give you a second hypothetical. Suppose that
18 some years after the information has been submitted --
19 submitted each year by the units, as you have described,
20 with the exception of the one year when two units did
21 not comply -- suppose that three or four years down the
22 road a question arises as to what is described by some
23 as "unacceptable" levels of mortality in a different
24 unit. That is the hypothesis.
25 A. Yes.
0022
1 Q. One would, would one, be able to go to the Secretary and
2 say "This has arisen. It is important in the interest
3 of patients and in the interest of clinicians who may be
4 wrongly accused, as it were, to uncover what the
5 position actually is, and has been"?
6 A. Yes.
7 Q. Would the Secretary then be able, from having looked at
8 the returns as they come in each year, to say, "Well,
9 I can go back and trace through this particular unit in
10 the returns and demonstrate it is either true or false"?
11 A. Yes. I believe that information has been kept complete
12 by the Society. In other words, all the returns that
13 have been submitted to the Society from units since
14 1977, which was the year of the first full register,
15 I believe are complete and available.
16 Q. The question which then follows is a policy question.
17 If that situation, the hypothetical situation which
18 I put to you, indeed arose, what, if any, duty in the
19 1980s would the cardiothoracic surgeons, the Society of
20 Cardiothoracic Surgeons, have regarded themselves as
21 being under with a view to examining the past data?
22 A. I think it would depend to a certain extent on the
23 authority from which the request came initially, but,
24 say, for example, that it came from the Department of
25 Health, who wanted to look back four years previously
0023
1 and that there were grounds for this inquiry, into
2 performance at that time, I would have thought that the
3 Society, the Executive, would have taken a decision to
4 release the information.
5 Q. That is the Department of Health. If it had come, let
6 us suppose, from the Royal College of Surgeons of
7 England, from the Council, is it, of the Royal College,
8 it would have been a matter of considerable concern,
9 because the hypothesis is that patients are at risk?
10 A. Yes.
11 Q. What would the response have been in that case?
12 A. I think it would have been the same; that the College
13 would have requested access and I think it would have
14 been granted.
15 Q. I have entered into the discussion of the cardiothoracic
16 register and its purposes and the way in which it worked
17 in part and parcel of my questions to you about the
18 Royal Colleges and the Royal College of Surgeons and its
19 functions.
20 The one function which I think I have not yet
21 dealt with -- it may be of some interest -- is that the
22 Royal College of Surgeons had a role, did it, in
23 reviewing and satisfying itself as to the training that
24 was given to junior and senior hospital doctors?
25 A. Yes. The College had two specific committees. One was
0024
1 the Hospital Recognitions Committee which dealt with
2 basic surgical training, and then the specialist
3 advisory committees looked at higher training in the
4 9 specialties that were recognised. So there was one
5 for cardiothoracic surgery and that was a different
6 committee, because it was made up of members from the
7 Colleges in Scotland and Ireland who were also involved
8 in higher surgical training.
9 Q. And these committees, would they regularly inspect units
10 to see that they remained fit to train junior, if it is
11 a Hospital Recognition Committee, or senior if it is the
12 Specialist Advisory Committee?
13 A. Yes. If we concentrate on the SAC for cardiothoracic
14 surgery, it, like the other SACs, had a general role of
15 inspecting all the units that were recognised for higher
16 training once every five years, unless there was a query
17 about training in a particular unit. For example, if
18 the higher trainees were not getting adequate access to
19 the Post-operative Intensive Care Unit, which may have
20 been run by a physician, then the SAC would visit and
21 say, "Well, you need to correct this or else your
22 recognition will be withdrawn".
23 There was also the other aspect, which was
24 interviewing the higher trainees who became enrolled as
25 higher trainees by the SAC at the time that they were
0025
1 appointed to a recognised Registrar's post, and they
2 were then interviewed either during a site visit or at
3 the Royal College of Surgeons.
4 The interval varied from time to time. It was
5 always regarded in our specialty, I think, certainly as
6 desirable as interviewing at the College towards the
7 beginning of -- soon after registration, and then again
8 towards the end of their training, so they could speak
9 frankly about the training they had received from their
10 consultants and confidentially to the SAC without fear
11 of reprisal from their consultants if they said things
12 which the consultants might not wish to hear.
13 Q. The hospital review by the SAC or by the Hospital
14 Recognition Committee was obviously a formal source of
15 knowledge and information about the way in which matters
16 were conducted, principally training, in particular
17 units.
18 In considering how training was conducted, was any
19 regard likely to be paid to, if I can use the expression
20 broadly, the "quality" of the surgery which was being
21 performed by the consultants who would necessarily take
22 part in that training?
23 A. I think this was approached variably by different
24 members of the SAC, different visitors. Some would
25 enquire informally into it, others would like to see the
0026
1 results from the previous few years. We had ours
2 available at visits with mortality statistics against
3 them; others did not. It was not a requirement as
4 such. It was perhaps something -- well, it certainly
5 did not receive as much attention as the quality of the
6 training which the individual was receiving.
7 Q. Quality of training was the whole purpose of the visit?
8 A. Correct.
9 Q. So inevitably, quality of outcome would not, could not,
10 receive as much consideration as that, but I think what
11 you are telling me -- I want to be sure I am right about
12 it -- is that whether formally or informally, it was the
13 expectation of all concerned that those visiting the
14 unit would ask about quality of outcome, or quality of
15 surgery?
16 A. I think the reality of it was that generally, throughout
17 surgery, it was not regarded -- it was not common to
18 enquire specifically about mortality at SAC visits.
19 I am not sure about that, but as a generalisation,
20 I think that is true.
21 Q. So the informal or formal enquiries about quality were
22 not necessarily enquiries about mortality?
23 A. No. The informal ones may have come during the
24 interview with the Senior Registrar and it is possible
25 that he might have been asked as to what the results
0027
1 were like in such-and-such an area. But it was very
2 informal rather than a formal part of the process of
3 review of that unit.
4 Q. I appreciate it may be different in different
5 disciplines, but if we can focus for a moment on the
6 cardiothoracic area, and take a typical visit by
7 appointees of the SAC on behalf of the SAC, or for that
8 matter, the hospital, the clinician committee, to
9 a particular unit, if enquiries, whether formal or
10 informal are not necessarily to deal with mortalities as
11 an indicator of quality, what factors -- again it is
12 a general question -- what factors would they be seeking
13 information on in order to assess quality?
14 A. They would be primarily interested in what the
15 facilities were in that hospital: the number of
16 operating sessions that were staffed and available for
17 training; the number of times that the Registrar could
18 attend an outpatient clinic, ward rounds with
19 consultants, how many times he or she was operating on
20 their own or with consultant help, or assisting
21 consultants. They had a logbook which was introduced in
22 the late 1980s, I think, which all trainees, when they
23 were registered with the SAC, had from then on to keep,
24 and it was an account of every operation that they were
25 involved with, either as the first operator or as the
0028
1 assistant, and they were required to keep information on
2 mortality in that.
3 That would always be discussed at the time of the
4 visit. But that was looking at the trainee's operative
5 outcome in terms of mortality rather than his boss's, or
6 the units.
7 Q. I think what you are telling me is that the objective
8 assessment, the objective factors which one would take
9 into account, were, as it were, features of the context
10 within which the surgery was delivered?
11 A. Yes.
12 Q. The availability of the ICU, the nearness to surgery,
13 and the hours, the ward rounds and so on.
14 A. Yes.
15 Q. We will take a break, I understand, in a few minutes,
16 but before we do that, can I just take you from the
17 visits of the Recognition Committee and the SAC for
18 a moment. Plainly that gave the Royal College some
19 formal knowledge of what was happening, but is it right
20 to say that within the medical profession, there is
21 quite a lot of knowledge of what is happening elsewhere
22 in other units? Is that the case?
23 A. Yes. I think that within a relatively small specialty
24 such as cardiothoracic surgery and neurosurgery, from
25 time to time the really good units came to become
0029
1 generally acknowledged within the members of the
2 specialty, and if there were units with problems, those
3 might become generally aware to the members of the
4 specialty, of course to be retrieved and move on, become
5 good again. So a certain amount of this was known,
6 yes.
7 Q. So the really good units that became known of -- this,
8 I take it, is sort of general gossip or understanding,
9 or recognition which did the rounds, is it?
10 A. Well, it could be that; it could be at a more scientific
11 level, that a unit had a particular interest in
12 a specific area within cardiothoracic surgery. It would
13 publish results in a peer review paper, an article that
14 would be published internationally that would show it
15 was performing particularly well. Surgeons read their
16 journals within their specialty. And they would know
17 these sort of things.
18 Q. And you, for your part --
19 A. And the annual meeting each year of the Society, when
20 papers were presented by most of the units, I would say,
21 would have one or more papers about a particular
22 cardiothoracic subject.
23 Q. So those in the field would gain a reasonable idea of
24 what was happening elsewhere in the field in England and
25 Wales at any rate?
0030
1 A. If they were interested in it they could, yes, get
2 access to that informal information.
3 Q. You, for your part when you were at Papworth, I think,
4 corresponded with Southampton?
5 A. Yes.
6 Q. And shared information?
7 A. And indeed, with Johannesburg, where I knew another
8 surgeon whom I regarded highly, and he used to send his
9 results to us and we would exchange them.
10 Q. So far as Southampton was concerned, the surgeons there,
11 Mr Monro?
12 A. Mr Monro and Sir Keith Ross, and our experience was very
13 similar at the two units, except for paediatric cardiac
14 surgery.
15 Q. When did Sir Keith Ross retire?
16 A. He was appointed at Southampton, I know, in 1972.
17 I think he would have retired about 1991 -- no, a little
18 earlier than that, I suspect.
19 Q. And Mr Wisheart, at Bristol: you have known, I think,
20 for what, since the early 1970s?
21 A. Yes, he was a Senior Registrar. Indeed, he had just
22 become a Senior Registrar, I think, when I was appointed
23 to Papworth in 1972, and I had known that he had been to
24 Birmingham, Alabama during his training, and we were
25 a small group and we tended to know each other, yes.
0031
1 Q. Was there a time when you may both have had the same
2 hospital post in your sights?
3 A. No, there was not, not with him -- well, I have to
4 correct that. What do you mean precisely by "a hospital
5 post"?
6 Q. Was there a job for which you were both candidates at
7 the same time?
8 A. There was indeed and which I withdrew from at the last
9 moment.
10 Q. Was that Bristol?
11 A. That was Bristol. I think the year was -- well, it was
12 when he was appointed.
13 Q. 1974, I think?
14 A. I think 1975.
15 Q. When Mr Halliday gave evidence to us -- I shall have to
16 read this to you, because we have not yet put it on the
17 screen. What he said was that the Colleges -- that
18 obviously includes the Royal Colleges -- inspected the
19 units regularly. For the reference, this is Day 13,
20 page 102, from line 5:
21 "They met with the people. They have a system of
22 training for their staff. They get to know. I mean,
23 within the specialties, the Colleges know each other
24 very well, and they know exactly their strengths and
25 weaknesses."
0032
1 How far is that accurate?
2 A. I think it is a little more comprehensive than I would
3 say was the reality. If you were a member of the SAC
4 for five years, during that time you may have visited,
5 I do not know, 10, 12, perhaps, units, assessed what
6 they were doing, what their staffing was, their training
7 structure, these sort of things. You would have become
8 better informed as to what was happening generally than
9 if you were not on the SAC or a member of the Executive
10 of the Society, say.
11 The College had information coming in, but it was
12 particularly keen to have good information on its
13 trainees and how they were progressing, where they were,
14 and so on. There were some members of the specialty who
15 were very much better informed about what was going on
16 generally within the United Kingdom in cardiothoracic
17 surgery than others, because they were that way
18 inclined.
19 Q. You personally being involved in the societies you were,
20 and we have seen your CV, modesty aside, would you have
21 described yourself as one of the better informed?
22 A. I certainly was until perhaps 1987, thereabouts. I had
23 become a member of the Council of the College of
24 Surgeons I think in 1981, and that began to demand a lot
25 of my time on College business. I was also deeply
0033
1 involved with the transplant programme at the time at
2 Papworth and my involvement in the Society as such, and
3 certainly in the register, diminished considerably from
4 the mid-1980s onwards.
5 Q. So up until the mid-1980s, you would have been --
6 A. I was well informed.
7 Q. Well informed?
8 A. Yes.
9 MR LANGSTAFF: Sir, I wonder if that would perhaps be
10 a convenient moment to take a break for those who wish
11 to smoke or have coffee? For our part, may I say that
12 Sir Terence English was kind enough to provide this
13 morning a number of documents, contemporaneous notes
14 which he had made in respect of a number of phone calls
15 in 1992, and meetings, which he has given to us. We
16 have had them photocopied, and scanned in, and it may be
17 that in order to allow for the assimilation of those
18 documents, that the break is 20 rather than 15 minutes.
19 THE CHAIRMAN: Thank you, Mr Langstaff, and I assume those
20 will be made available generally?
21 MR LANGSTAFF: They will be made available not only to the
22 Panel so that they may see them, but also to the various
23 representatives behind me. May I, in saying that, pay
24 tribute to the several of them who have passed notes and
25 comments to me about the substance of today's evidence.
0034
1 THE CHAIRMAN: I am grateful. We will therefore return at,
2 shall we say, 10 past 12. Is that enough time? Or do
3 you think a quarter past?
4 MR LANGSTAFF: A quarter past might be safer.
5 THE CHAIRMAN: Thank you. A quarter past 12.
6 (11.53 am)
7 (A short break)
8 (12.15 pm)
9 MR LANGSTAFF: I was asking you before the break about the
10 sources of information which would come to the Royal
11 Colleges and the members of it about other units in
12 a particular specialty.
13 Amongst the sources of information which would
14 come, as you have said, are the information available to
15 those on the Specialist Advisory Committee and the
16 Hospital Recognition Committee.
17 You made the point that those on such committees
18 are likely to have a greater knowledge in detail at any
19 rate on the unit than those who are meeting others at
20 conferences, listening to the gossip or the chat about
21 procedures and units and surgeons in the trade, as it
22 were.
23 We were told by Mr Halliday that in effect the
24 Supra Regional Services Advisory Group were dependent on
25 the co-operation of the Society of Cardiothoracic
0035
1 Surgeons for data; that they were dependent on the Royal
2 Colleges for the assessment of that data; that they were
3 dependent upon the Medical Royal Colleges for the
4 assessment of the unit and the service. That is my
5 summary of what he told us on Day 13, pages 1 to 4.
6 Leave aside for the moment whether he is right or
7 wrong about that, because I will invite your comment
8 later. He made the point to us a number of times that
9 the Royal Colleges were in a better position than the
10 Supra Regional Services Advisory Group itself to know
11 intimately what was happening in the unit, because they
12 went to inspect it. Can I ask you: is that a fair point
13 or not?
14 A. I do not know. I am not sure on that. But if we think
15 of some of the other supra-regional services, like heart
16 transplantation or liver transplantation or spinal
17 services and so on, certainly at the College of Surgeons
18 we, when asked, would get a working party for a specific
19 assessment of whether a unit should be designated or
20 not, and provide information and help to the Supra
21 Regional Services Advisory Group for that. But, for
22 example, the spinal services, I do not recall ever
23 having anything to do with that, and we as a College
24 would have been very ill-informed about it in comparison
25 with the Supra Regional Services Advisory Group.
0036
1 As far as neonatal and infant cardiac surgery is
2 concerned, the College would become informed and
3 involved at whatever time they were asked to look at
4 a particular problem or to do a particular piece of work
5 for the Group, but otherwise the detailed information
6 that we would gather from the five-yearly visit of the
7 SAC and the five-yearly visit of the HRC to a particular
8 designated unit, that information, although strong on
9 training, in terms of the total service, would be less
10 than I would have expected the Supra Regional Services
11 Advisory Group to have held themselves, because they
12 designated these units and they had the purse strings
13 and they were monitoring them.
14 Q. So far as the quality of service is concerned, where
15 else would the Supra Regional Services Advisory Group
16 have got their information, if not from the Royal
17 Colleges?
18 A. They would get specific information; they could have
19 asked for information -- indeed they did -- from the
20 register, which would be a baseline for neonatal and
21 infant cardiac surgery. The Society's annual general
22 meetings, the scientific meetings, Dr Halliday was
23 usually there, I think. He would have been present at
24 many of the presentations and heard what was going on,
25 and might have taken a particular interest in the
0037
1 designated services. The general literature, if the
2 Department had asked for published reports on work going
3 on in units, that would have been presented to them.
4 Q. So, apart from the Royal Colleges, there was the Society
5 of Cardiothoracic Surgeons and the database that it had
6 there; there were the published reports and there were
7 what one could glean from the various conferences and
8 meetings that might be held in relation to the
9 particular specialty.
10 A. Yes.
11 Q. So far as the information which might have come through
12 the Royal Colleges is concerned, he, it may seem to
13 those who read the transcript, placed a considerable
14 emphasis upon the review visits every five years by the
15 Specialist Advisory Committee, and for that matter the
16 Hospital Recognition Committee.
17 What I want to ask you about is just really to
18 invite your comment, ultimately -- I will tell you where
19 I am going and then show you what I want to draw your
20 attention to in order to answer the question. The
21 general issue that I want to explore is really how
22 detailed and how accurate the assessment, the data, the
23 information obtained by those visits was. I think there
24 must be nothing between and you me in theory, that
25 obviously the data and information ought to have been
0038
1 accurate and sufficiently complete for the job. I take
2 it you will agree with that as a proposition?
3 A. Yes.
4 Q. Can I ask you to look on the screen at RCSE 2/213? This
5 is a visit -- we will look in a moment at the next visit
6 after five years -- a report of a visit on behalf of the
7 Specialist Advisory Committee in cardiothoracic surgery
8 to the Bristol hospitals: Bristol Royal Infirmary and
9 Frenchay, Wednesday 22nd February 1989, by Professor Ken
10 Taylor and Mr Barry Ross. That is the document we are
11 looking at.
12 Did this happen at a time that you were in post in
13 the Royal College, or not?
14 A. I was a Council member of the College at the time.
15 Q. Can I go, please, to page 216, and see what is said here
16 about Bristol Royal Infirmary:
17 "This hospital provides the regional cardiac
18 surgical unit for the South West serving a population of
19 approximately 3.5 million people. The unit receives
20 patients from Cornwall, Devon, Somerset, Gloucester,
21 Avon and West Wilts. In addition, infants from South
22 Wales are treated in Bristol. It is closely associated
23 both functionally and geographically with the Children's
24 Hospital.
25 "Facilities: the cardiac surgical unit has 28 beds
0039
1 in one ward. This provides for progressive care. There
2 is a self-contained paediatric area in the ward where
3 children remain until returning to the Children's
4 Hospital."
5 Pausing there, one understands from this there is
6 no separate children's paediatric ward. You are
7 nodding. A nod does not go down on the transcript, so
8 I hope you do not mind my putting that in so the wider
9 audience can see that you agree.
10 "The ITU is a very impressive open unit recently
11 refurbished with eight adult beds and facilities for
12 children."
13 So again one would understand from that that the
14 ITU was mixed adult and children?
15 A. Yes.
16 Q. "Adjacent to the ward is the theatre suite with two
17 dedicated cardiac theatres which are used for every
18 available session."
19 By the expression "adjacent to the ward", one
20 reads "next to"?
21 A. Yes.
22 Q. So one would expect it to be across the corridor or on
23 the same floor? Again, you are nodding assent to that.
24 A. Yes.
25 Q. "As might be expected, a very active cardiac and imaging
0040
1 department with two cardiac radiologists. Full
2 investigative facilities are available including Doppler
3 echo and MRI ..."
4 Turn over the page. Then we have the weekly
5 programme, running down, please, the staffing, the
6 workload.
7 Over the page, the rotas, the library and the
8 interviews with the non-consultant staff.
9 Over the page, please, various names are
10 mentioned.
11 Conclusions and recommendation: the visitors were
12 impressed by the quantity and quality of work performed
13 at both hospitals and particularly by the training
14 offered. The balance of work between the two hospitals
15 is reflected in the staff allocations with three
16 trainees at BRI and two at Frenchay."
17 Then these words:
18 "There is a very adequate volume of paediatric
19 surgery at the BRI together with the closed procedures
20 performed at the Children's Hospital.
21 "We believe that it would make an even better
22 training facility if both units were on the same site."
23 Just pausing there for a moment, plainly the
24 authors thought it was desirable to have the same site
25 for the Children's Hospital and the surgery?
0041
1 A. If I may interject there, I think what they are
2 referring to is to have a combined cardiothoracic unit
3 at the BRI and Frenchay, in other words, have one rather
4 than two adult units. I think if you read that second
5 paragraph --
6 Q. I follow.
7 A. -- what they are saying is that both the cardiac and
8 thoracic component of the work should be in one unit.
9 But then they go on to say that if they move cardiac
10 surgery to Frenchay, this would not be a good move and
11 it would be difficult to do it any other way. So I do
12 not think there is any reference there to the children's
13 surgery, which of course was the other issue.
14 Q. One thing concerns me a little, about which I would
15 invite your comment and it is the way that
16 paragraph begins:
17 "We believe that it would make an even better
18 training facility ..."
19 A. Yes.
20 Q. In effect, this is a diplomatic way, it might appear --
21 this is what I invite your comment on -- a diplomatic
22 way of making a criticism of the fact that there is
23 a split between the units?
24 A. I do not read it quite like that. Within Britain there
25 have been several examples where one has had cardiac
0042
1 surgery on one side and thoracic surgery nearby. This
2 was true, for example, in Cardiff. The degree of
3 separation in these two surgeries within cardiac surgery
4 has been a feature of British cardiac thoracic surgery,
5 but many of us have believed that from the purposes of
6 training, it is highly desirable if possible to have
7 thoracic surgery and cardiac surgery in the same unit,
8 so that the trainees can get experience of both branches
9 of the specialty.
10 Q. Can I pursue my point, which is really a question of
11 drafting of the report, and invite you to go back to
12 page 213? It is Frenchay Hospital. We are not
13 concerned directly with Frenchay Hospital in this
14 Inquiry, but if one looks, it is really the first and
15 second sentences, at what is said there, it describes
16 Frenchay Hospital in the first sentence and one goes
17 down five lines and this follows:
18 "It is not meant as a critical comment but the
19 hospital epitomises disastrous planning and
20 fragmentation."
21 What else is a comment that "the hospital
22 epitomises disastrous planning and fragmentation", other
23 than a critical comment?
24 A. Indeed, it is a very bold statement on behalf of the
25 visitors.
0043
1 Q. The words I want to focus on are the opening words, "it
2 is not meant as a critical comment but ...". What
3 forces do you suppose were at play that made the
4 authors, as it were, "pull the punch" that they were
5 just delivering?
6 A. Politeness. These reports went to the Manager, the
7 Chief Executive of the hospital, and I can only assume
8 that is the reason why it has been phrased in that way,
9 but it does seem rather odd.
10 Q. So those who write this report -- because this is the
11 report the Royal Colleges get -- are at pains to avoid
12 being over-critical unless they have to be?
13 A. Not necessarily. I mean, they say that they are not
14 being very critical, and then they are.
15 Q. It is the same vein, the same vein of questioning,
16 really, if I can ask you to go to RCSE 2/222.
17 This is the next visit along, five years later,
18 thereabouts. The first was in 1989; there is 1994.
19 There are different visitors: Professor Hamilton and
20 Mr Dussek.
21 The introduction:
22 "The visit started at Frenchay Hospital ... the
23 visitors were shown round by Mr Jeyasingham and met
24 Mr Forrester-Wood." Then the next four words I would
25 invite you to focus on: "Following a generous lunch ..."
0044
1 It is the same type of point, I think. The menu
2 for lunch and the amount that was provided by way of
3 food or wine is completely irrelevant to the substance
4 of the report, is it not?
5 A. Yes.
6 Q. So what, if I can gently ask, is the purpose in
7 recording for posterity that Professor David Hamilton
8 and Mr Dussek enjoyed themselves at lunchtime on
9 8th July 1994?
10 A. I would agree it would have read better if it said
11 "following lunch at which some of the administrative
12 staff were met". Often these visits did start over
13 lunch, in which there was a general discussion and
14 papers may have been presented and so on, and it was
15 right and proper that the local managers should be
16 hospitable to the visitors. That may have been a way of
17 thanking them.
18 Q. It may be, and I will link this to some of the content
19 of the report in a moment, and I appreciate you were not
20 yourself involved in this, it is purely because you have
21 been involved as you have been in the Royal Colleges
22 that I ask you about it at all, but it may be thought
23 that there is an element of "massaging of the ego", if
24 you like, of those in the hospitals who have received
25 the visit in the way in which the reports are written.
0045
1 That is a rather more tendentious way of putting your
2 politeness which you mentioned in respect of the "this
3 is not meant as a critical comment" point. But is that
4 fair or is it not?
5 A. No. I do believe that that is a genuinely incorrect
6 interpretation of the relationship which existed between
7 the visitors and the visited, whether they be managers
8 or local consultants.
9 Q. If one may just move through to page 225, and under
10 "facilities":
11 "These are exactly as described in the 1989
12 visit ..."
13 It then repeats words which appear in the way in
14 which they paraphrase the earlier visit, that they may
15 very well have been maintained on the word processor,
16 one does not know, but certainly there is an obvious
17 similarity:
18 "The cardiac surgical unit has 28 beds in one
19 ward. This provides for progressive care and there is
20 a self-contained paediatric area in the ward where
21 children remain until returning to the Children's
22 Hospital. The ITU is an impressive open unit with
23 6 adult beds and facilities for children. Adjacent to
24 the ward is the theatre suite with two dedicated cardiac
25 theatres which are fully used, as might be
0046
1 expected ...", and it goes on.
2 So one has the same impression of the cardiac
3 theatres adjacent to, next to, on the same floor as the
4 ITU?
5 A. Yes.
6 Q. That visit, just to go back for a moment or two, to
7 page 222, was 8th July 1994. If we can go over to
8 page 234, there is a report of a visit which took place
9 on May 4th, reported on 13th July 1994, so within
10 a matter of weeks?
11 A. Yes.
12 Q. This time by the Hospital Recognition Committee?
13 A. Yes.
14 Q. Page 236, dealing with the Bristol Royal Infirmary, the
15 cardiac unit, the bottom of the page:
16 "The cardiac unit has a problem of its intensive
17 care ward being on a different floor to the theatre so
18 patients have to be taken there by the lift ..."
19 Then it goes into some detail as to the effect of
20 that.
21 "After the first case the SHO has to transport the
22 patient back to the ward and the second case is often
23 well under way by the time the SHO returns to theatre.
24 The SHOs see themselves really as being deployed for
25 service commitment to transport patients across a poorly
0047
1 designed department and to be intensivists, but they are
2 not taught simple surgery in the theatre or exposed to
3 outpatients."
4 That is a dramatically different picture of the
5 facilities, is it not?
6 A. Yes. I think -- I do not understand all of this, but
7 this report that is before us now was not done by
8 cardiothoracic surgeons. They were looking at the basic
9 surgical training of all surgeons who would be going
10 through the Bristol rotation at the time, the majority
11 of whom would never end up doing cardiac surgery. So
12 they were there to inspect and recognise the SHO
13 training.
14 I do not understand where it says that the cardiac
15 unit has a problem of its intensive care ward being on
16 a different floor to the theatre. Whether, in the
17 original report, the cardiac surgical beds were adjacent
18 to theatres and this is the cardiologists' beds which
19 are one floor up, I am not sure. I cannot explain the
20 difference, I am sorry.
21 Q. But one accepts that on the face of it -- and it is one
22 of those things which I appreciate you are not in
23 a position to resolve -- but on the face of it, one team
24 going in to look at senior doctors and their training
25 has reported that so far as cardiac surgery at the
0048
1 Bristol Royal Infirmary is concerned, the theatre is
2 adjacent to the intensive care ward and makes almost
3 a virtue of it?
4 A. Yes.
5 Q. This report, within days, appears to state the opposite
6 and marks it down as a very big black spot because it
7 affects the training of the Senior House Officer.
8 On the face of it, the two of them just do not
9 gel. What one is looking at here is not something which
10 is impressionistic. Either the theatre is on the same
11 floor or it is not?
12 A. Correct.
13 Q. We may hear, I suspect -- and I shall have to leave it
14 to the evidence -- but we may hear that indeed the
15 operating theatre for cardiac surgery was on the floor
16 below the Intensive Care Unit, so that one went in
17 a small lift up and down to ward 5 at the BRI. But that
18 is not something I ask you to comment on. I put it in
19 the transcript so that if there is anyone who takes
20 a different view, they can tell the Inquiry.
21 A. It would be nice to know where the cardiac surgical beds
22 were, too: whether they were adjacent to the theatres or
23 also on a different floor.
24 Q. Our present understanding -- we would like to be
25 corrected if we are wrong -- is that they were on the
0049
1 floor above. We shall be told.
2 A. Thank you.
3 Q. The next thing which we would simply draw attention to
4 is on page 236, where it deals with cardiac surgery.
5 "This is for 3 or 6 months. There is no
6 introductory course and there is no firm structure, with
7 partial shifts. This has detached them", and I think
8 "them" must be the SHOs, "from a team, so they no
9 longer have direct dealings with a consultant. The SHOs
10 are most unsatisfied with the training, except for the
11 experience and teaching in intensive care provided by
12 the anaesthetist. It is predicted that job satisfaction
13 will decrease with the anticipated appointment of
14 a surgeon's assistant.
15 "During a paediatric cardiac operation, the SHO
16 stands 'miles' away for hours and is unable to see what
17 is going on."
18 One could not describe that as anything other than
19 heavily critical?
20 A. That is so.
21 Q. If we go back to page 230, this is the questionnaire,
22 the results of which accompany the report. We can see,
23 under the questionnaire, at (2) the posts for which
24 recognition is requested: SHO. Cardiac surgery, 5.
25 Paediatric surgery, we think, is not looking at
0050
1 paediatric cardiac surgery, but again, I will be
2 corrected in due course by someone if I am wrong.
3 A. Paediatric general surgery, yes.
4 Q. The names of consultants met and their specialty
5 at (3). Cardiac surgery: Mr Dhasmana.
6 If we turn to page 231, the bottom of the page,
7 please, at (10):
8 "Operative experience: 10(a) consultant
9 supervision", and the result of the questionnaire has to
10 be put as "good", "average" or "poor". There are three
11 categories to the right-hand side which are preprinted:
12 "general surgery", "orthopaedic" and "other". General
13 surgery is "good", orthopaedic "good", trauma "good".
14 "Other: cardiac, very poor". I think that is what the
15 "V" must mean?
16 A. Yes.
17 Q. Paediatric surgery, that is something different.
18 "(b) Practical experience of trainees: cardiac, poor."
19 So no doubt about the tenor of that report: that
20 so far as SHOs, junior doctors were concerned,
21 dissatisfaction?
22 A. Correct.
23 Q. If one goes back to the conclusions of the Specialist
24 Advisory Committee looking at higher surgical training,
25 and we will find, I think, page 228, the visitors came
0051
1 away from BRI very impressed by the comments of the
2 higher surgical trainees, who had nothing but praise for
3 their tuition. "The unit seems to function well and the
4 degree of supervision of trainees was exceptionally
5 high. The potential for division between the academic
6 and the NHS aspects of the service has been recognised
7 by the staff there already, and we hope that there will
8 be good integration of the two units with sharing of
9 junior staff."
10 By "junior staff", we are there are looking at
11 Registrars, I think?
12 A. Yes.
13 Q. Can I invite your comment on two matters which arise,
14 really, from this? The first is that there is a very
15 obvious difference in the reaction given by the junior
16 doctors in training as reported and the view of the
17 Hospital Recognition Committee, those reporting to it on
18 the one hand and the description painted of the same
19 service by those who attended on behalf of the
20 Specialist Advisory Committee, all the more so because
21 the two reports are within weeks of each other.
22 As we see at page 228, "The unit seems to function
23 well and the degree of supervision of trainees was
24 exceptionally high". Two points there: "functions well"
25 and secondly, "supervision exceptionally high". Could
0052
1 one say that the unit seemed to function well if -- if,
2 this is the hypothesis -- the reality was that the
3 junior doctors in training in the unit were thoroughly
4 dissatisfied with the training they were getting and the
5 experience they were having?
6 A. The perspective of the visitors who are inspecting the
7 higher trainees was that the unit was functioning well
8 so far as they were concerned and their comments in
9 terms of their own supervision and experience, they were
10 obviously well satisfied with their training.
11 The SHOs were getting a bad deal. You might
12 regard that as being quite extraordinary within
13 a particular unit that this should happen, and it is
14 certainly not desirable, but my interpretation would be
15 that the consultants were more interested and more
16 responsible with regard to training surgeons whom they
17 knew were going into cardiothoracic surgery, than those
18 at a lower level, an SHO level, who were going to pass
19 through the unit for 3 months or 6 months depending on
20 the rotation, and who were then never going to have any
21 further interest in the specialty, and that they were
22 indeed neglecting their responsibilities to this group
23 of SHOs. So that the second report from the Hospital
24 Recognition Committee, once received by the BRI, and
25 then the conclusions discussed with them, should have
0053
1 drawn attention to the consultants in cardiothoracic
2 surgery that they really had to now fulfil their
3 responsibility to training not only the higher trainees,
4 which surgeons generally enjoy doing, but also the SHOs
5 on the unit.
6 Q. On the face of it, as you yourself recognise -- and tell
7 me if you do not -- there appears to be a surprising,
8 some might say staggering difference in the way in which
9 the two reports report training in the same unit, albeit
10 at different levels of doctor?
11 A. It is not too surprising to me. It is certainly
12 regrettable that it exists, but one has seen this before
13 with surgeons who have been far more interested in, as
14 I say, training would-be specialists in their own
15 specialty than looking after the interests of the much
16 more junior trainees who do not do a lot of operating,
17 who at that level are very inexperienced and are not
18 just simply of as much interest to train as the ones
19 higher along the path to consultancy.
20 Q. The difference between the two reports: does it suggest
21 that there is a problem to be sorted out?
22 A. Indeed, and I would hope that with the HRC report, there
23 would have been some recommendation -- and I am not sure
24 whether there was or not -- but that that failure to
25 train adequately the SHO group should be addressed or
0054
1 else recognition of that component of the rotation would
2 be withdrawn. This is what should have happened: that
3 there would be a warning given, "Fix that or else you
4 will not have SHOs in future". That is where the
5 College's limited power came from, and that is what
6 should have happened.
7 Q. So it, I think, may answer the second aspect of the
8 comparison of these two reports which arises: if one
9 were to look at the report of the Specialist Advisory
10 Committee, the one that we have on the screen at the
11 moment, one would see nothing at all to indicate any
12 problem either of local geography in terms of the
13 position of the operating theatre and the intensive care
14 wards, or in terms of the way in which the staff working
15 in the operating theatre related one to the other; one
16 would have really a very rosy picture. If one looked at
17 the Hospital Recognition Committee report one would have
18 a very different picture and a very dismal picture?
19 A. Yes.
20 Q. It would follow that no person could rely upon the
21 contents of a Specialist Advisory Committee report taken
22 at the five-year interval as giving a necessarily
23 accurate and detailed picture of what was happening in
24 the unit as a whole at the hospital.
25 A. "As a whole", in inverted commas, is important, because
0055
1 the perspective of the two reports, one is as seen by
2 the trainees who are in higher training and the other is
3 as seen from the perspective of the SHOs who are in
4 basic training. I think both could be accurate
5 perspectives of how they saw the unit and what it was
6 doing for them in terms of training potential and so on,
7 but the one unit was getting a raw deal and for the
8 other I have not seen the comments of the individual
9 trainees. There were two Senior Registrars and three
10 Registrars who were interviewed in some detail. They
11 would have had perhaps half an hour, 20 minutes each
12 with the visitors and discussed what their perspective
13 of the training was, and that would have been
14 incorporated in the abstracts given in the report
15 I imagine.
16 Q. If Dr Halliday, for his part, was expecting to rely upon
17 information fed through to him which came from one
18 report or the other, then it might -- it might -- be
19 very misleading, is the consequence of what you are
20 saying?
21 A. Yes. I think supra-regional services being what they
22 were, highly specialised areas of medicine, the input
23 from the higher trainees would have been regarded as
24 being of more value than the opinion of the SHOs, who
25 would have been very peripherally involved in the work.
0056
1 Q. And so far as giving a complete picture of the service,
2 not only the more important, as you describe it, senior
3 trainees, but also the less important junior trainees,
4 who in the Royal College would, as it were, look at or
5 be likely to look at the two reports, put them side by
6 side and say, "Well, we have a problem here which has to
7 be sorted", or something to that effect?
8 A. That to my knowledge, did not happen. The SAC, as
9 I explained earlier, was very much an intercollegiate
10 committee. The Hospital Recognition Committee was
11 strictly under the aegis of the Royal College of
12 Surgeons in England looking at training in England and
13 Wales alone. And the whole question of which units
14 should be recognised for training, which should be
15 warned if they were falling down in their training, was
16 dealt with very separately.
17 That may be an error, but that is the way it was.
18 I think it would have been difficult to try and
19 co-ordinate the two. Having said that, if there was
20 a problem in a particular unit that was brought to the
21 attention of the College, then I would hope that both
22 reports would be looked at critically.
23 Q. What I think you are telling me -- please confirm if it
24 is the case -- is that any cross-referencing between the
25 reports would occur by accident rather than design,
0057
1 except if there were a particular query about
2 a particular unit?
3 A. In essence, I think that is correct.
4 Q. I want to switch from the question of information and
5 what information was available and how reliable the
6 sources of information may have been. You will
7 appreciate that it is to that that these later questions
8 were directed, to talk about the question of the
9 designation of Bristol as a unit within a designated
10 service, that of neonatal and infant cardiac surgery.
11 May we have a look, please, at UBHT 62/32? Can we
12 go down, please, to the bottom of the page. I can tell
13 you, this document is a 1984 document. You do not need
14 to look at it for the moment; I will come to it in
15 a minute. When Bristol was designated, it had performed
16 in the year prior to first designation, we have been
17 told, either three or four, it depends which statistic
18 one looks at, open heart operations on the under 1s.
19 That is a minimal level, is it?
20 A. Correct.
21 Q. One would be looking for each surgeon in the specialty
22 doing a minimum of about 50 a year, would one?
23 A. Yes.
24 Q. We would know that there were two cardiothoracic
25 surgeons who might do cardiac surgery at Bristol in
0058
1 1983. That no doubt you would know, as someone who knew
2 what was happening at that stage, quite well?
3 A. Yes.
4 Q. You are nodding, and I hope you will forgive me for
5 saying that from time to time.
6 A. Yes, I am sorry.
7 Q. So far as infants were concerned, there was a site which
8 was split between the Bristol Children's Hospital and
9 the Bristol Royal Infirmary?
10 A. Yes.
11 Q. Undesirable?
12 A. Yes.
13 Q. We can perhaps see from what happened in 1986, and then
14 1988, because in 1986 new catheter labs were opened in
15 the Children's Hospital and in 1988 there was a renewal,
16 an improvement, of the ICU facilities in Bristol Royal
17 Infirmary, to which we have seen reference in those
18 recent reports that I have just shown you. But it might
19 be thought that those would indicate that there were no
20 modern catheter labs at Bristol in 1983. I do not know
21 if you are in a position to comment?
22 A. I am not. But one might assume that.
23 Q. When you yourself were interested for a while, at any
24 rate, in the job at Bristol, did you look at the
25 catheter facilities at the time?
0059
1 A. I honestly cannot remember whether I saw the catheter
2 facilities or not. I was more interested in discussing
3 things with the consultant cardiologists at the time
4 with whom I might have to work, and I certainly
5 inspected the theatres and what was available in terms
6 of cardiac surgical beds at the time at the BRI.
7 Q. Why was it that you chose to withdraw from the race?
8 A. It was not a race.
9 Q. I am sorry, it is my inapt word.
10 A. I was extremely happy at Papworth, where I had been for
11 three years, but it was clear to me at the time that we
12 did not have a sufficient population within East Anglia,
13 our total population we served was about 1.9 million, to
14 ever have a viable paediatric cardiac component to our
15 work there and that it would always need to go to
16 London. The South West region had a population,
17 I think, of 3.2 million, served by Bristol. Mr Belsey
18 had been here and done quite a lot of paediatric surgery
19 in his time. It was his departure, I think which
20 occasioned the post to be advertised, and I saw it as
21 an opportunity to become more involved with paediatric
22 cardiac surgery, which I had developed an interest in
23 during my training. It was really primarily for that
24 reason that I explored the possibility of competing for
25 the post here.
0060
1 Q. I was not so much concerned with why you wanted the
2 post, as why you did not; why you chose to withdraw.
3 A. I had been a consultant for three years and I was intent
4 on being able to do quite a lot of work. That is what
5 I wanted to do, not just the paediatric work. I had
6 difficulty in getting a reassurance from the BRI and
7 from the then Professor of Surgery in particular that
8 the operating facilities, the time in operating
9 theatres, with the back-up of the ICU beds, would be
10 made available to me and if I recall, I asked for
11 a certain number of sessions, serviced operating
12 sessions, which were not available at the time but which
13 I was promised, or told I would receive, but I could
14 never achieve, to me, a sufficiently satisfactory
15 reassurance of that. And I asked for a written
16 assurance, which I never received, and so I left at
17 noon, before the interview started at 2.30.
18 Q. So in essence, there was not going to be enough
19 throughput of paediatric surgical cases for you?
20 A. I did not look at it quite in that way, but I saw this
21 as a potential problem with the willingness to provide
22 the sort of facilities which I regarded as being
23 necessary to develop the programme with the sort of
24 speed in which I would have liked to.
25 Q. It brings us neatly, I hope, on to the question of why
0061
1 it should be that Bristol, with its population,
2 positioned where it was, with a catchment area you have
3 described as 3.2 million, should in fact be doing so
4 little paediatric cardiac surgery, at least for the
5 under 1s.
6 In this 1984 document there are notes -- let us
7 see what they attach to. I think they are general to
8 the page, but if we could just have a look at the
9 page as a whole, please, I think we will see that they
10 are indeed general. Can we go back to the bottom?
11 "(i) Plymouth sends most of its cases to London or
12 Southampton."
13 Southampton was known as a good unit?
14 A. Yes.
15 Q. You corresponded with Southampton whilst you were at
16 Papworth, no doubt because you held it in some regard?
17 A. Yes.
18 Q. "(ii) Non-urgent cases from Wales are dealt with in
19 Cardiff or sent to London."
20 So what is being said there is that "they do not
21 come to us in Bristol"?
22 A. Yes.
23 Q. "(iii) Referrals from Wessex and Wales are mostly
24 new-born emergencies, many of whom are now diagnosed by
25 echocardiograph and hence do not appear in these
0062
1 figures."
2 So that is a different aspect?
3 A. Yes.
4 Q. What is being described here, perhaps, are referral
5 patterns which take potential cases away from Bristol
6 and send them elsewhere?
7 A. Correct.
8 Q. We have heard, in other evidence, that it may be very
9 difficult to alter established referral patterns. What
10 would your comment be?
11 A. It may be, but it is not necessarily so. I mean, I have
12 seen referral patterns change quite quickly when units
13 have become particularly well-known for operating on
14 certain procedures. I think the reputation of
15 institutions can go up and down quite quickly, and
16 I think it does not take long for people to recognise
17 that.
18 However, having said that, there are loyalties
19 within referral patterns; physicians get used to dealing
20 with particular surgeons and do not lightly start
21 sending their patients elsewhere.
22 Q. Looking at the first of those notes as to referral
23 patterns, in Southampton, at the time, 1983/84, there
24 was an established team of paediatric cardiac surgeons,
25 was there?
0063
1 A. Yes. I mean, I am glad you raised Southampton, because
2 it is an interesting situation. You see the history of
3 it there is that I believe in 1972 the paediatric
4 cardiac surgery which was being done by a Mr Macmillan
5 until that time was stopped, because his anaesthetists
6 refused to work with him. That was not entirely because
7 his results were bad, but he was difficult and did not
8 arrive on time and conditions deteriorated to the extent
9 where they withdrew their services.
10 There was a very major determination on the part
11 of the local Regional Health Authority to establish
12 a unit in Southampton that would serve the whole
13 population, in adult and paediatric cardiac surgery. So
14 they set about recruiting two extremely good surgeons.
15 They recruited Sir Keith Ross, then a consultant at the
16 National Heart Hospital, who probably was in his
17 mid-40s, well-established and known to have done a lot
18 of general paediatric cardiac surgery, although he had
19 not had much experience with the neonatal and infant
20 work, and he then was responsible for, very soon
21 thereafter, recruiting Jim Monro, who had a lot of
22 experience with neonatal and infant surgery which he had
23 gained with Sir Brian Barratt-Boyes in New Zealand. So
24 that unit quite quickly developed from nothing, where it
25 had been really closed down, virtually, to being
0064
1 a relatively small but extremely high quality unit.
2 Q. What I think you are doing is confirming to me the
3 question which I began with, which was: by 1984
4 Southampton was held in very high regard as a centre for
5 paediatric cardiac surgery?
6 A. Correct.
7 Q. And was likely so to remain, given the age and
8 experience of the surgeons there and how
9 well-established they were there?
10 A. Yes.
11 Q. You nodded, for the transcript?
12 A. Yes.
13 Q. So that if one were to take the view from the bird's-eye
14 of anyone with experience in the Royal Colleges or for
15 that matter on the Supra Regional Services Advisory
16 Group, one might say there is not much chance, things
17 being as they are, for referrals to Southampton to
18 diminish. Would you care to comment?
19 A. Only if Bristol were able to provide a comparable
20 service, then one would expect them to diminish, yes.
21 But it would need to be comparable in the eyes of the
22 referring cardiologist and physicians.
23 Q. That would involve, would it, the unit at Bristol having
24 comparable facilities and surgeons held in comparable
25 regard?
0065
1 A. Correct. And getting comparable results.
2 Q. Yes. How would any cardiologist in the 1980s know what
3 results were actually being achieved by individual
4 surgeons, or, for that matter, by units, save by, if
5 I say "rumour", you will understand what I mean?
6 A. Did you say "paediatric cardiologists", or
7 "cardiologists"?
8 Q. Paediatric cardiologists.
9 A. Paediatric cardiologists, I do not know how many there
10 were in Britain in 1984, but at a wild guess, probably
11 not more than 30 or so. And they would know each other
12 very well and they would know where the good work was
13 going on, I would have thought.
14 Q. So the same sort of system, really, as amongst the
15 surgeons in the field: because of the size of the field,
16 people knew what was happening?
17 A. Yes.
18 Q. And the paediatric cardiologists would therefore know
19 who was weak, who was strong, if you like?
20 A. I would have expected them to, yes; if they had been
21 outliers they would know where the really good units
22 were and where the not so good units were.
23 Q. And the process of information would be plainly not
24 objective data because none was revealed save on a unit
25 level because of the way that the cardiothoracic
0066
1 register operated; it would have to be by word of mouth
2 from one person to another?
3 A. Yes. The paediatric cardiologists, of course, had no
4 direct access to the UK cardiac surgery register unless
5 they got it from the surgeons in that unit, which many
6 did. But I am sure that within their group they would
7 have exchanged information about things.
8 Q. What I would like to ask, having identified the workload
9 that Bristol was doing, the difficulties of the split
10 site, the potential difficulty, it might be thought, of
11 altering established referral patterns, why it was that
12 Bristol was ever designated in the first place as
13 a centre for neonatal and infant cardiac surgery.
14 Before you answer that, you recognised the
15 question by your nod; I wonder if you can have a look at
16 DOH 2/26. Let us identify the paper by going back to
17 the page before. It is a paper called "Centres of
18 Excellence and Supra-regional Units". It starts,
19 I think, at page 24. It is EL(88)P/153, to give it its
20 official reference, dated 12th September 1988. It is
21 addressed to managers, the first paragraph:
22 "The Supra Regional Services Advisory Group has
23 requested that additional guidance be issued to all
24 regional and special health authorities which are
25 providing services that may be suitable for designation.
0067
1 "This is attached as a follow-up to ... HN(83)36
2 which announced the inauguration of the supra-regional
3 services scheme ..."
4 It is signed by Mr Angilley.
5 Can we go back to page DOH 2/26?
6 "Centres of excellence: units which might qualify
7 for this title are those where a special expertise has
8 been developed in a particular area of medicine."
9 Pausing there for a moment, could it be said of
10 Bristol that in 1983 there had been developed there
11 a special expertise in neonatal and infant cardiac
12 surgery?
13 A. No.
14 Q. Can we go back to the page before?
15 "Supra-regional services". We have here
16 a convenient bringing together of the latest guidance
17 and the early guidance from 1983:
18 "Circular HN(83)36 defines supra-regional services
19 as the small number of specialised health services
20 which, in order to be economically viable or clinically
21 effective, need to be provided for a population
22 substantially larger than that of any one region. This
23 was expanded into the following criteria."
24 So we have the criteria for the service. Some are
25 service criteria, some are unit criteria. I recognise
0068
1 there is a difference between the two and anyone reading
2 this question and your answer, must read it subject to
3 that.
4 "The service should be an established clinical
5 service ..."
6 Plainly cardiac surgery on the infants and
7 neonates was established in the sense it was obviously
8 being done?
9 A. Correct.
10 Q. "(b) There should be a clearly defined group of patients
11 having a clinical need for the service."
12 That is also true of the service?
13 A. Yes.
14 Q. (c) and (d): satisfied in respect of the service, again,
15 I think you would agree?
16 A. Yes.
17 Q. "(e) Supra-regional funding as opposed to regional or
18 subregional developments should be clearly justified,
19 either (i) by the small number of potential patients
20 in relation to the minimal viable workload for
21 a centre ...."
22 Just pausing there, the minimal viable workload
23 for a centre: we spoke earlier of a surgeon needing to
24 do 50 as a minimum operations per year. Is that open
25 heart operations?
0069
1 A. Open heart.
2 Q. And that corresponds, does it, with the minimum viable
3 workload?
4 A. Yes. I think, actually, the figure that I had was
5 40 when this was calculated against the epidemiology of
6 congenital heart disease within the UK and they were
7 first thinking about it, but whether it is 40 or 50, it
8 was considered desirable that that should be roughly the
9 minimum number of open heart operations performed by
10 a single surgeon per year in the under 1 year old age
11 group and that there should be at least two surgeons in
12 a unit.
13 Q. Yes, which means the unit would have to do 80 to 100?
14 A. Correct.
15 Q. Just pausing there, Bristol never did, did it?
16 A. No. You have just pointed out that the year before it
17 was designated, it had done three.
18 Q. Or four?
19 A. Or four, correct. But may I add that that, in my view,
20 is not necessarily a reason for not designating
21 a centre, because designation, to me, involves -- the
22 whole concept of supra-regional designation was that it
23 was a mechanism by which a particular service could be
24 nurtured and strengthened and developed in certain parts
25 of the country, to provide service. That was the whole
0070
1 history of the designation of prospective heart
2 transplant units, so, whereas in certain instances --
3 for example, I believe with Newcastle, which was the
4 third unit to be designated for supra-regional funding
5 for heart transplantation, they had in fact done some
6 cases beforehand from money which they got, I know not
7 where, but they had done that to prove they could do the
8 work, but that was at a low level. But they were
9 seeking the designation so that they could get the
10 funding that would follow the designation so that they
11 could develop a proper service, which is indeed what
12 they did.
13 Q. Am I right, therefore, in thinking on that last answer,
14 that, without beating about the bush, the only reason
15 for the designation of Bristol as a centre was
16 geography?
17 A. It was its potential for development as a centre for
18 neonatal and infant cardiac surgery, and I believe it
19 was a correct decision at the time, I really do.
20 Q. A potential?
21 A. Yes. I do not know what the total number of operations
22 on the plus 1 year old age group was in 1983/84, but it
23 may have been 140 or something, I do not know. But let
24 us say, for example, that it is that. There was
25 children's surgery going on in the unit, and in order to
0071
1 qualify for the operations on this less than 1 year old
2 age group, there was certainly in my view -- I was not
3 asked at the time but I would have said that there was
4 a potential in Bristol to be developed adequately into
5 a supra-regional service, despite the fact that it was
6 not -- they had to start from somewhere. I have just
7 mentioned Southampton were doing none at the beginning.
8 Q. "The beginning" at Southampton you put back in the
9 1970s?
10 A. In the 1970s, correct, so they had built up to a more
11 respectable number by then.
12 Q. By the time designation began, Southampton had
13 reasonable numbers?
14 A. Probably 70 or 80 a year, I am not sure.
15 Q. Again, just pushing, really, on the point, I think you
16 are broadly in agreement with what I am suggesting to
17 you, but again, I want to make sure it is your evidence:
18 that the only reason that would justify Bristol becoming
19 a designated centre was the potential geography?
20 A. No, it is not just the geography, it is the potential
21 for development in a desirable geographical site.
22 Or desirable geographical region of England and Wales.
23 Q. That necessarily implies that patients would not be
24 well-served, in this case infants would not be
25 well-served, by there being a distance to travel to
0072
1 centres doing a larger workload with an established
2 staff, experienced surgeons, facilities where the ICU
3 and the open operating theatre were there on the one
4 site and so on.
5 A. Well, clearly if there was not a comparably good service
6 locally for those babies to go to, then they would not
7 be well-served by being sent locally, but if the two
8 services that they could get in London or Southampton
9 were comparable to what they could get locally, then it
10 would have been an added benefit to have had it done
11 locally.
12 Q. Can I again ask you a hypothetical question, and it may
13 be the last before it is appropriate to have a break:
14 Suppose that the year after designation takes
15 place one is looking at a unit which had, for the
16 previous two or three years, done somewhere between 3
17 and 10, 3 and 12, let us say, operations per year, open
18 heart on the under 1s.
19 That may indicate a potential for it becoming
20 a good centre, but potential is not actuality, is it?
21 A. No.
22 Q. If one were looking at the figures alone and the
23 experience that that would imply in the surgeons
24 concerned, in order to gain the necessary experience to
25 justify the potential, to make the potential become
0073
1 realised, there would have to be a number of operations
2 conducted over the next few years.
3 A. Yes.
4 Q. That would necessarily imply, would it, that children
5 who were part of the increasing number per year in this
6 particular centre were actually having, on balance, less
7 good care than they would have if designation was
8 restricted to those centres which actually demonstrated
9 at the time of designation a sufficient experience and
10 expertise?
11 A. This was the situation in the 1970s, before the service
12 was designated, that there were units that were
13 performing very small numbers of cases year in, year
14 out, without gaining the necessary experience ever to
15 become good enough, or as good as their colleagues who
16 were doing it in large numbers in good centres.
17 Q. It is not quite the question that I was asking you. It
18 is really a comment that I am inviting from you, not as
19 someone who was centrally involved in designation, but
20 from your knowledge of it through the years.
21 The point might be put in this way: the whole
22 point of designation, apart from the funding aspects,
23 was to concentrate surgery in a few units where there
24 was proper expertise?
25 A. Yes.
0074
1 Q. You are nodding assent to that?
2 A. Yes.
3 Q. Obviously the units which were selected for designation
4 would ideally be those units who had that expertise.
5 That is what we saw -- let us look at it again -- at the
6 top of the present page, DOH 2/25. Can we go over the
7 page, to 26? Those where a special expertise has been
8 developed.
9 A. Yes.
10 Q. The idea being that those that have the special
11 expertise are encouraged to continue and flourish and
12 the others to wither on the vine?
13 A. I am not sure what the question is.
14 Q. Was that the policy behind having supra-regional
15 designation: that you get rid of the proliferation of
16 smaller units and concentrate on those where the
17 procedure was well-established?
18 A. That was the basis from which the decision started.
19 Going on from there, one had to decide whether a unit
20 had the potential to develop into a really good centre.
21 I do not know how long Mr Ash Pawade has been in
22 Bristol. I do not know how long it took him to go from
23 however many operations which were open heart operations
24 were done in the year before he arrived, to, say, two
25 years after he arrived, and I do not know what the
0075
1 change in the mortality was during that period. But the
2 point I want to make is that Bristol secured the
3 services of a very good paediatric cardiac surgeon, and
4 gave him all the facilities that he needed and the
5 managerial back-up to make sure that the unit was high
6 class. And there was nothing to suggest to those who
7 were not intimately involved in 1984, and again in 1986,
8 at the time of the first report, the first Working
9 Party's report which I chaired, that Bristol did not
10 have the capacity to develop in that way if the will
11 were there. That was the reason for thinking that it
12 was reasonable to designate it in the first place and to
13 continue it.
14 Q. Is there perhaps a distinction between appointing
15 a surgeon to take part in a new development of
16 a procedure who has himself considerable experience in
17 the field and has the expertise which "doing numbers",
18 if I can put it crudely, brings?
19 A. Yes.
20 Q. The distinction between that case, which is perhaps the
21 case of Mr Pawade, and the case where one has surgeons
22 who are not doing numbers, who are not likely in the
23 immediate future to leave the post and who therefore do
24 not, by definition, have the experience, even though
25 they may have the potential?
0076
1 A. Correct. I do not know when Mr Dhasmana arrived in
2 Bristol, was appointed as a consultant, but --
3 Q. 1986, I think.
4 A. Was it 1986? Yes. So in 1984 there was a single
5 surgeon here who did both adult and paediatric.
6 Q. It was Mr Keen, I think, and Mr Wisheart?
7 A. Mr Keen did, I believe, very little in the way of
8 children's surgery, it was mainly Mr Wisheart, and at
9 that time there was certainly the potential to do what
10 Southampton had done eight years, ten years previously,
11 and seek to develop it along with the supra-regional
12 designation, the protected funding and everything else
13 that was being provided to the unit.
14 Q. Let me just ask the question in a different way, or the
15 theme of these questions. Is there not, perhaps,
16 a contradiction between the idea of establishing
17 a service limited to a few centres, taking advantage of
18 the numbers and the expertise and success that that
19 brings with it, on the one hand, and choosing for
20 designation one of the number of units in the country
21 which do a bit?
22 A. I think, looking back on it, it was always appreciated
23 that within supra-regional service designation of
24 neonatal and infant cardiac surgery, right at the
25 beginning, these nine centres had been chosen. Within
0077
1 them, there were four who were always going to be big,
2 and there were another two or three who were middling,
3 and there were two or three who were small to start with
4 and needed to be developed.
5 You could have argued that right at the beginning
6 it would have been better to have tried to concentrate
7 everything into four or five units? That would have
8 been a way of going forward, I suppose. But that was
9 not the view that was taken at the time, perhaps because
10 it was a rather radical step anyway to identify nine
11 units out of however many there were at the time who
12 were doing this work, perhaps 15, 18, I do not know, and
13 it may have been felt at the time that nine was
14 a reasonable number too. Well, it was the maximum
15 number that was allowed anyway, and that that would be
16 reasonable to start from.
17 Q. Would it have been more radical to go for five or six,
18 rather than nine or ten?
19 A. No, not a lot.
20 Q. Sir Terence, may I thank you for your patience in going
21 a little past our anticipated lunchtime. Sir, would
22 this be a convenient moment to have a break?
23 THE CHAIRMAN: Yes, it would be, but I would like to, if
24 I may, for once exercise my prerogative as Chairman by
25 asking two questions, as it were, out of the normal
0078
1 order, Sir Terence.
2 The reason I interject is because it is an
3 important gloss on my understanding of the criteria for
4 designation, the idea of potential for development.
5 The question I put to you is: if that criterion
6 were adopted, what would your view be about the
7 proposition that it could only be justified as
8 a variation from the existing criterion if the progress
9 of development was very clearly, very tightly and very
10 carefully monitored?
11 A. I believe that is absolutely right, Chairman.
12 Q. My second question is to a degree intrusive, but it is,
13 I think, relevant to what we are talking about. If the
14 potential for development was not there when you
15 withdrew, because I interpreted from your reply that
16 that was probably why you withdrew, what had changed so
17 as to persuade other people that it might be there not
18 very much longer afterwards?
19 A. They may have been younger, Chairman, and I was at that
20 stage in somewhat of a hurry, and I was not prepared to
21 wait a long time and go into a prolonged battle with
22 management to try and get the resources which I thought
23 ought to be provided.
24 THE CHAIRMAN: I am grateful. We shall take, let us
25 say, 30 minutes. I am told my clock here, despite
0079
1 the benefits of technology, is slow, so let us say
2 10 past 2?
3 (1.40 pm)
4 (Adjourned until 2.10 pm)
5 (2.15 pm)
6 MR LANGSTAFF: Sir, during the lunch break enquiries have
7 been made of a number of people, principal amongst them
8 our long-suffering stenographer, as to what time we may
9 go on to this evening, subject of course to the Panel's
10 convenience.
11 Our understanding is that if we do not succeed in
12 completing the evidence which Sir Terence has to give,
13 and it may be thought that it is of such importance that
14 we should not take it quickly if that would in any sense
15 diminish the quality of his evidence, if we do not
16 finish it by 5 o'clock, we should in any event stop then
17 and, again, for the convenience of the stenographer who
18 has kindly indicated they are prepared to stay here
19 until 5 o'clock, if we have one break during the
20 afternoon session of about a quarter of an hour,
21 somewhere in the middle of it.
22 Sir, I hope that satisfies the curiosity of those
23 who have been asking me during the lunch break when it
24 is likely that we might end today, how long we might go
25 on for, if Sir Terence's evidence takes as long as it
0080
1 might.
2 THE CHAIRMAN: Yes, thank you. I think the criteria that
3 I would use is fairness to our witness and fairness to
4 those who are assisting us. Principally, we can sit but
5 there are others who have to assist us, and it is they
6 who I bear in mind most. We are, I think, prepared to
7 sit until 5 o'clock, with a break, and we will see where
8 that leaves us. You rightly say, if I may say so, that
9 Sir Terence's evidence deserves to be heard properly and
10 appropriately and fairly, and if that means that we have
11 to hold over, then so be it. Thank you.
12 MR LANGSTAFF: Sir, may I indicate that Sir Terence has been
13 spoken to during the luncheon break and asked, if it is
14 necessary for him to come back, can it be arranged. He
15 has indicated he will consult his diary and talk about
16 it during the break, if it looks as if it is heading
17 that way.
18 THE CHAIRMAN: We will cross that bridge when we come to it.
19 MR LANGSTAFF: Sir Terence, if I can return, just before
20 lunch we were talking about the potential for
21 development of Bristol and whether that was an
22 appropriate criterion for designation.
23 Can I invite you to take a look at DOH 4/29,
24 because you raised the question quite rightly in your
25 evidence as to the overall numbers of operations which
0081
1 were being done, paediatric operations, of the open
2 heart sort per year. You anticipated something like
3 120, 140, I think was the figure you had in mind, at the
4 time of designation.
5 The best we can do to help for the moment -- it
6 may be that we have better figures available which we
7 will come upon later, at greater consideration, and if
8 we do, we will send them to you for comment -- but at
9 DOH 4/29, if we just look and see what the figures were
10 in 1990 and in 1991, the open operations in 1990, 39 in
11 the neonates and infants, and 95 of those over 1 year,
12 and the corresponding figures for 1991, 46 on the one
13 hand and 93 on the other.
14 If one were to assume that the figures for open
15 operations over 1 year were, if anything, likely to be
16 greater in 1990 and 1991 than they had been in 1984, one
17 would not have, would one, the 120 to 140 that you were
18 thinking might have been the case?
19 A. I think the 140 which I suggested was both open and
20 closed. I think.
21 Q. You know because you gave the suggestion to us, but that
22 is what you had in mind?
23 A. Yes. I think -- it would be very easy to find out,
24 anyway, exactly what was being done in 1984.
25 Q. That is what we will be able to put our fingers on,
0082
1 given a little greater leisure to do so.
2 Again, if I can just pick up on one point that you
3 were making, you were saying to us, I think, that the
4 philosophy of supra-regional services was to concentrate
5 the operations into relatively few centres.
6 I wonder if we can just have a look at DOH 2/240?
7 This is a paper which went to the Supra Regional
8 Services Advisory Group in 1988. We can see that from
9 the top right-hand corner, SRS(88)2. So a little before
10 your time on the Group itself. But if we look at
11 paragraphs 1 and 2:
12 "In 1983 the Supra Regional Services Advisory
13 Group considered the provision of treatment for children
14 born with congenital heart disease. At that time, two
15 current reports were available from the BPA and the
16 Joint Cardiology Committee of the Royal College of
17 Physicians and the Royal College of Surgeons.
18 "The fundamental theme [as it is described]
19 accepted and endorsed by the Group was that provision
20 should be concentrated into relatively few centres to
21 ensure a high standard of diagnosis and treatment ..."
22 Pausing there, that is correct, is it?
23 A. That is correct, yes.
24 Q. "It was also noted that there were too many small units
25 receiving financial support that would be better
0083
1 directed towards developing the larger and more
2 efficient ones."
3 Is that also a true statement of the aims which
4 lay behind designation?
5 A. Yes, and I think the second sentence, where it is
6 referring to the "small units receiving financial
7 support", this must have referred to regional funding
8 for that unit, rather than supra-regional funding.
9 Q. Yes, and if one were to have taken a bird's-eye view of
10 the situation in 1983, Bristol would have qualified for
11 the description "small unit"?
12 A. Yes.
13 Q. The potential for development to which you referred
14 before lunch would envisage the number of referrals
15 increasing?
16 A. Yes.
17 Q. Do I understand from that which you said earlier about
18 your own decision not to go to Bristol, not to pursue
19 your application, that the facilities available in the
20 mid-1970s were such that you saw little prospect in
21 reality of an increase in throughput?
22 A. I think what I saw was a struggle that one would need to
23 become engaged in in order to achieve the facilities
24 that were necessary to support the sort of size service
25 which I thought would be necessary.
0084
1 Q. So does it follow that there could not be, in practice,
2 an increase in the number of neonates and infants being
3 operated upon unless the facilities were commensurately
4 improved and increased?
5 A. Almost, yes.
6 Q. Why "almost"?
7 A. Because surgeons can do wonderful things with very
8 restricted facilities, as I know from my own experience,
9 and one has to go through a difficult phase of using
10 your facilities to bursting point and facing problems
11 with staff morale, the pressure of the work, but if you
12 can get over that, then you might get the facilities
13 that you need.
14 Q. So if you for your part had been looking at the position
15 of Bristol in 1983, you would have been saying to
16 yourself, "Well, it needs to do more operations; to do
17 that, it needs to have a commensurate improvement in
18 facilities and that is going to be a struggle"?
19 A. Yes.
20 Q. You have described that as a personal view, but given
21 the criteria which was set out in the documents we have
22 looked at, anyone looking at the situation at Bristol
23 objectively at that time would have been compelled,
24 would they not, to have come to a similar view?
25 A. I think those who knew the situation within the UK would
0085
1 have come to the similar conclusion: that in order to
2 have got over the relatively low throughput, this would
3 have required a major determination from management and
4 consultant staff to achieve this, and -- if I could just
5 add in that, the attraction of the supra-regional
6 designation was that if Bristol was being inhibited in
7 1983, shall we say, from developing a service, one of
8 the reasons may have been lack of funding. The
9 supra-regional designation and the funding would have
10 abolished that block and should have allowed them to
11 have had the necessary funding to develop the service.
12 Q. The thesis of a potential for development, obviously,
13 looks to a time in the near future when the
14 development's potential is realised?
15 A. Yes.
16 Q. One might possibly liken it to waiting at a bus-stop for
17 a bus. If the bus does not come you eventually give up
18 and that is in the knowledge that the bus is going to
19 come along at some stage, subject only to withdrawal of
20 the service.
21 In a case like this where one is looking for the
22 realisation of potential, how long would it be
23 reasonable to give it?
24 A. When the Royal College of Surgeons and Physicians
25 Working Party was convened in 1986 to look at the
0086
1 supra-regional services then, I think it was apparent
2 that Bristol had not developed to the extent that we may
3 have expected; that there was a problem with respect to
4 the development at that time. It had certainly not
5 increased its numbers hugely. But it was felt that
6 there was still the potential there and that it would be
7 worth reviewing it and seeing how it went in the next
8 few years.
9 Q. I am not sure that necessarily answers the question. It
10 may be that one cannot answer it. How long does one
11 give it, as a general proposition?
12 A. I think it is a very difficult question to answer.
13 I would not like to put a number of finite years on it.
14 Q. You mention the 1986 Working Party and it is that to
15 which I now want to take you. We find it at RCSE 2/9.
16 If we just scroll down to the bottom of the page, we can
17 see the members of the Working Party and you were the
18 Chairman?
19 A. Yes.
20 Q. Mr Hamilton, as we can see, was on the Working Party.
21 You were, I think, looking at the whole structure
22 of neonatal and infant cardiac surgical services in the
23 light of further applications for designation?
24 A. Yes.
25 Q. Can we have a look at page 10? It is the first page of
0087
1 the report. You set out the designated hospitals. If
2 we go down to the bottom of the page:
3 "In April 1986 the DHSS sought advice from the
4 medical profession on the future of neonatal and infant
5 cardiac surgery as a supra-regional service. The
6 impetus for this was an application from Harefield ...
7 and the knowledge of possible further applications from
8 at least two other centres, Leicester and Hammersmith."
9 A. Yes.
10 Q. As part of that paper, we can see, page 12, at
11 letter A, the second sentence:
12 "The expansion of neonatal and infant services in
13 the larger supra-regional centres has been accompanied
14 by a reduction in mortality which can be related to
15 increased experience".
16 Pausing there for a moment, the word "larger" is
17 no doubt carefully chosen?
18 A. Yes.
19 Q. Does it follow that it was the feeling of the Working
20 Party that the smaller supra-regional centres had not
21 had the commensurate reduction in mortality?
22 A. I think that may have been the feeling. We did not, as
23 I recall, have access to mortality data at this first
24 report -- I am not sure about that, but I do not think
25 we did; we were looking strictly at numbers. We
0088
1 suggested in the report that mortality should be looked
2 at in future, and I think that the statement in the
3 second sentence reflects an impression rather than
4 anything being based on hard statistics. It was the
5 impression of those -- of which Professor Macartney was
6 the Professor of Cardiology at Great Ormond Street
7 Hospital and knew what was going on in London -- that
8 the big centres, like Great Ormond Street, the Brompton
9 and Liverpool and Birmingham, that overall mortality was
10 coming down and that this was probably a result of the
11 supra-regional designation having an effect, a centre
12 effect.
13 Q. Let me go back to that last answer, because the
14 proposition I was putting to you was that there is
15 a distinction between larger and smaller, and I think
16 that your opening words confirmed that was the case?
17 A. I think we felt that this was related to our
18 recommendation that mortality be looked at in future;
19 that there was --
20 Q. And related to your impression percolating through that
21 the larger ones had benefited and ergo the smaller
22 ones ...
23 A. Had not been, yes, I think that is correct.
24 Q. "B: On the basis of current and future likely demands
25 for this type of surgery, it is not possible to justify
0089
1 more than nine centres for England and Wales. Indeed,
2 on the grounds of cost-benefit considerations alone, it
3 might be advantageous to concentrate the work in as few
4 as six larger centres ..."
5 Just pausing there, that would, I think, have
6 implied that the three smallest centres, then Bristol,
7 Newcastle and Guy's, would no longer have had
8 designation?
9 A. Correct.
10 Q. "However, the Working Party recognises that historical
11 and geographical factors also need consideration and
12 recommends that the existing nine units continue to be
13 designated and funded.
14 "Historical factors".
15 A. Yes.
16 Q. It is the first time we have come across a reference to
17 that. What was meant?
18 A. What was meant there was that in some of the smaller
19 centres there had been paediatric cardiac surgery
20 practised for a considerable period of time; that this
21 was predominantly in older children, but that there was
22 a familiarity with the specialty, and Bristol fell into
23 this category, with the number of open and closed
24 operations in the older age group. As I mentioned,
25 Mr Belsey had an interest in it; Mr Wisheart was
0090
1 interested in pursuing and promoting this. The same had
2 been true of Newcastle, where they had done rather more
3 than some of the very small or small volume units in the
4 1970s, so there was a history behind the original
5 designation.
6 Q. Can we, just so we see the numbers that were involved,
7 comparatively, at this stage, have a look, please, at
8 RCSE 2/17. This is one of the tables to this report, so
9 you will be familiar with it, I have no doubt.
10 If one looks at the table, just so you understand
11 what is being shown, these are the number of operations
12 on the under 1s for 1984 and 1985 in the designated
13 centres and for that matter, the others?
14 A. Correct.
15 Q. And one can look across the top, Bristol, and see
16 11 open operations in 1984, 14 in 1985. There is
17 a little growth, but nothing like the growth you had
18 hoped for?
19 A. Yes.
20 Q. If one takes the total number of open operations in
21 1985, it is 456. If one were to divide by 9, the
22 average would be just over 50, per centre.
23 A. You would need to divide by 11, because you have added
24 up, you have included, Harefield and Groby Road.
25 Q. But the total number of operations done, as revealed to
0091
1 you, was 456?
2 A. Yes.
3 Q. If that were to be split between 9 centres, one would
4 have more than 50 operations per centre, on average?
5 A. But the total number amongst the 9 centres was 402, not
6 456.
7 Q. The position I am putting to you must be mathematically
8 correct. Forgive me, if you go with me to this extent
9 of using the question as the basis for a further
10 question, you are absolutely right in saying that the
11 designated centres between them did 402, but the total
12 number of operations which one was looking at, and these
13 presumably were pretty well the majority, if not all of
14 the operations in the UK for that year --
15 A. No, there were quite a substantial number being done in
16 Scotland, and a few in Northern Ireland. These are
17 English figures.
18 Q. So if one adds to 402 the 38 and 16 at the bottom, the
19 total, bar the odd outlier which we may have been done
20 elsewhere which we do not know about, appears to be 456
21 total number of operations. If designation was to work,
22 as had been intended, one would have that done by
23 a limited number of centres, that total workload?
24 A. I do understand what you are getting at, yes.
25 Q. That is the point. If it is done by 9 centres, on
0092
1 average you have 50, thereabouts?
2 A. Right.
3 Q. If it is done by six centres, you have 70 plus, on
4 average?
5 A. Yes.
6 Q. And if one takes it as a simple percentage of the
7 whole, divide 100 by 9, 11.1 per cent of the total
8 English would be done by the average centre, if there
9 were just 9?
10 A. Yes.
11 Q. Bristol, doing 14, would, on my calculations -- I do
12 not ask you to check the maths in your head, but I can
13 tell you that 14 operations out of the 456 is just under
14 3 per cent, so one can compare the 14 with the average
15 of 50 plus, if there were just 9 centres: Bristol very
16 much below the average.
17 Again, you are nodding. You do not have to say
18 "Yes", because if you do not, I will simply say you are
19 nodding, for the transcript.
20 A. Yes.
21 Q. Like outcomes in surgery, there has to be, necessarily,
22 a best, a worst, a unit that does most, a unit that does
23 least operations in a year. But it is true in each
24 case, is it not, that there must be a range around the
25 average which is acceptable?
0093
1 A. Yes.
2 Q. Am I right in thinking that a number as small as 14,
3 less than 3 per cent, when the average, assuming nothing
4 but designated centres, over 50, or 11.1 per cent in
5 percentage terms, would be outside the range of the
6 acceptable?
7 A. I accept that the throughput at Bristol at the time was
8 very low and Guy's was the other unit which, I think the
9 report looked at and it also had concerns about the low
10 throughput. I think these concerns were expressed in
11 the report.
12 Q. If I may just press you on whether you accept that it is
13 outside the range of the acceptable, on the face of it?
14 A. I find that a difficult question to answer. Acceptable
15 in what? Just purely numerically?
16 Q. Acceptable to you --
17 A. In terms of how long they have been funded for, or in
18 terms of their staffing?
19 Q. Acceptable as meeting the criteria and purposes of
20 designation.
21 A. It is certainly not pleasing. But I would not like to
22 use the word "acceptable", or "unacceptable".
23 Q. If we go back to the text, having seen those figures at
24 page 13, letter D:
25 "The Working Party noted that three units, namely
0094
1 Bristol, Newcastle and Guy's, were doing fewer
2 operations per year than desirable for a supra-regional
3 centre. Bristol and Newcastle have legitimate claims
4 for development" and there the word "development" is
5 used, "on geographical grounds and should be
6 encouraged."
7 This was a report addressed to the Supra Regional
8 Services Advisory Group?
9 A. Correct.
10 Q. Were you there suggesting that the Supra Regional
11 Services Advisory Group itself should do the
12 encouraging?
13 A. Yes, and more generally than that: that one would hope
14 that it would have filtered down from there to the
15 hospital itself, to the management of the hospital and
16 to the staff involved in that hospital; that a report
17 like that, which would inevitably go to the
18 supra-regional units themselves, one would hope, that
19 they would take account of it.
20 Q. The encouragement that was to be given: what form did
21 you think that would take?
22 A. I think all sorts of ways: the provision of the
23 facilities, if this was the block, appointment of an
24 additional surgeon or anaesthetist skilled in paediatric
25 anaesthesia -- wherever the block lay, it ought to be
0095
1 corrected.
2 Q. So far as you were concerned, thinking of Bristol at the
3 time, where did the block lie?
4 A. I do not think we were too sure. We knew that
5 Mr Wisheart had been in post then for nearly ten years;
6 we knew that for the great majority of that time he had
7 been trying to run the service on his own, really,
8 effectively from the point of view of being the only one
9 doing paediatric cardiac surgery, but he had an adult
10 cardiological load as well and we suspected that there
11 may have been continuing management problems in
12 providing the support and the services that were
13 needed. We knew that there was a split site that was
14 operating. There were many things that we felt should
15 be corrected. And these were the sort of things that
16 could be accomplished with supra-regional funding, which
17 did not come easily from the region to units.
18 Q. Anticipating ahead, so far as the split site was
19 concerned, I can tell you -- you may know of this --
20 that in the bids for 1993 to 1994, the last year of
21 designation, the Bristol Trust applied for money in
22 order to reverse the split.
23 A. Yes.
24 Q. Amalgamating, if I can put it that way. But that was
25 then deferred to the next year.
0096
1 A. Yes.
2 Q. The next year, of course, being one where there was not
3 actually supra-regional funding available. But there is
4 no record, I think, of it having been done before that.
5 If the split site had been seen as a block, and
6 obviously, because you mentioned it, from your point of
7 view you thought it might be, how would Bristol be
8 encouraged to deal with it?
9 A. I would have said that if the Department, the minister,
10 the Secretary of State, had designated a centre and was
11 funding that centre, that the Department ought to have
12 a role in speaking to the hospital management and
13 saying, "We need you to set them a target and say 'We
14 need to see you try and achieve this greater
15 throughput'."
16 Q. So this was something, really, for the Group, having
17 read your words, to take on board through the Medical
18 Secretary, pass it to the financial man, the
19 Administrative Secretary, who would then go to the Trust
20 and say, "Can we encourage you to put in an application
21 for more funds, because it is obviously necessary"?
22 A. Absolutely. I do not think there was anything that the
23 two Colleges of Physicians and Surgeons could do, other
24 than to draw attention to the problem.
25 Q. I want to replay to you that last answer, and the reason
0097
1 why I wish to do so is that we have been told, not long
2 ago by Dr Halliday, that he felt there was nothing that
3 the Supra Regional Services Advisory Group could do, and
4 encouragement was entirely a matter for the Royal
5 Colleges.
6 Your answer, to me was:
7 "I do not think there was anything that the two
8 Colleges of Physicians and Surgeons could do, other than
9 draw attention to the problem."
10 Would you think about it for a moment? Was there
11 anything other than drawing attention to the problem
12 which you feel the Royal College of Surgeons could have
13 done?
14 A. Within the context of the work that we were asked to
15 undertake by the Supra Regional Services Advisory Group,
16 I do not think there was anything further that we could
17 do. The two Presidents had decided on, I think, the
18 composition of the Working Party: two surgeons, two
19 physicians, one a cardiologist, one a paediatrician. We
20 had very broadbrush terms of reference. We had a fairly
21 short time to operate in, if I remember. We set about
22 trying to get the activity data from the designated
23 centres and the other ones who were doing some work, who
24 were not designated, and these are the conclusions that
25 we came to.
0098
1 I do not think that there was any specific
2 encouragement which either the Royal College of
3 Physicians or the Royal College of Surgeons could have
4 given to the BRI at that time to increase their
5 throughput in paediatric neonatal and infant cardiac
6 surgery.
7 Q. I think what was being suggested to us by Dr Halliday
8 was the longer term; not simply a function of what the
9 Working Party may have said to clinicians on site. But
10 once the report had been delivered, and once it had been
11 accepted by the Supra Regional Services Advisory Group,
12 that they, the Group, would look to the Colleges over
13 the long term to use their good influence to encourage
14 the unit to expand.
15 A. If the Supra Regional Services Advisory Group had wished
16 that, they should have asked the Colleges at that time,
17 and I do not believe either Mr Todd or Professor Raymond
18 Hoffenberg were ever asked to take up and follow
19 anything from this 1986 report.
20 Q. Your assumption was that the encouragement was to be
21 given by others than the Royal Colleges. That is what
22 I think you are saying to us?
23 A. Yes. I think the only personal peripheral encouragement
24 that we were able to give was in fact through having
25 Mr Hutter, one of the trainees as a Senior Registrar who
0099
1 was sent to Papworth to train with us, but that was not
2 specifically in paediatric work, that was in
3 transplantation work. Because Bristol at that time was
4 thinking of starting a transplant programme, possibly;
5 this was one way of helping at the time. But that was
6 not a College discussion.
7 Q. So again, really, looking at the issue of who was to be
8 responsible for encouragement -- because that is the
9 question which I am addressing -- Dr Halliday says "Not
10 us, it was the Royal Colleges". You say "Not us, it was
11 the Supra Regional Services Advisory Group". Are you
12 making the point that if it was to be the Royal
13 Colleges, then he, Dr Halliday, or the Group through
14 Mr Angilley, should have asked?
15 A. Absolutely; but this was a service which had been
16 designated by the Advisory Group. They had asked an
17 opinion in the Colleges as to what the present situation
18 was; they were given that opinion, but controlling the
19 purse strings, as I have already said, really gave the
20 Department a huge potential for some control over
21 development. I can only suspect that that was not
22 exercised in this particular case where it perhaps
23 should have been.
24 Q. I can see the encouragement that might be given by
25 inviting the unit to ask for more finance for particular
0100
1 developments, that being, if you like, financial
2 encouragement. The financial encouragement would
3 necessarily, would it not, be secondary to the desire to
4 develop and improve the services?
5 A. Yes.
6 Q. And that would be the desire of the clinicians within
7 the practice that they were following?
8 A. Yes.
9 Q. Is that not a matter which would concern the Royal
10 Colleges?
11 A. No. No, that is a local matter. Without the local
12 desire of a surgeon or a paediatric cardiologist to
13 improve and extend the practice in their particular
14 hospital, there is nothing that the College can do to
15 breathe on them and say, "You should do this". There
16 really is not.
17 Q. We come back, do we, to the Colleges having a duty and
18 a role to do what they can to improve standards?
19 A. Yes.
20 Q. But it was seen that supra-regional services were one
21 mechanism for improving standards in the interests of
22 patients?
23 A. Indeed, they were, generally.
24 Q. And you yourself found, or thought in this report in
25 1986, that greater numbers meant greater success, and
0101
1 hence benefits for patients?
2 A. Correct.
3 Q. And I understand it correctly, do I, that your view
4 throughout the history of designation was that
5 designation was very much to the patient's benefit?
6 A. Absolutely.
7 Q. So we have a system which the Colleges believe to be in
8 the best interests of the patient?
9 A. Not so much the Colleges, because generally, I mean, the
10 Presidents were aware of what was going on, but it was
11 the specialty of cardiothoracic surgery in Britain which
12 felt that supra-regional designation of neonatal and
13 infant cardiac surgery was very desirable.
14 Q. So those who have a clinical perspective regard this as
15 being in the interests, very much, of the patient?
16 A. Correct.
17 Q. That to have designation operated on a proper basis is
18 to improve standards?
19 A. Yes.
20 Q. Therefore, the Royal College, it might be thought, and
21 the specialties, have an interest in doing what they can
22 to develop the service in a proper way?
23 A. Not to develop the service in any active sort of way;
24 I mean, that is not in the nature of the Royal College
25 of Surgeons, nor of Physicians. They are made up of
0102
1 specialists from all sorts of different specialties.
2 They are talking of surgery as a whole. They seek the
3 advice of the specialist organisations for particular
4 problems which arise from time to time, but in terms of
5 actively developing a service in a particular hospital,
6 that has never been perceived as being within its remit.
7 Q. Do we have a situation, then, when the interest of the
8 patient, which is recognised as being paramount by the
9 Royal Colleges, cannot be directly advanced by
10 encouraging in one way or another the development of
11 a neonatal and infant cardiac surgical unit, because
12 that depends upon local desires on the one hand and the
13 supra-regional services finance on the other?
14 A. Yes, and if the local team is not up to it, or lose the
15 desire to actually develop that particular service, then
16 the funding and the designation should be withdrawn.
17 Q. That is what I was going to ask. Is this not perhaps
18 where the Royal Colleges would obviously have the
19 feedback as to what the local desire was?
20 A. We would have some of the answers, but we would not know
21 necessarily what the managerial blocks were to develop,
22 unless, if we had, for example, following the 1986
23 report, shall we say, if the Supra-regional Services
24 Advisory Group had said, "Look, Bristol has been going
25 for three years and the numbers are still extremely low,
0103
1 we would like you as a professional group to go down and
2 actually make a report for us, the Department of Health,
3 as to what the cause of this is", we would then have had
4 the authority to go in and interview the consultants and
5 everybody else, management, and write a report, and we
6 would have been very happy to do that. But without that
7 authority, and without being asked to do that, I do not
8 see that the College would have ever embarked on that
9 ab initio.
10 Q. It may be to the observer of this that the interests of
11 the patient are in effect falling between three stools:
12 one being the Supra Regional Services Advisory Group,
13 which does not take a financial initiative; one being
14 the Royal College of Surgeons which, as you say, has no
15 right to intervene without being invited to do so; and
16 the third being local management, which does not have
17 the necessary impetus or interest in developing the
18 service further, at least in competition with those
19 other services operated locally?
20 A. I accept that, and I think, to explore just the
21 relationship between those three responsible bodies,
22 I would put it to you that the Colleges have the
23 responsibility of providing a professional report on
24 a particular service or a particular issue when asked by
25 the Supra Regional Services Advisory Group, who, on the
0104
1 basis of that report, ought to then require the local
2 hospital to improve that service, because they are
3 funding it.
4 Q. Encouragement has, as its reverse side, deterrence or
5 discouragement?
6 A. Yes.
7 Q. From what you have been saying, it might be thought, and
8 this is what I want your comment on, that those in the
9 Royal Colleges whose views were sought from time to time
10 by Dr Halliday or others connected with the Supra
11 Regional Services Advisory Group, might, unless
12 sufficient advance were shown, justifiably come to the
13 conclusion that there was not the local impetus to
14 develop that is one of the three stools I have just
15 mentioned. And the consequence of that would be
16 a recommendation for de-designation?
17 A. Yes.
18 Q. Do you know whether any view of that sort, any threat,
19 if you like, of that sort, was ever conveyed to the
20 units under consideration here: Bristol, Newcastle,
21 Guy's?
22 A. I do not know of any. Dr Halliday used to visit these
23 centres and I think did so after each of these reports,
24 to discuss them with them. I do not think that he would
25 have made threats of de-designation on his own, so
0105
1 I rather think they never happened. The only time that
2 the College formally recommended de-designation of any
3 units was in the 1992 report.
4 I believe that there was -- I am not absolutely
5 sure of this, but I believe in the other field of liver
6 transplantation, that a designated centre in London had
7 been stopped at some time, because of poor results, and
8 that it was indeed restarted again after a new surgeon
9 had arrived and it was felt that it was worth
10 supporting.
11 Q. Just so I have it clear: never formally recommended
12 de-designation, you said. Informally?
13 A. Informally. When I was on the Advisory Group,
14 I certainly made it known informally to those whom I met
15 and who served on the Group that I felt that
16 de-designation should be considered more readily than it
17 was, because if one had a situation where a designated
18 unit was not even taking the trouble to submit its
19 annual activity figures, the mortality figures, when
20 asked, or if it was not providing proper accounts, that
21 then a threat of de-designation would have been
22 perfectly reasonable.
23 Q. You go on, in the report, page 2/13, letter D, to say
24 that Bristol and Newcastle have legitimate claims for
25 development on geographical grounds. That really is the
0106
1 only ground, as I understand it, put forward in this
2 report for their continued designation. Am I right?
3 A. Yes, I think you are right there; that they had been
4 designated two years previously. They were not doing
5 the sort of numbers that one would like to have seen,
6 and those were the main grounds for carrying on. As we
7 see, Newcastle subsequently improved and Bristol took
8 a long time to increase its numbers.
9 Q. You recommend that the workload of those three centres
10 and Harefield should be reviewed in two years' time?
11 A. Yes.
12 Q. May we have a look at WO 1/339, please? This is
13 something which came into being at about the time we
14 have been looking at. I think it may be slightly after
15 your report. It is the Royal College of Physicians'
16 Report on Advisory Group on cardiac services in South
17 Wales.
18 Did you know, at about this time, that Wales was
19 contemplating the possibility of developing a cardiac
20 surgical service in Cardiff?
21 A. Could you tell me what the timing was?
22 Q. This is 1987, I think, but I shall have it checked.
23 A. I am not sure when I first became aware or was informed
24 of the possibility of Wales wanting to start paediatric
25 cardiac surgery, but it would have been about this
0107
1 time.
2 Q. Certainly the matter was live in 1986, the suggestion
3 that Wales should develop, and we have heard evidence
4 about this from Mr Gregory and others.
5 A. Yes, thank you.
6 Q. In fact this report was asked for in 1987 but was not
7 published until 1988, hence my confusion.
8 May we turn, please, to page 341, paragraph 5.6.
9 This is a Welsh report and plainly it is dealing with
10 Welsh considerations. It is looking back to the earlier
11 report, the second report, and exploring the
12 considerations pertaining to the siting of facilities
13 for paediatric cardiology and paediatric cardiac
14 surgery. "850 infant operations ... can be expected
15 from England and Wales each year, each surgeon to carry
16 out at least one such operation a week. To provide
17 cover at least two surgeons are required."
18 All that is familiar territory.
19 "The report suggested a limited number of
20 supra-regional centres was appropriate. The DHSS
21 endorsed the establishment of nine such centres which
22 now receive central funding for the surgery that they
23 carry out on children under the age of one. All the
24 rest of the paediatric cardiological services are funded
25 by regional monies."
0108
1 So 5.6 is all received wisdom, is it not?
2 A. Yes.
3 Q. "5.7:
4 "It is considered essential that a centre involved
5 in infant cardiac care should be an integral part of
6 a larger unit dealing with a wider range of
7 patients ...", and it goes on down to "the cardiac
8 centre for infants and children shall be in close
9 association with the children's department to provide
10 appropriate general paediatric care for the patients.
11 It should, however, be pointed out that this is
12 a counsel of excellence; it seldom exists. At the
13 present moment all the major paediatric cardiology units
14 exist either in close proximity to a cardiac centre or
15 as part of a large paediatric unit, but not necessarily
16 both."
17 Pausing there, the split site that existed at
18 Bristol was presumably -- tell me if I am right -- an
19 additional black mark, as it were, against Bristol
20 continuing to be a designated centre, a supra-regional
21 designated centre, for the cardiac surgery on the
22 neonates and infants?
23 A. I think it may have been an inhibition to the proper
24 development of the service, yes, and in that respect,
25 may have been seen as an undesirable feature, but not
0109
1 necessarily a black mark.
2 Q. Can you help me with what other problems it was seen at
3 the time may have inhibited Bristol from developing in
4 the way it was hoped originally that they might?
5 A. I think, as we have mentioned, the possibility of
6 a Welsh unit came into it, because clearly, if the Welsh
7 Office decided to establish a unit in Cardiff, this
8 would have seriously compromised Bristol. The split
9 site you have referred to, the fact, perhaps, that there
10 was no dedicated paediatric cardiac surgeon; that there
11 were dedicated paediatric cardiologists at the time.
12 Those are some of the things, I think, which I can think
13 of.
14 Q. Can you think of others?
15 A. Given time I might be able to, sir, but not just at
16 present.
17 Q. You say that the blocks, as you call them, to Bristol
18 were a matter of concern because no-one quite knew what
19 they were at the time. These are all, obviously,
20 therefore possibilities and speculations that you have
21 or had at the time.
22 Would that, do you think, argue for an earlier or
23 later reconsideration of whether Bristol should remain
24 designated?
25 A. I think what it should have resulted in was the Medical
0110
1 Secretary making it his business to find out that the
2 blocks were in Bristol. If he had been able to do that
3 on his own through his own visits, fine, but if, as
4 a result of those visits, he still felt that there was
5 a problem, then he could have asked for a specific
6 visitation from, say, the two Colleges involved, one
7 physician, one surgeon, to actually find out what the
8 difficulties were and write a report for the Supra
9 Regional Services Advisory Group so that they could
10 bring that, then, to the attention of management.
11 Q. Just jumping ahead for a moment, when you later became
12 a member of the Supra Regional Services Advisory Group,
13 you were obviously a cardiothoracic surgeon who knew the
14 field intimately. Had there been such an expert on the
15 Group before that?
16 A. I do not believe so. It was the role of the President
17 usually to serve as the College representative on the
18 Supra Regional Services Advisory Group, or a Senior Vice
19 President, and I cannot recollect there being any
20 cardiac surgeon performing on the Group.
21 Q. When you were on the Group, did the Group naturally look
22 to you for information about the ins and outs of
23 neonatal and infant cardiac surgery?
24 A. Yes. I was often asked to comment on any issues which
25 arose with regard to both neonatal and infant cardiac
0111
1 surgery and transplantation.
2 Q. Because your knowledge of the field would be naturally
3 much greater than that of Dr Halliday, however great it
4 may have been?
5 A. Yes. I mean, my knowledge of the transplant issues were
6 greater than they were of the neonatal and infant
7 cardiac surgery, because I had become somewhat removed
8 from that, but I had access to good information,
9 certainly.
10 Q. When you were on the Group, do you recall ever asking
11 for the Group to suggest, through Dr Halliday to the
12 Royal Colleges, that they should ask for an
13 investigation as to what the block was at Bristol?
14 A. No, I do not think that ever happened.
15 Q. May I ask you why not?
16 A. Well, in 1989, when the whole issue of de-designation of
17 the service surfaced again, yet again after there had
18 been -- after the second report things lay dormant for
19 a year and then they came up again. There was,
20 somewhere around there, the suggestion that Dr Halliday
21 should get in touch with me with a view to discussing
22 how the matter might be taken forward within the
23 Advisory Group. There was then a long delay, I think,
24 and that took us through to, well, really into 1991 when
25 the beginnings of the third report which was
0112
1 commissioned in January 1992 started.
2 So the matter was discussed once or twice during
3 the preceding two years within the SRSAG, but it
4 resulted in this request for a further Working Party.
5 Q. So despite your special interest in the field, and
6 despite your -- you had known Dr Halliday for a long
7 time. Despite your contact with him and others on the
8 Group, it never occurred to you as such to say, "Well,
9 let us see if Bristol could still be developed, no
10 matter what the blocks are"?
11 A. No, it did not, because I do not think I was aware,
12 until I saw the results which were published in the 1992
13 report, that the mortality statistics were as they
14 were. I would not have seen them; they would not have
15 come to me. They were not generally discussed within
16 the Group meetings, I do not think, although they might
17 have been available to Dr Halliday and his team.
18 Q. I jumped ahead a little bit. We have looked at the 1986
19 Working Party of which you were Chairman. The next
20 report into neonatal and infant supra-regional cardiac
21 surgical units which the Group asked for I think was in
22 July 1989, and if I can have a look at that, it is
23 RCSE 2/24.
24 Did you see this report at the time?
25 A. Yes, I did, and it was a report which I had little to do
0113
1 with, because although I was just President in July
2 1989, the request for commissioning the report had gone
3 to the Society and the then President of the Society,
4 Sir Keith Ross. On this occasion, Dr Halliday did not
5 return to the Royal College of Surgeons.
6 Q. At page 26 -- you read the report at the time?
7 A. Yes.
8 Q. At page 26, the definition of a supra-regional unit:
9 "The Working Party considers that a supra-regional
10 unit should be adequately staffed and equipped in
11 a satisfactory physical environment", and those words
12 would be capable of covering whether it is a split site
13 or not?
14 A. Yes.
15 Q. You are signifying agreement to that, I think, "and
16 should serve a large catchment area preferably of over
17 3 million population" which presumably the South Western
18 region was?
19 A. Yes.
20 Q. "Ideally, staff should include two consultant surgeons
21 who are experienced in paediatric surgical practice".
22 That begs the question how experienced?
23 A. Yes.
24 Q. "And at least two consultant paediatric
25 cardiologists ..."
0114
1 The bottom of the page:
2 "ITU facilities which are adequate for the unit's
3 workload in children, infants and neonates and staffed
4 to full establishment are essential if a steady level of
5 patient throughput is to be maintained."
6 The ITU facilities which we have had described to
7 us -- one does not have to go back to the 1989 or 1994
8 SAC reports to understand their nature -- were mixed
9 adult and children?
10 A. Yes.
11 Q. Principally adult ward, with a child area.
12 Does that fit the description given here?
13 A. No. I think at that time it certainly was regarded as
14 being desirable to have separate paediatric ICUs.
15 Q. Not least because of the staffing implications?
16 A. Yes -- mostly because of general staffing implications.
17 Q. Page 28, the fourth line down:
18 "Financial support should not be calculated on the
19 basis of projected workload. A scale could be devised
20 which takes account of the previous two years
21 performance, for example."
22 My understanding of the implication of this is
23 that the amount of money which a unit got for performing
24 a service was dictated by the numbers which went through
25 it. Broadly, was that right?
0115
1 A. Broadly it was right. In reality, I think what happened
2 was that designated units presented to the department an
3 estimate of projected throughput for the coming
4 financial year, and then they received a budget on
5 projected workload.
6 What was being suggested here was that that was
7 not a good mechanism and that it should be done on
8 actual workload.
9 Q. So how, within the system, was the encouragement, the
10 financial encouragement, to be delivered to develop
11 facilities in order to increase the numbers, if the
12 funding was dependent upon numbers?
13 A. Because there were two separate funding streams. There
14 was the revenue bit for the coming year, and then there
15 was a capital allocation which you asked for
16 separately. It was there, which you asked for, the
17 capital needs for a new theatre or a major development,
18 necessary for developing the service. This was terribly
19 important to us in Papworth in the early years of
20 transplantation, to get proper capital development, and
21 it came through the supra-regional funding.
22 Q. Just reading on:
23 "Annual audit of work performed (including
24 hospital survival) in this age range should continue to
25 be carried out by the Department of Health."
0116
1 That suggests that the Department of Health was
2 auditing not only the throughput, work performed, but
3 also to some extent the outcome?
4 A. Yes.
5 Q. Was that the case?
6 A. I am not absolutely clear on this, but I do believe that
7 there is, in one of the letters that Dr Halliday wrote
8 to Sir Keith, somewhere there, there is a reference to
9 the Department being able to provide the necessary
10 information of audit data on the designated units for
11 the previous few years, and I think the assumption was
12 made that this included mortality data as well as
13 activity.
14 Certainly, it was our belief that the Department
15 had access to the UK cardiac surgical register data
16 which each unit would have filled in, and could have
17 provided to the Department if asked. I believe they
18 were asked about it.
19 Q. So your understanding was that, if you like, if you put
20 yourself in Dr Halliday's shoes, you would have had the
21 Cardiac Surgical Registry returns for each individual
22 unit?
23 A. Yes.
24 Q. So putting yourself in, as you thought, leaving aside
25 whether it is right or wrong, but as you thought
0117
1 Dr Halliday's position was, you would have been able to
2 see how one unit compared against another?
3 A. Yes, and also, if one unit seemed to be doing rather
4 badly against the national ...
5 Q. If we follow on the next sentence in the report:
6 "Case mix should be studied with special reference
7 to complex cases."
8 That is directed, is it, to the analysis of crude
9 outcome data?
10 A. Very much so.
11 Q. Because it must have been anticipated, or at least it
12 was anticipated, as I apprehend it, by Mr Hamilton and
13 those who took part in this report, that crude data
14 would need to be interpreted?
15 A. Yes.
16 Q. And it goes on to say:
17 "The interpretation of these findings should be
18 made in consultation with ... and should be taken into
19 account when special funding is allocated for the next
20 year."
21 A. Could you move the frame up a little?
22 Q. You are absolutely right, thank you:
23 "The interpretation of these findings should be
24 made in consultation with professional advisers ... (who
25 are actively involved in this field of work) and should
0118
1 be taken into account when special funding is allocated
2 for the next year."
3 A. Yes.
4 Q. What has been urged here is, is it, that special funding
5 should be dictated in part by the quality of outcome?
6 A. Yes.
7 Q. Did it ever happen?
8 A. The only case I can think of is the Royal Free Hospital
9 liver transplant unit, where the money ceased when it
10 was de-designated.
11 Q. Because of results?
12 A. I believe so.
13 Q. But otherwise, so far as you know, no follow-up on this
14 particular recommendation?
15 A. I do not believe so. It was a very clear and I believe
16 a sound recommendation from the report, that the
17 profession was prepared to help with the interpretation
18 of this data, but that it was the Department's
19 responsibility to get the data from the units that they
20 had designated.
21 Q. So in effect, putting, as it were, flesh upon the
22 principles we have been debating, this would involve
23 Dr Halliday, would it, getting the data from the
24 register and then going to you or some other expert and
25 saying, "What do I make of this"?
0119
1 A. Not getting the data from the register, but getting the
2 data from the designated units.
3 Q. This report itself, as I understand it, did display
4 a number of tables which showed the data that it had
5 collected, and we see, at the bottom of page 28, sent
6 out questionnaires in respect of workloads. If we go
7 overleaf, please, that is presented in histogram form.
8 We will see in a moment or two, that that shows some of
9 the data that apparently had been collected in respect
10 of mortality.
11 A. And this data was collected specifically by the Working
12 Party on the basis of the questionnaire which they had
13 sent out.
14 Q. So if I can just ask you to look at the figures which
15 were produced, DOH 2/231, it is the same report but with
16 a different reference. This has become familiar to us
17 but you may not have seen it for some time. This refers
18 to the histogram referred to in the report. Second from
19 the left is Bristol, and one can see the numbers.
20 A. Yes.
21 Q. For 1988, one could, if one wanted to, add up the
22 numbers that are done.
23 A. Yes.
24 Q. If we turn over to page 233, the open operation for the
25 under 1s -- and it is the under 1s that the service is
0120
1 concerned with, is it not?
2 A. Yes.
3 Q. The second from the left in terms of percentage
4 mortality is the number which corresponds with Bristol?
5 A. Yes.
6 Q. Looking at the evidence presented in this particular
7 way, what would one conclude about the relative
8 performance of Bristol as a designated centre for this
9 particular year?
10 A. With the confidence limits as they are, there are
11 2 units who are doing a small volume of surgery, both
12 with statistically higher mortality than the remaining
13 5 on the figure.
14 Q. And one would conclude, I think, that second from the
15 left had a statistical mortality rate which was
16 significantly different from 5 of the other centres?
17 A. As indeed did the first. I mean, the overlap in
18 confidence limits is almost complete.
19 Q. So it would follow, I suspect, from anyone looking at
20 the data presented in this way, that one would want to
21 know, really, why these two centres were statistically
22 significantly worse than the others.
23 You are agreeing?
24 A. Yes, I would.
25 Q. It is the sort of data you would expect, would you,
0121
1 questions to be asked about?
2 A. Yes, indeed.
3 Q. On the face of it, it is disquieting, is it, because
4 this is a reflection of, put crudely, patients dying?
5 A. Yes.
6 Q. Did you, for your part, when you read the report, take
7 particular notice at all of this table?
8 A. Here I am not absolutely sure that these figures which
9 we have been looking at were actually part of the report
10 which was distributed in the papers. They may have been
11 tabled for the meeting, I do not know, but I do not
12 remember being struck by them, certainly before the
13 meeting.
14 Q. I can help you with that. If you go back to page 228,
15 the bottom of the page:
16 "Mortality (30 day hospital) ... there is
17 a tendency for mortality to be higher in the units
18 performing the smallest number of cases in the group of
19 infants undergoing open heart surgery under 1 year of
20 age (figure 3)."
21 A. Yes.
22 Q. If we go back to 233 --
23 A. That suggests they were published with the report.
24 Q. Do I take it from your last answer you are not so sure
25 that you went so far as to look at the tables, indeed
0122
1 with any detail?
2 A. Indeed.
3 Q. Had you looked at them in any detail, you for your part
4 would have said "This requires some serious
5 explanation", would you?
6 A. Yes. I suppose that if I had been involved with
7 commissioning the report, it was not a College of
8 Surgeons' report, this, I think it came from the
9 Society, I would have wanted to know more about it, and
10 I think probably, as a member of the Advisory Group,
11 I should have taken more account of this.
12 Having said that, I think the general
13 recommendations from the report which I read carefully
14 were sound.
15 Q. If I may say so, that is very frank of you. Had you
16 been the author of the report, you would have wanted,
17 would you, to have made further enquiries as to why on
18 earth this was?
19 A. Well, both units. I do not want you to talk just about
20 Bristol here, because they are two together. There is
21 no distinction between them, mortality wise.
22 Q. The answer to that is "Yes", in respect of both units?
23 A. Yes.
24 Q. And it follows that if one is to put a moral imperative
25 on it, you think that should have been done if it was
0123
1 not done?
2 A. Yes. I do.
3 Q. Just skipping forward a little, when ultimately you were
4 told -- we will come to the details in a little while --
5 that the Bristol rate for mortality in the neonates and
6 under 1s was 30 per cent, or thereabouts, which was
7 double that of the national average, so it was said, you
8 regarded it, you have already agreed with me you told
9 the Dispatches programme, as disturbingly high?
10 A. Yes.
11 Q. And the same comment would fall to be made about what
12 this page, this set of diagrams reveals, because if one
13 were to do a very rough approximation, the two centres
14 which are above 30 and very nearly 40 per cent mortality
15 across the board appear to be in distinction with the
16 rest, which are at or below 20 per cent, and may suggest
17 that the performance of those two was probably roughly
18 double the performance of the national average, broadly
19 speaking?
20 A. The mortality, yes.
21 Q. It follows that if you found the figures in 1992
22 disturbingly high, those you had, you would have done
23 exactly the same with these figures?
24 A. Yes. There was the difference in 1992 that I received
25 a letter which acted as a stimulus.
0124
1 Q. I will come to that. You are taking me ahead. Will you
2 let me get there in my own time?
3 A. Indeed.
4 MR LANGSTAFF: Sir, talking about my own time, may I talk
5 about hours and suggest that this might be a moment for
6 the stenographer to have a break, and us as well?
7 THE CHAIRMAN: Yes, and I think the witness. Shall we say
8 15 minutes break. That means -- you tell me, because
9 I cannot synchronise my timepiece here with everyone
10 else's.
11 MR LANGSTAFF: 5 to 4.
12 THE CHAIRMAN: Thank you. We will adjourn until 5 to 4.
13 (3.40 pm)
14 (Adjourned until 3.55 pm)
15 (4.05 pm)
16 MR LANGSTAFF: Sir, I am sorry everyone has been kept
17 waiting. They know by now your practice is to come in
18 at the last dot of any break. Let me explain, so that
19 those who are here know, the delay has been caused by
20 trying to sort out dates and to see when Sir Terence can
21 come back. On the assumption, as I think is likely,
22 that he will not finish his evidence today and in the
23 knowledge that his evidence is likely to be of
24 considerable benefit to the Inquiry, he has kindly
25 agreed to come back on Monday and we shall take his
0125
1 evidence then. I think we have in mind it will be at
2 12.30 or 1 o'clock, if that is convenient. We therefore
3 propose to see how far we can get today so that we are
4 confident that, come what may, we will be able to
5 release Sir Terence on Monday afternoon.
6 THE CHAIRMAN: Mr Langstaff, may I just interject to say
7 thank you to Sir Terence? It does look as if we may go
8 over from past 5 o'clock this evening, and I think it
9 would be important to hear the rest of your evidence and
10 so we, for our part, are extremely grateful if you are
11 able to do that for us.
12 SIR TERENCE ENGLISH: Well, thank you Chairman. Could
13 I just mention that if it were possible for me to give
14 that evidence a little earlier in the day, it would be
15 convenient, but if it is not, I am happy to abide by the
16 12.30 start.
17 MR LANGSTAFF: May we say, Sir Terence, we will see what we
18 can do in what time is left to us today, and I hope that
19 those who may be watching this on closed circuit
20 television downstairs have heard that and will make the
21 appropriate arrangements.
22 I was asking you, Sir Terence, about the report in
23 1989, and if I can now bring up to date your concerns
24 with the supra-regional designation, following that
25 report, let us look at DOH 2/204.
0126
1 This is the meeting of 1990, the first meeting of
2 the Supra Regional Services Advisory Group for 1990. At
3 this stage you were considering, as I apprehend, the
4 impact of the NHS reforms upon designation?
5 A. Yes.
6 Q. We see, if we can go over to 205, paragraph 4.3, that
7 you for your part thought that supra-regional
8 designation should continue with the costs being borne
9 centrally. That, I take it, was your view at the time?
10 A. Yes.
11 Q. Can we look at DOH2/202, please, going down to the bottom
12 of the page and, so we follow what this document is, if
13 we can go back to the beginning of it, which is at 200,
14 it is SRS(90)6, and it is a paper which deals with
15 neonatal and infant cardiac surgery. If we just pick up
16 a consequence of the 1990 February meeting:
17 "1. At the February meeting of the Advisory
18 Group, officials were invited to visit the units
19 referred to in the reports of the Royal College of
20 Surgeons and the Society of Cardiothoracic Surgeons and
21 to prepare a paper setting out the options for the
22 future arrangements for these services."
23 That is a response to the July 1989 Working Party
24 report?
25 A. Yes.
0127
1 Q. It describes there the centres, and at paragraph 3,
2 those that were singled out as requiring review:
3 Bristol, Newcastle and the Harefield part of the joint
4 Harefield/Brompton centre.
5 Can we look at what is said about Bristol at the
6 foot of the page:
7 "Officials visited the Bristol unit and met with
8 cardiologists, cardiac surgeons, nursing staff and
9 management. The centre had had considerable difficulty
10 in getting the service started."
11 That is something about which you undoubtedly
12 agree?
13 A. Yes.
14 Q. "Although the service remains split between two sites,
15 there has been considerable capital development in
16 the ... BRI and in the diagnostic facilities in the
17 cardiology department in the Children's Hospital. The
18 referral of patients has increased and the centre
19 appeared to be on a much stronger base."
20 This paper was not your authorship, I take it?
21 A. No. I think it was from the Secretariat of the Supra
22 Regional Services Advisory Group.
23 Q. The "much stronger base". What did you, as a member of
24 the Group, take that to refer to?
25 A. To the referral of patients.
0128
1 Q. Can we look at DOH 4/28? We have here the open heart
2 surgical numbers. It picks up in 1983, 4 -- that is
3 where I got my 4 from. It could have been 3 in some
4 reports, 4 in others; 11, 14, in 1985; 24 in 1986. May
5 I say that a point which is made on behalf of
6 Mr Wisheart is that this is actually an expanding
7 service. One has a service which is expanding by
8 600 per cent between 1983 and 1986.
9 A. Yes.
10 Q. From 4 to 24. But do I take it that that expansion is
11 not sufficient, at any rate, drawing the line at 1986
12 for the moment, to establish anything like a viable
13 number for continued designation if one were to stop the
14 line there?
15 A. Yes, I would agree.
16 Q. And 25, 29, 40, in 1989; 39 in 1990. At the time the
17 discussions took place in 1990, then one would be
18 looking at the 1989 figure of 40 operations. There
19 would appear to be a modest expansion, one might say,
20 a one-third expansion over 1988, in terms of the open
21 heart operations performed?
22 A. Yes.
23 Q. Is 40 a viable number of operations bearing in mind the
24 need to have two paediatric cardiac surgeons?
25 A. Certainly not for two paediatric cardiac surgeons who
0129
1 are not doing anything else, and it is low even for two
2 cardiac surgeons who are doing both paediatric and adult
3 work.
4 The total number of paediatric operations which is
5 not given here would be illuminating, because the total
6 number under 1 is 98 in 1989. Do we know what the total
7 paediatric cardiac surgical numbers were in that year?
8 Q. I shall find out for you. Mr Maclean will tell me in
9 a moment or two.
10 A. I accept the point that 40 is low to be distributed
11 between two paediatric surgeons for open heart.
12 Q. Is there evidence in these numbers, would you say, to
13 justify a conclusion that the referral of patients had
14 increased and the centre appeared to be on a much
15 stronger base?
16 A. That is why I would like the other information as well
17 to see whether that was growing, because the surgeons
18 are not just doing the under 1 year olds, so obviously
19 operating on slightly older children as well. There is
20 not a lot of evidence to suggest here, but perhaps there
21 was other evidence I am not aware of which suggested
22 that referrals were likely to go on increasing. Could
23 it be that the Welsh Office had decided they were not
24 going to start a unit at that time? I do not know.
25 Q. That might be answered by the next sentence on page 200,
0130
1 if we go back to that. Go down to the bottom of the
2 page and focus on that. After it says the referral of
3 patients has increased and the centre appeared to be on
4 a much stronger base, can you pick that up in the text,
5 it goes on to say:
6 "There is however a threat to Bristol in the
7 future which arises with the decision by the Welsh
8 Office to establish a neonatal and infant cardiac
9 surgical service in Cardiff. When such a unit is
10 established it will reduce the number of patients
11 referred to Bristol from Wales. Further, a proportion
12 of the patients who could be referred to Bristol in fact
13 go to the Brompton, and it is likely that this referral
14 will continue."
15 So that rather answers your thoughts on that. It
16 is the reverse, really, is it not: that the die appears
17 to be cast?
18 A. There does remain a question mark over the centre's
19 long-term viability.
20 Q. That is what it says at the bottom.
21 A. Yes.
22 Q. So one has at this stage a centre which has never been
23 viable in the terms that the Supra Regional Services
24 Group would have set itself, save only as a prospect,
25 and indeed, one sees recognition of that, perhaps, does
0131
1 one, in the fourth from bottom line:
2 "Although officials found the Bristol centre to be
3 soundly based and giving every sign that the centre
4 would be a viable designated unit", in other words, one
5 might infer from that, if one is being a linguistic
6 purist, that it was not then a viable unit?
7 A. Yes.
8 Q. So if one takes that as the meaning, this centre had
9 never been viable within the terms the supra-regional
10 services group had set itself?
11 A. It certainly had not come up to the expectations that
12 the group had of it.
13 Q. How long would one wait?
14 A. I do not know. I mean, one would -- it was being
15 reviewed in 1986, then in 1989 by the College, again in
16 1992 by the College at the request of the group. What
17 sort of reviews were being undertaken by the Department
18 at that time, I do not know.
19 Q. You asked about the figures for operations, total
20 operations performed, and we have those, thanks to
21 Mr Maclean, at DOH 2/118. Can we have a look at that?
22 It is comparative numbers. The total of open and closed
23 cases for 1989 at Bristol, at 99, seventh in the list,
24 with only Guy's and Newcastle doing less?
25 A. Yes.
0132
1 Q. If we go down to the bottom of the page, older children
2 over 1 year, Bristol doing 151, and being the fourth
3 biggest, bigger than Leeds and Leicester, and Wessex,
4 Southampton.
5 A. Which I suspect is a consideration that would have been
6 and should have been taken into consideration.
7 Q. These numbers? Would that make all the difference?
8 A. No, not all the difference, but certainly some.
9 Q. Returning, if I may, to the page we were on, which is at
10 200, if we go over to 202, the options are set out.
11 This is, again, from the Secretariat, the same
12 supra-regional services paper. The option is to
13 continue to designate the service but to reduce the
14 number of centres within the designated service. It
15 records:
16 "The profession's advice is that about 7 centres
17 are required to cover the caseload of England and
18 Wales. The case for designation of the service in the
19 interests of patients has been strongly made and holds
20 good."
21 A. Yes.
22 Q. It talks about good evidence for the benefit of support,
23 designation allowing for concentration of the service in
24 a few centres. Then the last sentence, under
25 paragraph 10:
0133
1 "The de-designation of two centres and the
2 rejection of the Leicester bid would be necessary to
3 achieve this option."
4 That is looking to reduce 10 centres down to 7?
5 A. Yes.
6 Q. The top of the next page:
7 "11. The centres to be considered for
8 de-designation on the basis of the profession's advice
9 are: Harefield, Guy's (based on surgical activity),
10 Bristol and Newcastle.
11 "12. In general terms, all other factors being
12 equal, there is a strong case for Bristol and Newcastle
13 in terms of geographical spread."
14 So once again, one sees the reason for Bristol
15 being there at all is geography?
16 A. Yes.
17 Q. The second option, just to flag it up for the moment, is
18 paragraph 14, to de-designate the service as a whole.
19 That paper fell for consideration as I understand
20 it at the second meeting of the Supra Regional Services
21 Advisory Group in 1990?
22 A. Yes.
23 Q. If I can pick up the consequence of that, it is
24 DOH 2/173, this is the paper which is going to go to the
25 October meeting, the third meeting in the year:
0134
1 "At its last meeting, the Advisory Group reviewed
2 the provision of neonatal and infant cardiac surgery and
3 considered whether, in view of the number of units
4 undertaking this work, the service could continue to be
5 designated", SRS(90)6, which we have just looked at?
6 A. Yes.
7 Q. "Members were in favour of continued designation and
8 asked whether there were any units which might be
9 de-designated."
10 A. Yes.
11 Q. We see the suggestion is repeated.
12 A. Yes.
13 Q. The second paragraph:
14 "Members asked that more information be obtained
15 about the units at risk. Bristol and Newcastle were
16 considered to be essential on geographical grounds but
17 officials were asked to discuss with both units ways in
18 which the activity might be increased."
19 Pausing there, could you look at DOH 2/53 -- I am
20 sorry, it is the same reference, my apologies for that.
21 You took the view, did you not, at some stage,
22 that it was not essential?
23 A. I did, and I expressed that view formally in a letter
24 I wrote to Dr Halliday, I believe at some time towards
25 the end of 1991, or the beginning of 1992, when
0135
1 a further paper was shown to me which was going to come
2 to the February meeting of the Group in 1992, which --
3 Q. We have it at RCSE 2/81. Paragraph 2 of the letter.
4 This letter you will see is 8th January 1992, to
5 Dr Halliday. Paragraph 2:
6 "I do not believe that Bristol and Newcastle
7 should be considered 'essential on geographical
8 grounds'."
9 So going back to SRS(90)15 in our consideration,
10 there the Supra Regional Services Advisory Group,
11 through the Secretariat, were producing a paper in 1990
12 which was saying, "Well, the only claim that Bristol and
13 Newcastle have is geography".
14 You are saying, in January 1992, geography is not
15 an essential reason?
16 A. Correct.
17 Q. For how long had you held that view?
18 A. I do not know how carefully I had thought about it,
19 until I saw that it was being proposed as an "essential"
20 criteria, and I certainly never regarded any centre as
21 warranting supra-regional designation on purely
22 geographic grounds. The quality, the performance, all
23 sorts of other things had to come into consideration.
24 Q. So it was just geography; there would be no real reason
25 for the continued designation of the centre?
0136
1 A. Absolutely not, and it seemed to me here, on reading
2 this report, that it was suggesting that these two
3 units, Bristol and Newcastle, could not be de-designated
4 on purely geographical considerations, and I did not
5 share that view.
6 Q. I am not sure that you have answered, save by saying you
7 did not really think about it, for how long you had had
8 the view that they were not essential.
9 A. I genuinely do not know how long I held that view for.
10 Q. But the way you describe it, it is not a four-line
11 conversion from having had the view that geography was
12 of the essence to that geography was not; you make it
13 sound more like an appreciation that this is what was
14 being said and it was wrong?
15 A. I think my view probably throughout was that geography
16 was an important factor to be considered, but I do not
17 believe I ever thought it was essential.
18 Q. And the way you put it is that when you did think about
19 it in 1992 or shortly before you compiled the letter, in
20 your mind at any rate, you would be looking for
21 something more than geography as a reason for continued
22 designation?
23 A. Correct.
24 Q. Does it follow that, had you turned your mind to it, in
25 1988/89, and someone had said to you, "Well, what about
0137
1 Bristol, should it continue to be designated?" you would
2 have said "If the only reason is geography, no"?
3 A. Yes, I think that would have been my view.
4 Q. As you saw it at the start of 1989, was there in fact
5 any other reason for the continued designation of
6 Bristol then?
7 A. I think there was still a belief that I held, and
8 I suspect others within the specialty held, that there
9 was still the potential to develop the unit and to
10 a satisfactory throughput and quality.
11 Q. If anyone had asked you at the start of 1989, would you
12 have been able to point to any particular plans Bristol
13 had for the future that would have given you any
14 confidence that that potential might be realised?
15 A. No.
16 Q. So could one effectively draw a line at about 1989/early
17 1990, so far as you personally were concerned, in coming
18 to the conclusion, had you thought about it, that
19 Bristol really had no continued case for designation as
20 a unit part of the service?
21 A. I think I was impressed by the report of 1989, which had
22 had its questionnaire and looked at activity and looked
23 at mortality, considered the matter and said "There is
24 a problem here, but we think it is reasonable that
25 Bristol goes on, but annual mortality needs to be
0138
1 carefully monitored", and I accepted that view in 1989.
2 Q. Accepting that the question is hypothetical, at what
3 stage had you been asked, do you think you might first
4 have volunteered a different answer?
5 A. I think if it had been drawn to my attention that there
6 was a serious problem in Bristol with mortality, then
7 I would have wished to have seen that investigated
8 further.
9 Q. I am not sure that answers the question that I was
10 asking. If I can just go through the building-blocks to
11 it again, the proposition that I am asking for your
12 comment on is given that the only reason for the
13 designation of Bristol is geography or potential for
14 development -- those are the two reasons -- geography on
15 its own is not and never has been, in your view,
16 sufficient as a reason for designation?
17 A. Yes.
18 Q. At what stage following 1989, five years after first
19 designation, would you have come to the conclusion, do
20 you think, had you thought about it: "Enough is enough;
21 there is no proper reason for the continued designation
22 of Bristol"?
23 A. I really find that difficult to answer, because I would
24 have needed to have had evidence that there was no
25 further potential for trying to develop Bristol; that
0139
1 the problems were too deep-seated to warrant continued
2 designation, and I did not have that information. So
3 your question as to how long one would continued to see
4 a very small increase in the under 1 year old throughput
5 with a relatively high mortality, or a high mortality.
6 I imagine at the time of the 1989 report when the
7 mortality figures were presented for the first time,
8 that the response was to keep a very close eye on that
9 at annual intervals and if they had not improved, then
10 to have taken the appropriate action.
11 Q. That may seem to some to have the danger in it that it
12 amounts to continued designation, as it were, on "a wing
13 and a prayer"; that although there is no geographical
14 reason strong enough on its own, although there never
15 has been a sufficient track record of numbers, one can
16 hope that the service will develop even though there has
17 been no sufficient development up until now.
18 Would you care to comment on that way of looking
19 at the issue?
20 A. Yes. I think one could look at it in that way.
21 Q. Appreciating, of course, that I ask these questions in
22 retrospect, is that in your considered view an
23 appropriate way for the Supra Regional Services Advisory
24 Group to have looked at the issue of continued
25 designation?
0140
1 A. I find that a very difficult question to answer. There
2 were the two groups; I mean, Guy's as we pointed out was
3 very similar in terms of numbers on mortality. There
4 were other issues working there. Their overall numbers
5 were much lower. There were still three units in
6 London. There was Bristol which had these disturbingly
7 low numbers and high mortality, but the professional
8 opinion which had been sought from the Society was that
9 it was worth continuing, but monitoring the mortality
10 very carefully.
11 Q. If I can just take you up in the documents to the date
12 on which you expressed your view in January 1992 that
13 geography is not an essential reason for continued
14 designation, can I confirm with you that by that stage
15 at any rate you had come to the conclusion that "enough
16 is enough", as it were, and that really Bristol should
17 be de-designated?
18 A. No, I did not come to that conclusion until July 1992.
19 Q. So even although you were expressing the view, having
20 thought about it, in January 1992, that geography was
21 not essential --
22 A. Yes.
23 Q. -- you still had some hope that there might be
24 sufficient development?
25 A. Yes, I did. I had the feeling at the time that there
0141
1 was a desire to de-designate the service within the
2 Department, rightly or wrongly, I do not know, and some
3 of these arguments which were brought to us, like the
4 difficulty of de-designating units because they were
5 essential on geographical grounds, I saw them in the
6 light of creating difficulties which were not
7 necessarily there.
8 Q. The argument that they were essential on geographical
9 grounds might be thought to be protective of the units
10 concerned, in the sense that if they were not essential
11 they could be removed from the list of designated
12 centres, designated service would continue with the 6 or
13 7 units which the profession had advised was desirable,
14 and the general conditions for designation would be met
15 by the group?
16 A. Yes. They could be seen in that light, or it could be
17 seen in the light, as I have suggested, that they are so
18 important geographically that to de-designate them is
19 not on.
20 Q. A letter was written to you in 1991, the middle of 1991,
21 by Norman Halliday. We will look at it. It is DOH 3/1.
22 "The Advisory Group at its meeting yesterday
23 considered ways in which the cardiac surgical service
24 for neonates and infants might be rationalised in order
25 to ensure the continued designation of this service. It
0142
1 was suggested that it would be possible to define within
2 the existing designated service those complex cardiac
3 surgical procedures which should continue to be
4 designated and to identify the units where this service
5 could be effectively provided. If this were possible,
6 it would mean that some units presently designated under
7 the existing arrangements could then be de-designated,
8 thus bringing about a rationalisation of the service."
9 So the idea is, "let us find a candidate or two to
10 knock off the list". I am putting it crudely, but that
11 is the essence of it, is it not?
12 A. Correct.
13 Q. And the Advisory Group is asking you, as President of
14 the Royal College of Surgeons, to select a Working Group
15 to consider whether the execution should proceed of one
16 or two of the centres. Again, I am putting it
17 pejoratively.
18 A. There were various options, one of which was, as is
19 suggested in this first paragraph, of accrediting units
20 to do certain complex cardiac surgical procedures, as
21 opposed to designating that unit to do all open heart
22 surgery on the less than 1 year old.
23 Q. Yes. You reply to that on 19th September 1991, the
24 letter which we have at DOH 3/3, and you say in the
25 first sentence you have delayed replying because you
0143
1 wanted to think about the implications of the letter.
2 A. Yes.
3 Q. You deal with the question of designation for specific
4 categories of operation in the third paragraph, and you
5 go on to say you want to see the annual audit data from
6 each designated centre that presumably you have received
7 over the last few years and which you allude to in your
8 letter. You had not therefore seen any such data?
9 A. No, and I am suggesting that there be a meeting between
10 Dr Halliday and myself whereby we could discuss this.
11 Q. You then say this, in the last two paragraphs:
12 "It is my view that if supra-regional designation
13 is to continue, as I firmly believe it should, it should
14 be related to the annual workload of open and closed
15 operations performed on", and you underline, "neonates
16 and infants ..."
17 Leave aside the reason for that, but you are
18 saying it should be related to the numbers of the
19 under 1 operations performed?
20 A. Yes. I should have included mortality there as well.
21 I think it was well-understood from all the comments
22 I had made that I regarded that as been an important
23 part of the monitoring process.
24 Q. Workload, in one sense, was a surrogate for quality,
25 without having the data, was it not?
0144
1 A. In a way, yes.
2 Q. Because ultimately, if one had a unit which was actually
3 performing excellently, albeit only doing a few numbers,
4 there may be special reasons for saving it from
5 de-designation. One would not want to prejudice patient
6 care; the object is to improve patient care?
7 A. Yes.
8 Q. And workload, I imagine, is referred to because it is
9 the best available surrogate measure?
10 A. It is not a very good one; it is an index in this
11 particular field of surgery, yes.
12 Q. And you say:
13 "Finally, I believe that any such endeavour would
14 have to accept the possibility of some of the smaller or
15 less effective units ... being de-designated in order
16 that the good and responsible units could continue to
17 provide a valuable service."
18 You had in mind the units which actually provided
19 the service when you wrote this?
20 A. Yes.
21 Q. And indeed, you had taken the best part of two months to
22 consider your reply in order to work out the
23 implications in your own mind?
24 A. Yes.
25 Q. So when you spoke of the "smaller or less effective
0145
1 units", you had one or two or three in mind, did you?
2 A. Yes. I felt that if the evidence was there that they
3 were not up to the standard that one would expect or
4 wish, then they should be de-designated.
5 Q. That is not quite the question. The question is really
6 not so much whether as a matter of principle you are
7 saying to yourself, if something is not as good as
8 something else, then it should get the chop, but you are
9 actually thinking to yourself: I know these places. In
10 my mind, X and Y and Z should be considered at least as
11 candidates for de-designation, whereas A and B and C are
12 good and responsible units and should therefore survive?
13 A. Yes. I have to say that I genuinely did not appreciate
14 at the time that that letter was written what the
15 current mortality statistics were in the smaller units.
16 I knew that there were currently Guy's, Bristol,
17 Newcastle, Harefield, that had never achieved the sort
18 of numbers in this field of open heart surgery in the
19 less than 1 year olds that we would have liked, and --
20 Q. Again, I do not think it is addressing the question I am
21 asking, perhaps because it is late in the day, but I am
22 suggesting, asking for your comment, when you used the
23 expression "smaller or less effective units", you had in
24 mind particular units -- not that you knew their
25 mortality data, but you had in mind particular units.
0146
1 Did you?
2 A. I do not think I did.
3 Q. When you describe "smaller or less effective units", you
4 use it as a counterpoise in the sentence in the "good
5 and responsible units". You appear, in the paragraph,
6 to be equating the good and responsible units with the
7 larger ones?
8 A. The correlation is usually there, but not always.
9 I mean, there was a unit which -- I think it is
10 well-documented -- would have found it difficult to
11 provide its information to the Department of Health.
12 The Leeds unit for quite a long time had difficulty in
13 responding to the professional questionnaires and so
14 on. I think when I was thinking and referring to the
15 "responsible units", I was thinking of those units
16 which always provided the information that they were
17 required to for these sort of exercises promptly and
18 accurately.
19 Q. It is your letter, and I am asking you whether or not
20 you were balancing the smaller and less effective on one
21 side against the good and responsible on the other by
22 using the phrase as you did in this paragraph?
23 A. I was saying there that if the smaller and less
24 effective units, if it was proven that they existed,
25 then there should not be an issue with de-designating.
0147
1 That was the basis of my message to Dr Halliday.
2 Q. You told us that you had in mind, when you used the word
3 "responsible", the converse, the irresponsible unit at
4 Leeds which had not provided the data?
5 A. Yes.
6 Q. So you actually had in mind Leeds as not being
7 responsible?
8 A. Correct. A different level of assessment, but one that
9 I regarded as important with respect to ensuring the
10 discipline that the Group should expect from those who
11 they were funding.
12 Q. I appreciate the principle; it is the identity that I am
13 asking about. What did you have in mind in terms of
14 identity as being the "good units" to which you were
15 then referring?
16 A. Great Ormond Street and Birmingham, particularly;
17 Liverpool and Brompton, Southampton, still small but
18 good.
19 Q. It follows that you had in mind that the small and less
20 effective -- and I accept that it is all subject to
21 verification of your view by data et cetera -- were
22 others including Bristol and Newcastle?
23 A. Bristol, Newcastle Harefield and Guy's. Those were the
24 ones I think there were question marks over in my mind.
25 Q. And question marks not only of their size, which was
0148
1 well-known, but over their effectiveness as surgical
2 units?
3 A. Yes.
4 Q. Did you know Professor Henderson?
5 A. I did, yes. I have not seen him for many, many years,
6 but I have met him in the past.
7 Q. Had you seen him at all during the 1980s?
8 A. I do not believe so, no. I might have seen him at
9 a cardiac society meeting, I do not know.
10 Q. Had it come to you at all that he had been expressing
11 concerns in 1986 about the quality of surgery being
12 performed at Bristol?
13 A. Not at all.
14 MR LANGSTAFF: Sir Terence, I look at the time. It has come
15 to the stage I think that the shorthand writers will
16 very shortly at 5 o'clock I know appreciate a break.
17 I know they have indicated they will go on until that
18 time, so can I thank you for your evidence thus far, and
19 ask you to return, if you would, on Monday?
20 If it is possible, before you come back, for you
21 to record or have recorded by someone in typescript the
22 manuscript notes which you have brought with you, then
23 I shall be grateful. If it is not possible, it is not
24 possible?
25 SIR TERENCE ENGLISH: I can do that, but is it sufficient to
0149
1 provide them on Monday for distribution?
2 MR LANGSTAFF: Yes. Thank you.
3 I understand from the electronic communication
4 which is made possible to us that you, Chairman, have
5 some information denied me in respect of times for
6 Monday. May I simply say that for the balance of today,
7 I understand that from what I have been told, Mr Lissack
8 may have something to say to you, and may I pass the
9 matter over to you, sir?
10 THE CHAIRMAN: Thank you, Mr Langstaff. Sir Terence, it has
11 been a long day and we are very grateful to you for
12 coming. We will continue on Monday. I will announce
13 the times in a moment. But I feel it my obligation to
14 say that Mr Lissack has helpfully indicated through
15 Mr Langstaff, the Inquiry counsel, that he may -- and
16 only may -- make an application to the Panel to be
17 allowed to cross-examine. Whatever transpires in that,
18 I do feel it proper to say that you may well wish to
19 consider appearing with a legal representative.
20 Obviously, however, it is a matter entirely for you, but
21 I do say that from my position.
22 Mr Lissack? May I, while you are coming forward,
23 say that we are in, as it were, mid-evidence. What is
24 it exactly you want to help us with?
25 ADDRESS TO THE PANEL BY MR LISSACK:
0150
1 MR LISSACK: I would like to raise the issue of
2 cross-examination, but naturally I immediately recognise
3 that of course any application can only be made once the
4 evidence is concluded in accordance with the procedure
5 you outlined in October of last year.
6 But we think it right and helpful to the Inquiry
7 that we set out our stall now, because we, as you have
8 told the witness, suspect that we may well be applying
9 in due course for leave to cross-examine. Therefore, we
10 thought it appropriate that the witness may know and
11 more importantly, perhaps, you may know the basis upon
12 which we may be applying -- it takes but a moment to
13 explain -- so that no-one is taken by surprise by the
14 application we make in due course on Monday.
15 THE CHAIRMAN: Just bear with me a moment. (Pause whilst
16 Panel confers).
17 Mr Lissack, you will forgive me if -- we think it
18 may be a little premature for you to intervene at this
19 point, because we understand you may make an
20 application, and then we will listen to it. It may well
21 be wiser to address us when you have made your decision,
22 because, as you rightly say, any decision can only be
23 made once Mr Langstaff has finished and we therefore
24 know what needs to be explored further, if anything.
25 So we are not entirely sure that you can help us
0151
1 at this point, but that said, please go ahead.
2 MR LISSACK: Thank you very much indeed. May I preface what
3 I say about the issue of cross-examination, which I will
4 continue with, by saying two things.
5 Firstly, we have supplied in writing before today,
6 namely last night, to my learned friend Mr Langstaff,
7 a detailed analysis of the documents and issues which we
8 invite him to deal with, and which are of concern to
9 those who instruct us.
10 They break down to nine distinct and focused
11 areas, with the possibility of adding a tenth by reason
12 of material provided to us today. We have provided
13 references to all documents and so there is no question
14 of our going behind the clear direction that questioning
15 primarily should come from the Inquiry.
16 THE CHAIRMAN: Absolutely, and I understand that. We are
17 grateful for that. Let us not go into the details of
18 what it constitutes, because we will have to hear the
19 evidence as it comes out.
20 MR LISSACK: Absolutely. I will not weary you with that
21 now.
22 The second matter by way of preliminary I would
23 like to say is that we have carefully reflected on the
24 extent to which any submissions at this stage would be
25 of the slightest assistance to you, for the reasons
0152
1 which you of course all know and said, but we do think
2 after that reflection, that we should make these points,
3 and I do so at the express instructions of the Executive
4 Committee of the lay clients that I represent, and you
5 will notice that the Executive Committee are all here in
6 the Inquiry today.
7 On 27th October 1998, you, sir, said that after
8 examination by Counsel to the Inquiry, that, and I quote
9 from the transcript, "There will not normally be
10 cross-examination by others, except where demanded by
11 the requirements of fairness or the need to resolve
12 otherwise intractable disputes of fact to assist us [the
13 Inquiry] in fulfilling our terms of reference.
14 We submit that it is highly likely that in due
15 course that fairness of which you spoke will demand that
16 we be permitted to cross-examine this witness. Fairness
17 to our clients, fairness to our clients' dead and
18 injured children demands we be allowed to do so.
19 By way of background I say this: on 2nd April
20 1998, as you may or may not know -- I do not know
21 myself, you will find out -- the Secretary of State,
22 Mr Frank Dobson, told my clients in a meeting minuted by
23 his Department, and from that record I quote, that he
24 was "anxious to deliver an inquiry that would satisfy
25 the parents and their representatives if at all
0153
1 possible."
2 At the same meeting, sir, the Secretary of State
3 was told by my clients that they strongly suspected
4 a cover-up involving the Royal College of Surgeons of
5 England, the Department of Health and the Bristol Royal
6 Infirmary. That remains their view.
7 It is their understanding, which appears to be
8 supported by material produced not least by this
9 witness, that by July 1992, at the very latest, all
10 three of those bodies that I have mentioned knew at the
11 highest level that babies were dying at unprecedented
12 number at Bristol, yet nothing was done about it;
13 nothing for three years, sir, by which time at least
14 44 others had died.
15 On 10th June 1998, a further meeting was held
16 between the Department, setting up this Inquiry, and my
17 lay clients. The meeting was addressed by Sir Cecil
18 Clothier, who had then just chaired the inquiry into the
19 Beverley Allitt affair, and he at that meeting told my
20 clients, again minuted in a departmental note, that at
21 a Public Inquiry counsel would ask the question for the
22 parents. So my clients won the Inquiry they fought so
23 hard for, sir, and which you are burdened with
24 resolving.
25 Your terms of reference, we are conscious, require
0154
1 you to establish what action was taken both within and
2 outside the hospital to deal with concerns raised about
3 the surgery and to identify any failure to take
4 appropriate action promptly.
5 This witness, we submit, is central to the events
6 at Bristol, your terms of reference and many of the
7 issues you have helped identify in the Issues List
8 disseminated a long time ago. I identify but a handful
9 of them: A1, A7, A12, A13, C1, C2, D8 and so forth.
10 He was, as we know, President of the Royal College
11 of Surgeons of England and significant member of the
12 Supra Regional Advisory Group through a significant part
13 of the period with which you are concerned. We submit
14 that it is highly likely that a denial to our lay
15 clients for us to be permitted on their behalf to
16 cross-examine on issues central to who knew what and
17 when, who did what and when, and who died needlessly,
18 would amount to a gross denial of justice.
19 THE CHAIRMAN: You will forgive me, I do not want to
20 interrupt you greatly, but I understand entirely and
21 exactly the point you have made. You are now beginning
22 to, as it were, prejudge what will happen in terms of
23 whether there will be an application or whether in fact
24 Mr Langstaff will have explored these matters.
25 I entirely see your point. I accept the way you put it,
0155
1 but I would much rather wait and not prematurely judge
2 what we are all going to do.
3 You have my assurance, as does the witness, as
4 does everyone in the room, that we the Panel will seek
5 to strive to be fair to everyone and give everyone the
6 opportunity to tell their story, but let us not delude
7 ourselves that we yet know the full story or we are yet
8 in a position to reach conclusions. We want to hear,
9 and we will hear primarily through Mr Langstaff, but
10 also through others.
11 MR LISSACK: Sir, I do not want in any sense to cut across
12 the comforting and most helpful comments you have just
13 made. But may I just make two more points and then
14 desist, and they will not touch upon the territory that
15 caused your intervention, because I quite understand
16 it. You, sir, will understand equally that I have
17 instructions and there are times at which matters ought
18 to be raised, and you will understand what I mean by
19 that shorthand, I hope.
20 May I turn to the procedural position we are in
21 because this is a practical matter which if, whether
22 with this witness or another, application is made, which
23 we need to have resolved, please. I have tried, as you
24 know, repeatedly to persuade the Inquiry -- not you,
25 sir, in open session, but the Inquiry generally -- to
0156
1 establish a procedure to permit resolution of procedural
2 issues, but each time the Secretariat has rejected that
3 approach.
4 I have put in writing to you a framework to govern
5 applications for cross-examination. You have, for
6 reasons you have explained, rejected that, but suggested
7 so far as I am aware nothing in its place.
8 I have seen correspondence to and from the Inquiry
9 which states that you have been aware of our specific
10 detailed, reasoned and written concerns over
11 cross-examination since October of last year. Yet, in
12 the seven months that has passed since, there has not
13 been clarification or guidance until this morning, when
14 my learned friend Mr Langstaff was good enough to
15 indicate a procedure, but it was in the moments before
16 we sat and I am anxious to get it right.
17 Therefore, so as not to transgress against your
18 rules, I am keen, at some stage convenient to you, that
19 we are told, if anyone is to apply -- and I know this is
20 a concern of others than just me -- how we do it.
21 I must tell you this, sir: that the
22 dissatisfaction in my 600-strong body of lay clients is
23 growing at an alarming rate; one of the reasons why I am
24 mentioning this to you now.
25 But may I finish with this note. So that no-one
0157
1 misunderstands, Mr Trusted, Mr Skelton and I would like
2 to pay tribute to the Counsel to the Inquiry. We have
3 had unfaltering cooperation and assistance from
4 Mr Langstaff, Miss Grey and Mr Maclean and my clients
5 have no criticism in the context of what I say here of
6 them at all. They, and I, for that matter, fully
7 understand the difficult job that Counsel to the Inquiry
8 has. All our clients ask, sir, is that we be allowed to
9 do our job too. Thank you very much indeed for
10 listening.
11 THE CHAIRMAN: Yes, I hear what you say and of course
12 criticisms or unhappinesses are crosses that we, the
13 Panel, must bear. There will be occasions when we will
14 no doubt make each and everybody unhappy as we proceed.
15 That is in the nature of things.
16 Mr Lissack, I would remind you that we made it
17 clear from the outset that this is not a court. We are
18 not judges. We are not going to follow a procedure
19 which you and others may be familiar with, but in our
20 view and our estimation, has no real role here. In
21 other words, we are not going to follow an adversarial
22 process.
23 That said, let no-one be in any doubt that if
24 tough things have to be asked or tough things have to be
25 said, they will be asked and they will be said. Let
0158
1 no-one be in any doubt that the role of legal
2 representatives is redundant; far from it. It is just
3 different.
4 As Lord Howe once said in his criticism of the
5 Scott Inquiry, that the Scott Inquiry was the first time
6 that lawyers were seen and not heard. We do not endorse
7 that particular approach, but we do say that we would
8 largely want to hear the evidence through counsel for
9 the very reason that our procedure is inquisitorial.
10 We are grateful to you for your help and we would
11 ask you, in turn, to help us to explain our position,
12 our role, our procedure, our obligation, and our
13 determination to serve the public interest and not just
14 any particular interest, to those whom you in turn
15 advise. Thank you very much indeed.
16 MR LISSACK: May I say, I am extremely grateful to you for
17 what you have just said. It will be of enormous
18 assistance to those who read and hear the outcome of
19 today's proceedings. That alone gives cause to think
20 I made the right decision in addressing you, and I am
21 very grateful to you for what you have told us.
22 May I assure you that, long before today, I have
23 told my Executive Committee, professional and lay
24 clients en masse at public meetings and so forth,
25 exactly the difference between a court and an inquiry.
0159
1 I have told them the procedure. They know it; they
2 understand it.
3 You will understand equally their sense of pain
4 and frustration and the fact that when it comes to the
5 part of the evidence that first appears to be crucial,
6 their concerns may be heightened.
7 But enough is said. I have detained you long
8 enough and I am enormously grateful to you for listening
9 to what I have had to say with such good grace. Thank
10 you.
11 THE CHAIRMAN: Thank you, Mr Lissack.
12 Sir Terence, forgive us while we had that
13 conversation. I return to my thanks to you. We are in
14 your debt, particularly because it has been a long day.
15 We reconvene on Monday. I am telling you this and
16 telling people here out of the normal fashion of
17 Mr Langstaff doing it, because he does not know and
18 I do, that we will see Professor Baum at 10 o'clock; we
19 are bringing the proceedings slightly forward from 10.30
20 to 10, so I make that clear and emphasize to all who are
21 listening. If you could be available, I think it is
22 lawyer-speak to say, "not before 11.30, but at around
23 11.30", would that be possible?
24 SIR TERENCE ENGLISH: Yes, Chairman.
25 THE CHAIRMAN: May I say, we are very deeply in your debt
0160
1 for your agreeing to that. So it is 10 o'clock on
2 Monday and we will then also be able to take advantage
3 of Sir Terence's evidence at 11.30. Thank you.
4 MR LANGSTAFF: Thank you, sir.
5 (5.11 pm)
6 (Adjourned until 10 o'clock on Monday, 17th May 1999)
7
8
9
10 I N D E X
11
12
13 SIR TERENCE ENGLISH (Sworn)
14
15 Examined by MR LANGSTAFF ..................... 2
16 ADDRESS TO THE PANEL BY MR LISSACK ........... 150
17
18
19
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Published by the Bristol Royal Infirmary Inquiry, July 2001
© Crown Copyright 2001