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Daily transcripts
Hearing summary
17TH MARCH 1999
Today the Inquiry heard from three witnesses: Mr Philip A Wagstaff, Mr Michael J
Parsons and Mr John S McLorinan.
Mr Wagstaff related to the Inquiry the circumstances surrounding the birth, diagnosis
of a heart murmur and treatment, of his daughter Amy, born at Heavitree Hospital in Exeter
in June 991. An operation carried out on Amy by Mr Wisheart at the Bristol Royal Infirmary
in March 1993 was successful and Mr Wagstaff felt that the treatment and care Amy received
was thoroughly caring and that full explanations of everything that was involved were
given. Mr Wagstaff identified two areas of concern. Firstly, that conversations between
hospital staff took place at inappropriate times and places on the ward. Secondly that a
mixed ITU ward was inappropriate for children recovering from major heart surgery.
Mr Parsons told the Inquiry about his and wife’s experiences leading up to and
following the death of his daughter Mia, who died during an operation performed by Mr
James Wisheart in May 1993. Mia was born with Downs Syndrome in May 1992 at Treliske
Hospital in Cornwall. Later it was confirmed that Mia had a heart condition and would need
surgery. Mr Parsons expressed many concerns relating to the death of his daughter and the
subsequent treatment of himself and his wife both by staff from the Bristol Royal
Infirmary and later by the solicitors acting on behalf of the GMC Inquiry, who failed to
notify Mr and Mrs parsons that Mia’s case was investigated by that Inquiry.
Mr McLorinan, whose son Joseph (Joe) was born in November 1989 at Southmead Hospital,
Bristol, gave evidence to the Inquiry this afternoon. Immediately following Joe’s
birth it became apparent that Joseph had Downs Syndrome and also that he had a heart
defect. There was further problem in relation to his intestines, identified as
Hirschsprungs Disease. Mr McLorinan told the Inquiry about Joe’s care from various
doctors and hospitals in Bristol culminating in a successful AVSD repair operation
undertaken by Mr Wisheart in February 1991. During his evidence Mr McLorinan highlighted
the inconvenience of the Split Site i.e. care and treatment shared between the Bristol
Children’s Hospital and the Bristol Royal Infirmary. He concluded that Joe as the
patient, but also himself and his family, had been very well cared for.
|
FULL TRANSCRIPT
1 Day 2, 17th March 1999
2 MR LANGSTAFF: Chairman, today we have to hear from three
3 witnesses, I am sorry about the microphone boom you are
4 getting at the moment. The first will be Mr Wagstaff
5 and Eleanor Grey will be asking him questions. Then we
6 hope to have a quarter of an hour break. Mr Parsons,
7 followed by a further quarter of an hour break, and then
8 Mr McLorinan to finish the day's proceedings. Before
9 Mr Langstaff comes to give his account of what happened,
10 as I think I indicated yesterday, Mr Lissack has an
11 application to make to you.
12 MR LISSACK: Thank you, sir.
13 APPLICATION BY MR LISSACK
14 MR LISSACK: The application I make is for leave to make an
15 oral statement at this stage on behalf of the families
16 I represent.
17 THE CHAIRMAN: Yes. Thank you. Reminding you that
18 ordinarily, it is only in exceptional circumstances that
19 such submissions are to be presented orally rather than
20 in writing. Obviously we want to move on and hear as
21 many witnesses and what they have to tell us, but we are
22 just beginning and therefore I am prepared in these
23 circumstances to make an exception. I trust your
24 submission will assist the Inquiry in particular
25 following Mrs Clarke's evidence yesterday, and is of
0001
1 a nature such that it ought to be made orally rather
2 than in writing.
3 MR LISSACK: I hope it fulfills those tests too. So you may
4 know I submitted this in writing to counsel to the
5 Inquiry last week as forming the text of what I would
6 wish to say, so they understand exactly the position and
7 they know what is going to be said, and I hope it will
8 be of assistance to you.
9 The death or injury of a child in any circumstance
10 is, as has already been recognised, a private tragedy
11 for the family concerned. That so many died or were
12 injured at the Bristol Royal Infirmary has led directly
13 to this Inquiry being set up and turned hundreds of
14 private tragedies into a matter of public concern.
15 The families that we represent, sir, fully
16 understand that today is neither the time nor the place
17 for accusation or recrimination, or prejudging the
18 issues or the conclusions that will be reached on them.
19 This is a time for measured and quiet reflection on the
20 months which lie ahead.
21 In this Inquiry we fully recognise that there are
22 no sides, no causes, and no room for hidden agendas.
23 The task ahead and the subject matter are far too
24 important for that.
25 Our clients also appreciate the weight of the
0002
1 burden on this Inquiry. It is charged with establishing
2 what happened and why, and vitally to make
3 recommendations as to how the National Health Service
4 can best ensure that the circumstances in which the BRI,
5 its staff and above all its patients found themselves,
6 does not happen again.
7 At this early stage of the Inquiry, those who we
8 represent have every hope and confidence that the
9 Inquiry will discharge its onerous task and that its
10 investigations will be full, fair, fearless and
11 constructive. Our clients are determined that both
12 through us and directly from them in their oral and
13 written evidence, you will have all the assistance that
14 they can give you in your search for the truth and your
15 recommendations as to the future.
16 We hope that we can assist the Inquiry in three
17 key areas. Firstly, to establish whether anything went
18 wrong with the medical and surgical management of
19 specific cases, and if so, what. This will include
20 considering, on a child by child basis, the medical and
21 surgical procedures, problems and complications. How
22 the surgical procedures to be undertaken and the risks
23 of failure were presented to the parents; how the
24 medical staff dealt with the parents after the operation
25 failed, including the sufficiency of any counselling
0003
1 provided, the emotional and practical support that was
2 in place and the extent to which the failure of the
3 operation was explained.
4 Secondly, we hope we can assist by informing the
5 answer to the question, was there institutional failure
6 at the BRI? This will include an examination of the
7 treatment of Dr Bolsin's concerns; the speed of reaction
8 to the expressions of concern that there were; audit;
9 and the highly sensitive issue of the wholesale
10 systematic retention of hearts and other organs removed
11 post-mortem, and the related issues of knowledge and
12 consent and an understanding of why the extent of the
13 retention of organs was only revealed last month.
14 Thirdly, we hope we can assist this Inquiry to
15 ensure that you are best placed to make recommendations
16 as to the future of paediatric cardiac care in this
17 country.
18 Our clients, sir, are desperately concerned that
19 from each of the individual calamities should come some
20 general good. The future health service for children
21 should offer only the very best in medical and surgical
22 care, with doctors and nurses fully and openly
23 accountable and with the families of sick children kept
24 fully informed and properly reassured at times of their
25 greatest need. Nothing can bring back our clients' dead
0004
1 children. Nothing can make the injured children whom
2 our clients care for better. We are not here for
3 retribution, but we respectfully submit that we can be
4 of substantial constructive assistance to this Inquiry
5 which we know wishes and intends to contribute to the
6 future shape of the Health Service in this country.
7 Sir, there can be no memorial more fitting for the
8 children of the families for which we act than for each
9 parent to be able to say "At least they and we did not
10 suffer in vain".
11 That is all that I propose to say.
12 THE CHAIRMAN: Mr Lissack, thank you very much indeed.
13 MR LISSACK: Sir, may I, whilst I am here, move to
14 a different matter. It is not a party matter. It
15 concerns counsel generally instructed on behalf of
16 parties who appear before you to assist the Inquiry,
17 separately represented. It concerns an aspect of
18 procedure. May I seek a clarification on the point, so
19 we may not transgress against the rules that are in
20 place.
21 On 27th October 1998, you outlined the procedures
22 to be followed by the Inquiry. In that outline, you
23 dealt, amongst other matters, with the issue of
24 re-examination.
25 Yesterday I asked of Mrs Clarke seven questions on
0005
1 one issue, which were not offensive against the rules
2 you had set in place in the sense of being repetition.
3 They were all relevant. They were all important to
4 Mrs Clarke. Of course I discussed them with her before
5 she gave her evidence. They were all informative for
6 the Inquiry on the main issues of concern to the
7 families I represent. They constituted fresh material
8 not elicited by Mr Langstaff in his examination on
9 behalf of the Inquiry and they took less than three
10 minutes. For that I was rebuked with these words:
11 "You will forgive me if I say perhaps those
12 questions could have come through Mr Langstaff, and
13 could do in the future."
14 What we on behalf of the families -- and I am
15 supported in this request for clarification by other
16 counsel, who will be concerned by this issue as much as
17 we are -- what we need to have clarified is the scope
18 and extent of re-examination which you will permit. If
19 it is to be confined to matters raised in statements
20 previously submitted in accordance with the procedure
21 outlined, we need to know. Here, for example,
22 Mrs Clarke signed her witness statement on 18th February
23 of 1999. That was before she knew about the retention
24 issue so far as her daughter's heart was concerned. She
25 had no idea about it at all. The issue of retention,
0006
1 however, is well known to the Inquiry, and I know, from
2 my discussions -- helpful ones at that -- with
3 Mr Langstaff and his team, that it is an important issue
4 to the Inquiry and that is something that those whom
5 I represent are pleased to hear.
6 Plainly counsel for the Inquiry chose not to ask
7 about it, probably because it was not contained within
8 the statement and therefore had not done the round of
9 testing by those who are criticised by the evidence.
10 That I did ask about it, in our submission, was
11 perfectly proper and not open to criticism. Of course
12 it is a truism to say that any questions posed by any
13 party in these proceedings in the next 9 months could
14 come through Counsel to the Inquiry. Of course, they
15 could. That, if I may say so, with the greatest of
16 respect, is not the point. We are troubled to
17 understand better what the Inquiry had in mind when we
18 look at page 15 of the transcript for 27th October
19 1998. May I read into the record, please, what was said
20 then by you, sir, about re-examination:
21 "This questioning [that is to say the oral
22 questioning by Counsel to the Inquiry] will be
23 supplemented by questions from me and by members of the
24 panel. At the end of this questioning, the witness's
25 legal representative will have an opportunity to put
0007
1 questions to the witness by way of re-examination. The
2 purpose of this is to clarify any area which the legal
3 representative feels may have been left unclear and to
4 enable the legal representative to ensure that the
5 witness has given a proper account of him or herself.
6 It is not intended as an opportunity merely to repeat
7 that which has already been put to the Inquiry, whether
8 orally or in formal written statement. For that reason,
9 we would expect it to be rare for any such
10 re-examination, if taken advantage of, to exceed 15 or
11 20 minutes."
12 What we respectfully seek your guidance on,
13 please, sir, is this: does that ruling as to the scope
14 and extent of re-examination still stand? If yes, why
15 did my re-examination offend in the way that it did
16 yesterday? If no, what is the position, please?
17 Ultimately the question which concerns all of us -- some
18 of us here at considerable public expense, which we are
19 conscious of -- ultimately the question may be, what is
20 the role of counsel here who are not Counsel to the
21 Inquiry?
22 THE CHAIRMAN: Thank you, Mr Lissack. You refer to what
23 I said in October. I take the view and took the view,
24 that what you did last evening did not comply with that;
25 it was to introduce fresh material; it was not to refer
0008
1 to what had been pursued. I think it rather misses the
2 point that we have sought to make clear from the outset
3 that there are ample opportunities to submit additional
4 statements, had the matter warranted an additional
5 formal written statement it could have been submitted.
6 Alternatively, on the following day, a written
7 submission could be made.
8 There is a lot to do here today and for the next
9 9 months and there are a lot of witnesses to hear from.
10 What I would propose to do -- I meant no discourtesy
11 yesterday -- I have to remember that we have many people
12 who have waited a long time to give evidence and we want
13 to hear them. Some of them have come a long way. Under
14 those circumstances, what I propose to do is to let you
15 have a response to what you have just said in writing at
16 the close of proceedings today.
17 MR LISSACK: That will be very helpful to all of us, to
18 ensure that we do not offend in future. Thank you very
19 much.
20 THE CHAIRMAN: Miss Grey?
21 MISS GREY: Could I invite Mr Wagstaff to give evidence,
22 please? Mr Wagstaff, I think that the first thing that
23 will happen is that you will be invited to take the
24 oath, so if you would like to stand for that, please.
25 MR PHILIP ANTHONY HENRY WAGSTAFF (Sworn):
0009
1 Examined by MISS GREY:
2 Q. Would you just like to sit down again? Mr Wagstaff,
3 I will be asking you questions, but everyone in the room
4 is interested in your answers, and of course
5 particularly the panel, so do not feel that you always
6 have to face me in giving replies to them.
7 Could you just tell us your full name, please?
8 A. Philip Anthony Henry Wagstaff.
9 Q. I think you may need to speak up a little bit, or
10 perhaps draw the microphone closer to you.
11 You are a Customs & Excise officer; is that right?
12 A. Yes, that is right.
13 Q. Are you married?
14 A. Yes.
15 Q. Do you have a daughter called Amy?
16 A. That is right, yes.
17 Q. When was she born?
18 A. 30th June 1991.
19 Q. Where was she born, Mr Wagstaff?
20 A. At Heavitree Hospital in Exeter.
21 Q. Can I just check if you answer the next question you can
22 be heard. Was her birth normal?
23 A. Yes. Yes, it was.
24 Q. How soon after Amy's death did you discover that there
25 might be problems?
0010
1 A. It was about three days afterwards.
2 Q. What happened to alert you to that?
3 A. It was at a meeting, an examination by one of the
4 doctors at the hospital, and he told us that there was
5 a heart murmur that he could hear.
6 Q. So what did he do next, then?
7 A. He referred us to --
8 THE CHAIRMAN: I am sorry, Mr Wagstaff, it is simply
9 I cannot hear very well. So please, it is because I am
10 a little deaf, so I apologise for imposing on you, but
11 perhaps if you could speak just a little bit louder. It
12 is I, not you.
13 A. All right. He referred to us a paediatric clinic a few
14 weeks later.
15 MISS GREY: Where did that paediatric clinic take place?
16 A. At Heavitree Hospital in Exeter.
17 Q. Had your wife been discharged home with Amy by then, or
18 not?
19 A. Yes.
20 Q. So you went back into a clinic at Heavitree Hospital;
21 is that right?
22 A. Yes, that is right.
23 Q. Who did you see there? Do you know his or her name?
24 A. I cannot recall, I am afraid.
25 Q. What sort of doctor was it?
0011
1 A. He was a paediatric -- I am not sure if he was
2 a consultant, but a paediatric doctor.
3 Q. A paediatric specialist or doctor?
4 A. Yes.
5 Q. What did he tell you about Amy's condition?
6 A. He said that there was a loud heart murmur and that
7 sometimes it was a hole that would close on its own,
8 given time.
9 Q. So he told you, did he, that the heart murmur indicated
10 that there was a hole in the heart; is that right?
11 A. Yes, that is right.
12 Q. But that sometimes it might close of its own accord?
13 A. Yes.
14 Q. Did he say anything about whether that was likely in
15 this case, or not?
16 A. He said in most cases they close on their own, so he
17 said to give it a few months and then they would
18 re-examine her.
19 Q. Did he suggest that it was a problem or anything to be
20 concerned about?
21 A. No, not at that stage. The impression we got was that
22 in most cases they did close on their own.
23 Q. So what action was to be taken, then?
24 A. He gave us another appointment for a few months later,
25 to come back.
0012
1 Q. So in the meantime, before you went back for that next
2 appointment, were there any unusual features about how
3 Amy was developing or growing?
4 A. I mean, the growth was normal, but she would go blue
5 around the lips and her sort of fingertips we would
6 notice, but apart from that, she was developing
7 normally.
8 Q. So you went back to see the paediatrician again after
9 about three months; is that right?
10 A. Yes, that is right.
11 Q. That was at the same hospital, then?
12 A. Yes.
13 Q. At that stage, did he suggest that things were getting
14 better or had remained the same?
15 A. He said that really it had remained the same, that the
16 murmur was still there, and so he decided to refer us to
17 a cardiologist.
18 Q. A cardiologist from where?
19 A. From Bristol.
20 Q. Did he give a name to that person?
21 A. Yes, Dr Martin.
22 Q. Was there any discussion of whether or not it would be
23 appropriate to go to Bristol or another centre?
24 A. No, no other centre was mentioned.
25 Q. So when did you then next see Dr Martin?
0013
1 A. I believe it was early in 1992 that we had an
2 appointment at the Wonford hospital in Exeter.
3 Q. So Dr Martin came to the Exeter hospital; is that right,
4 and you had a meeting with him there?
5 A. Yes.
6 Q. What sort of examination did he perform?
7 A. He took x-rays and listened to Amy's heart. I believe
8 he did some ECG checks as well at that stage. He then
9 told us that he suspected this condition called Fallot's
10 tetralogy, but to be sure, he had to do an echogram
11 which he did in the afternoon. We went back.
12 Q. So after the echocardiogram had been taken in the
13 afternoon, what were you then told about Amy's
14 condition?
15 A. He confirmed that it was Fallot's tetralogy, and he
16 explained the various problems, what was wrong with the
17 heart.
18 Q. Can you explain to us what you were told about those
19 problems?
20 A. He said that one of the tubes in the heart was too
21 narrow; it was restricting the blood flow, and that also
22 there were two holes in the heart as well, and because
23 of the holes, one of the chambers was too big.
24 Q. What did he tell you would happen if nothing was done?
25 A. He said that by the age of about 10, Amy would die if it
0014
1 was not treated.
2 Q. So did he imply therefore that it would get worse?
3 A. Yes, that is right. He said she would get progressively
4 worse and be able to do less and less activity, so, yes,
5 it needed sorting out.
6 Q. How serious a problem did you get the impression that
7 this was?
8 A. The impression, I mean, obviously with it being the
9 heart, we were very frightened because it was obviously
10 life-threatening, and we got the impression that if it
11 was not treated it would be the end of her life, in
12 effect.
13 Q. Can I just clear up one small matter then about the date
14 when you saw Dr Martin? Could we have a look on my
15 screen at medical record 2056/65?
16 Can we enlarge it so we have the date at the top,
17 initially?
18 If we can just put that up for a moment, you
19 should be able to see now on your screen a date on that
20 letter, and an address to Dr Sullivan, a paediatric
21 Registrar at the Wonford. If we could now have a look
22 at the body of the letter, and in particular
23 paragraph 1, you see there that there is a record of
24 a discussion that has been held about Amy, who is noted
25 to have a cardiac murmur at two days, and then the
0015
1 history of the examination is set out. If we can scroll
2 down a little, please, we see there that the echo
3 cardiograph examination has confirmed a diagnosis of
4 tetralogy of Fallot. If we would look at the next page,
5 page 66, we see there Dr Martin has written that letter,
6 and there is the advice that was given to you at that
7 meeting; is that right?
8 A. Yes.
9 Q. So he had explained to you that it was a serious defect,
10 as I think you told the Inquiry?
11 A. Yes.
12 Q. And that surgical correction was required, usually
13 between 1 and 2 years of age?
14 A. Yes, that is right.
15 Q. Can you tell us a little more about what the surgery
16 that was suggested consisted of?
17 A. He drew a diagram for us, and it would involve widening
18 the narrow tube in the heart, and closing the holes.
19 Q. Closing the holes between the two chambers in the heart?
20 A. Yes, that is right. He said that by doing that, the
21 enlarged chamber would then return to normal size.
22 Q. Did he explain to you whether that was a risky operation
23 or what its risks were?
24 A. I cannot honestly recall at that stage being told what
25 the risks were, but obviously we were aware, being heart
0016
1 surgery, there was a risk.
2 Q. Do you think you might have had a discussion with him at
3 that stage, or is it that you did not have a discussion
4 with him?
5 A. I cannot remember, to be quite honest, no.
6 Q. Did Dr Martin say where he thought the surgery should be
7 carried out?
8 A. Yes, he said at Bristol, it would be performed.
9 Q. Was there any discussion as to where the best place for
10 that surgery would be?
11 A. No, never the places were mentioned, just she would be
12 referred to Bristol.
13 Q. Did you ask any questions about whether Bristol would be
14 a suitable centre, or whether there were other centres?
15 A. No. We just accepted that Bristol would be the place.
16 Q. Can I just ask you why, Mr Wagstaff, you accepted that
17 from Dr Martin?
18 A. I mean, living down in Exeter, we knew that Exeter and
19 Plymouth, there was no cardiac surgery undertaken, so we
20 assumed that Bristol was the centre for the south west.
21 Q. So you have seen Dr Martin in his clinic. He has
22 diagnosed tetralogy of Fallot and that all took place in
23 November of 1991. Did you have follow-up meetings with
24 Dr Martin?
25 A. Yes, I believe we had two or three meetings the
0017
1 following year, check-ups.
2 Q. How was Amy during that interim period?
3 A. The blueness seemed to get gradually worse, and as she
4 began to move around more and crawl, you could see that
5 she was getting out of breath with crawling around and
6 exercise.
7 Q. The surgery you mentioned would have taken place at the
8 Bristol Royal Infirmary?
9 A. Yes.
10 Q. Did you go straight to that hospital or did you have an
11 initial encounter with the Children's Hospital?
12 A. Yes, she had a catheterisation at the Children's
13 Hospital before she went to the Royal Infirmary.
14 Q. Could we look briefly at 2056/17. If you can just
15 enlarge the top paragraph, can we see that, please? Do
16 you see there the headline there, Mr Wagstaff, "The
17 Royal Hospital for Sick Children, cardiac
18 catheterisation laboratory", and the date there is given
19 as 16th March 1992?
20 A. Right, yes.
21 Q. Would that be when Amy was admitted for the cardiac
22 catheterisation procedure?
23 A. Yes.
24 Q. If we could scroll down through that page, at the bottom
25 we see there the provisional diagnosis of tetralogy of
0018
1 Fallot, and if we can read it, "looks suitable for first
2 correction."
3 So Amy was admitted to the Children's Hospital for
4 a cardiac catheterisation --
5 THE CHAIRMAN: We think it is "primary correction".
6 MISS GREY: Can you tell us, was she admitted overnight or
7 how long did she spend there?
8 A. We think it was over two nights she was in. We went on
9 the Sunday and it was done on the Monday, but we believe
10 we came home on the Tuesday.
11 Q. What sort of a ward was she admitted to?
12 A. It was like the baby word. I am not sure if it was
13 a specific heart ward, but it was a baby ward at the
14 Children's Hospital.
15 Q. What sort of environment was the Children's Hospital for
16 a baby such as Amy?
17 A. My impression of it was that it was a very cramped,
18 closed-in environment. Although there were areas to
19 play, it just seemed very sort of built-up and closed
20 in, but we were only there sort of the two days.
21 Q. How were the nursing staff? Were they helpful to you?
22 A. Yes, they kept us informed of what was happening and
23 what procedures were going on.
24 Q. From that point of view, did Dr Martin explain what was
25 happening in the cardiac catheterisation?
0019
1 A. Yes, that is right, yes. We saw him before Amy went
2 down. He explained what he was going to do.
3 Q. Can you tell us what he told you?
4 A. He said that he put a small tube into the vein, in Amy's
5 groin, and that would be fed up into the heart, where he
6 could sort of take measurements of -- like the size of
7 the holes and the restriction of the tube.
8 Q. Was there any discussion of the risks attached to that
9 procedure?
10 A. He mentioned that there was a very small risk of death,
11 but that it was negligible, really, just the risk of
12 introducing a foreign body into the heart.
13 Q. So did you feel that the procedure had been properly
14 explained to you?
15 A. Yes. Yes, I did.
16 Q. Were you asked to sign a consent form?
17 A. Yes.
18 Q. Did you do so?
19 A. Either myself or my wife, one of us, yes.
20 Q. So Amy had a procedure in March 1992, the cardiac
21 catheterisation procedure. On the basis of that, was
22 there any further discussion of what should happen to
23 her next?
24 A. Dr Martin saw us again and really just confirmed the
25 diagnosis of Fallot's, and said that he would be
0020
1 referring her to a surgeon.
2 Q. Did he give you the name of the surgeon?
3 A. Yes, Mr Wisheart.
4 Q. So when did you first meet Mr Wisheart?
5 A. I believe it was later in 1992, at Exeter, Wonford
6 Hospital.
7 Q. If we could have a look, perhaps, at medical record
8 2056/51, if we just look at first of all the signature
9 at the bottom, that is Mr Wisheart's signature, and at
10 the top the date. Have you seen both of those,
11 Mr Wagstaff?
12 A. Yes.
13 Q. Does that give you the date of the clinic in Exeter that
14 you attended to see Mr Wisheart?
15 A. Yes, that is right.
16 Q. Can you tell us first of all what examination was
17 conducted by Mr Wisheart?
18 A. I believe he took sort of x-rays of the heart and
19 I think, again, sort of ECG examination.
20 Q. What then did he tell you about the nature of her
21 problem?
22 A. He really confirmed what Dr Martin had told us, the
23 Fallot's tetralogy and the -- really what was wrong with
24 the heart, the two holes and the narrow tube.
25 Q. So what did he explain that he wanted to do in order to
0021
1 correct or improve the position?
2 A. He said that he would operate on Amy and that the
3 operation entailed sort of widening the narrow tube and
4 stitching the holes, closing the holes.
5 Q. Was there any discussions of the risks attached to that
6 surgery?
7 A. I believe, I am not sure at that time, that there was
8 a 95 per cent success rate.
9 Q. What did you understand that statistic to be based on?
10 A. I assumed other similar operations that were being
11 carried out before.
12 Q. Are there similar operations carried out at Bristol?
13 A. Yes. Yes, I suppose yes.
14 Q. At Bristol or nationally?
15 A. I suppose the impression we got was at Bristol, sort of
16 similar operations he had performed at Bristol.
17 Q. You say similar operations that he had performed. What
18 do you mean by that?
19 A. I suppose we took it as his sort of success rates for
20 the operation. We did not really give it much thought.
21 Q. Can you actually remember what questions you asked him
22 about it?
23 A. No. I mean, I think we really said "What are her sort
24 of chances of survival?" and his answer was that there
25 was a 95 per cent success rate.
0022
1 Q. Did he discuss any other difficulties that might be
2 linked to the operation?
3 A. I do not believe so, not at that stage, not at the first
4 appointment.
5 Q. But you were implying that there were later discussions
6 that were more detailed?
7 A. Yes, that is right.
8 Q. We will pass on to those later. How did Mr Wisheart
9 strike you?
10 A. He came across as very caring. He took time with us to
11 explain the problem, what he was going to do, and also
12 came across as knowing what he was doing, what he was
13 talking about.
14 Q. How easy was it to discuss with him firstly the nature
15 of the procedure that Amy was to undergo?
16 A. We found it very easy. He was very approachable. We
17 could ask him questions as to what he was going to do,
18 and, yes, I mean, he was always open to any questions,
19 really.
20 Q. Were you able to discuss your fears about the procedure
21 with him in any way?
22 A. Yes, yes. I mean, obviously he was aware that as
23 parents it was a very frightening time, so you could see
24 that he took time to explain everything to us.
25 Q. So how did you feel after that surgery had been planned
0023
1 for Amy after that visit?
2 A. I was obviously very frightened by it, but sort of
3 confident in his ability.
4 Q. So that is May 1992. Were there any follow-up meetings
5 or encounters between and you Mr Wisheart before Amy was
6 admitted for surgery?
7 A. I cannot recall, to be quite honest. I believe we saw
8 Dr Martin again in the interim.
9 Q. So there were follow-up clinics for Amy, but involving
10 the cardiologist?
11 A. Yes.
12 Q. So when was Amy finally admitted to the Bristol Royal
13 Infirmary?
14 A. In March 1993.
15 Q. I think 28th March perhaps would have been the date she
16 was admitted to surgery?
17 A. Yes, that is right.
18 Q. When she was admitted, where exactly was she admitted
19 to, Mr Wagstaff?
20 A. To the heart ward, 5B, I think it was.
21 Q. What sort of a ward was that?
22 A. It was a mixed ward, adults and children, but she was in
23 a children's room, a separate room on its own.
24 Q. All on her own?
25 A. No, a room of -- I think there were four or six beds in
0024
1 it, all children.
2 Q. On her first day of admission, who was Amy seen by?
3 A. We were seen initially by the nursing staff, and then
4 later in the day we saw the anaesthetist who was to
5 carry out the operation.
6 Q. What did he explain to you?
7 A. He really explained the anaesthetic procedure: that she
8 would be taken down -- well, she would be given a drink,
9 a sort of pre-med drink early in morning, and then taken
10 down to the operating theatre.
11 Q. Was there any discussion of risks or side effects of the
12 anaesthetic?
13 A. I cannot remember, to be quite honest.
14 Q. Did you see Mr Wisheart at any time before the operation
15 took place?
16 A. Yes, we saw him on that day, on the Friday as well.
17 Q. What happened then?
18 A. He came to Amy's bed and again, he ran through what the
19 operation entailed and what he was going to do. He also
20 mentioned that the narrow tube possibly, if it was too
21 narrow, he may have to put a patch into it, to widen it,
22 and he explained, really going over what he had been
23 through before, that he was going to close the holes and
24 that sort of thing.
25 Q. Did he say how long the operation would take?
0025
1 A. I believe he said about three or four hours.
2 Q. Was there any discussion of the risks attached to the
3 operation?
4 A. Yes. I mean, again, we discussed the, I suppose the
5 mortality rate, the 95 per cent figure. He also
6 mentioned the risks concerned with going on to the
7 bypass machine, that it could affect other organs in the
8 body.
9 Q. Such as?
10 A. Such as the kidneys and the brain may be affected
11 because the blood was being pumped through a machine
12 rather than by the heart.
13 Q. Were you told anything about how likely any possible
14 brain damage might be?
15 A. No. I mean -- no, he did not put a figure on it.
16 Q. What about the possibility of any future surgery, was
17 that discussed?
18 A. Yes. He said that sometimes with this problem, as the
19 children grow up into to their teens, they may need
20 further correction. I am not sure why. Perhaps they
21 grow out of the changes that are being made to the
22 heart.
23 Q. What about the question of any drugs that Amy might
24 need? Was that discussed?
25 A. I cannot remember at that stage, actually. But we knew
0026
1 she would be on drugs after the operation, sort of
2 intensive care, there would be heart drugs and such.
3 Q. Were you shown around the ITU itself that Amy would be
4 taken back to?
5 A. Yes. Yes, we were shown around there. I believe that
6 was the night before her operation.
7 Q. Who performed that exercise?
8 A. It was Helen Strachan, the cardiac liaison sister.
9 Q. What did you understand her role was?
10 A. I understood she was actually employed by the Children's
11 Heart Circle, which is a charity and her role really was
12 to sort of help parents through the ordeal, really, to
13 liaise with the parents and the hospital staff.
14 Q. Was that a helpful exercise, being shown around the ITU?
15 A. Yes, it was.
16 Q. Why?
17 A. I think it really prepared us for the shock of seeing
18 Amy with all the tubes and pipes and everything coming
19 out of her, so at least we knew what to expect the
20 following day.
21 Q. So the following day was when the operation took place?
22 A. Yes.
23 Q. What happened?
24 A. Amy was taken down early in the morning, about half 7,
25 8 o'clock, and we went down with her to the anaesthetic
0027
1 room, and left her there for the operation.
2 Q. Where had you been staying that night?
3 A. The previous night, my wife actually stayed in the ward
4 with Amy, by her bedside and I think I was in a hostel
5 up the road.
6 Q. So whilst the operation took place, what did you do?
7 A. We actually came into Bristol, looked around the shops
8 for a couple of hours, just really to try and take our
9 minds off it.
10 Q. Was that your own idea?
11 A. I think Helen Strachan sort of suggested that we go
12 somewhere and sort of at least go for a walk, to try
13 and -- not just sit in hospital, waiting, as such.
14 Q. So how did you find out when the operation had finished?
15 A. Well, we went back to the hospital, I believe about half
16 past 10, and we saw Helen Strachan there, and really,
17 she sat with us in the -- there was like a common room
18 there. She sat with us there, really waiting for news,
19 how the operation had gone. I believe she phoned down
20 to theatre a couple of times just to find out how it was
21 going.
22 Q. So when did you first see Amy?
23 A. I believe it was about sort of lunchtime, we saw her in
24 ITU.
25 Q. Was that where she had been the previous night?
0028
1 A. No. She had been on the ward previously.
2 Q. What did you observe about the ITU to which Amy was
3 admitted?
4 A. I mean, really, the impression of the ITU was that I was
5 surprised that it was a mixed adult and children's unit
6 as such. When we saw it the night before, I believe
7 there was only one or two children in there, and the
8 rest of the beds were adults who had undergone heart
9 surgery. And obviously the adults were very poorly, and
10 we found it distressing seeing all the other patients in
11 there. It just struck us as unusual, that they were all
12 mixed in at that stage.
13 Q. When you say it was unusual, had you any other previous
14 experience of these ITU wards?
15 A. No, we had not. I mean, we had walked past the one at
16 the Children's Hospital, which is obviously just
17 children, but no, we had never been in one before.
18 Q. Did the staff make any attempt to try and separate out
19 children from adults in the ITU?
20 A. Yes, I mean, the children were in one corner as such.
21 I think the first four sort of bays you came to were
22 children's, and then the rest of it was adults', but
23 there was no screen or anything; it was a sort of open
24 ward.
25 Q. There was no fixed screen. Were there any other forms
0029
1 of screens?
2 A. I mean, there were temporary screens that they brought
3 around if they were carrying out procedures or anything
4 on any of the patients.
5 Q. So you went in to see Amy. How did she look?
6 A. Very frightening, really, all the tubes and wires coming
7 out of her. Although we had seen the other children the
8 night before, it was still shocking to see your own
9 child like that.
10 Q. So was anyone explaining to you what was happening at
11 that stage?
12 A. Yes, when we initially went in, I believe the
13 anaesthetist was still there. He explained things like
14 the ventilator, how that was keeping her breathing. The
15 nurses were there explaining what was going on, and it
16 was about 10 minutes after that Mr Wisheart then came up
17 as well.
18 Q. So what did Mr Wisheart tell you?
19 A. He said that the operation had gone as planned. He said
20 that he had had to -- because the tube in the heart was
21 very narrow, he had had to put a patch into it. The
22 only cause for concern was that her blood pressure was
23 low at that stage, so they were keeping an eye on it.
24 Q. Did he do anything to investigate her condition further?
25 A. Yes. They took sort of x-rays at that stage, and they
0030
1 were really just keeping an eye on the blood pressure
2 with the machines.
3 Q. May I just pause for a moment and ask for the medical
4 record of 22nd May to be removed from the screens? It
5 is unnecessary.
6 THE CHAIRMAN: It is off.
7 MISS GREY: It is off, I am sorry. So he mentioned
8 a potential problem of low blood pressure?
9 A. Yes.
10 Q. Did he explain what was causing it?
11 A. No, I think initially they were not sure what the cause
12 of the problem was, and during the afternoon they did
13 various tests. My wife actually reminded me they did
14 one of these echograms on her heart as well, during the
15 afternoon.
16 Q. When you say that your wife reminded you, what do you
17 mean by that?
18 A. When I did the statement, as I said, there had only been
19 x-rays done, but when she read it, she reminded me that
20 they actually did an echogram as well.
21 Q. When you say the statement, that is the statement you
22 put in to the Inquiry; is that right?
23 A. Yes, that is right.
24 Q. So some initial investigations of the problem of low
25 blood pressure. Was any further explanation offered to
0031
1 you during that day?
2 A. We saw Mr Wisheart a couple of times during the day, and
3 as the day went on, I believe it came clear to him that
4 it was a blood clot on the heart that was causing the
5 low blood pressure.
6 Q. Was that something you had heard mention of before?
7 A. No, he had not mentioned it before the operation. He
8 said it was one of the things that sometimes happens in
9 surgery.
10 Q. If there was a blood clot, what danger did this pose?
11 A. He said that with the low blood pressure, if it was not
12 sorted out, then potentially she could die.
13 Q. So what was the action that he could take to improve the
14 situation?
15 A. He said he was going to reopen her chest and remove the
16 blood clot.
17 Q. Was that a decision taken at that stage?
18 A. Yes.
19 Q. Can you just tell us what investigation took place or
20 was happening throughout that day to keep an eye on
21 Amy's condition?
22 A. I mean, there were various sort of x-rays taken and the
23 nursing staff were there all the time. I believe she
24 was on like sort of 15-minute checks with the doctor as
25 well. He would come and check her. So, yes, they were
0032
1 all keeping a close eye on her.
2 Q. How often did you see Mr Wisheart that day?
3 A. I believe he came up -- I believe he was operating in
4 the afternoon as well, and he was there initially, and
5 then he came up later in the afternoon again to see what
6 was happening.
7 Q. You mentioned he took the decision that the chest needed
8 to be opened?
9 A. Yes.
10 Q. Was there a discussion of when that step should take
11 place?
12 A. Really, as soon as possible, to alleviate the problem,
13 really to raise the blood pressure.
14 Q. Did Mr Wisheart have any discussion with any of the
15 theatre staff or nurses about the need for this
16 procedure?
17 A. Yes. There seemed to be a few discussions. One of the
18 theatre staff came up -- by this time it was getting
19 probably 5, 6 o'clock in the evening. One of the
20 theatre staff came up and seemed to be sort of
21 pressurising him for an answer. They wanted to know
22 whether he was going to operate or not, and then later
23 on we overheard a phone call where he was phoning the
24 theatre --
25 Q. Can I just stop you there. You say one of the theatre
0033
1 staff came up. What was she saying to Mr Wisheart?
2 A. It really seemed to be that they were wanting to go
3 home, basically, that they wanted -- well, they wanted
4 an answer, whether they were going to operate or whether
5 they could go home. They seemed to be fed up standing
6 there waiting for his decision.
7 Q. What was Mr Wisheart's reaction?
8 A. Really, that they would have to wait; that the
9 impression we got was that he was looking out for Amy's
10 best interests, and he wanted more time to consider what
11 the problem was. They seemed to be pressurising him to
12 come to a decision.
13 Q. What was your reaction to that?
14 A. In hindsight it was quite upsetting. At the time,
15 because of the problems Amy had, it seemed quite minor,
16 I suppose, because you are worried about what is
17 happening to her. In hindsight, perhaps, it should not
18 have taken place on the ward.
19 Q. You then mentioned a telephone call that happened
20 a little later?
21 A. That is right, yes. We overheard Mr Wisheart phoning
22 the theatre staff, really trying to arrange for them to
23 come up to ITU to perform the second operation, and he
24 seemed to get quite heated on the phone, that they were
25 perhaps delaying it.
0034
1 Q. Can you just explain that? Was there a problem because
2 they were delaying it, or Mr Wisheart was delaying it?
3 A. I think at that stage he wanted them up there virtually
4 straightaway, and perhaps they were a bit slow in coming
5 up, I think. The expression that I can remember is that
6 he wanted them up now, that he was getting quite heated
7 that it needed to be done at that stage.
8 Q. You say that he wanted them up now. Where was this
9 opening of the chest going to take place?
10 A. In the ITU.
11 Q. In the ITU itself?
12 A. Yes.
13 Q. Was there any discussion with you of why that should
14 take place in the ITU?
15 A. I cannot remember, to be honest. I think it was purely
16 a matter of, they had located where the blood clot was,
17 and it was sitting on top of her heart, so they really
18 wanted to open up and get it out as soon as possible, so
19 I think at that stage they thought it was a fairly
20 straightforward procedure and it could be done in ITU
21 quicker than taking her back down to theatre.
22 Q. When you say "they thought", can you remember any
23 specific conversations about this or is this
24 a generalised deduction?
25 A. This is the impression that we got.
0035
1 Q. So the operation to reopen the chest was to take place
2 in ITU. How was that managed from the point of view of
3 the ward as a whole?
4 A. They screened off Amy's bed with the mobile screens, and
5 really sort of brought in sort of the lights and things
6 and performed it there. We were sort of taken out of
7 the ward into a side room, but other than that, it was
8 just screened off.
9 Q. Who actually performed it?
10 A. Mr Wisheart.
11 Q. So you were taken off into a side room?
12 A. Yes.
13 Q. You did not actually see this happening?
14 A. No.
15 Q. And was anyone with you whilst that took place?
16 A. I believe Helen Strachan came with us again and sat with
17 us.
18 Q. How long did it take?
19 A. It was only a matter of about half an hour, I think, we
20 were away from the ward.
21 Q. What was Helen Strachan's role when she was sitting with
22 you?
23 A. I think really to sort of reassure us, and I think,
24 again, she acted as a go-between, finding out what was
25 happening.
0036
1 Q. So how did you find out what had happened?
2 A. I think Helen took us back on to the ITU and Mr Wisheart
3 was still there. He explained that the blood clot had
4 been taken off.
5 Q. You describe this as if it all happened on the same day
6 as Amy was operated on. Can I look at medical file
7 237/46?
8 If we look at the top of that page, the date there
9 is given as 30th March 1993. Is that the date of Amy's
10 operation?
11 A. Yes. Yes, I believe so.
12 Q. Could we just have a quick look at page 47? At the top
13 there is given the date of 29th March and written
14 against it is "total correction of tetralogy of Fallot."
15 That would appear to be the note of the operation
16 itself, or a record of it?
17 A. Right.
18 Q. If we scroll down the page, again you are seeing there
19 further investigations also taking place on the same
20 date?
21 A. Yes.
22 Q. From that, would it perhaps be the case that your
23 recollection of the date of the operation was incorrect,
24 it was in fact the 29th?
25 A. Yes. Yes, it may well be, yes.
0037
1 Q. If we can just go back to page 46, that is the following
2 day. At the bottom of the page, the second half, we see
3 there, at 6 o'clock, chest opened and a clot [and its
4 size is given] is removed from the left side of the
5 pericardium?
6 A. Right.
7 Q. So it may be that all of this took place across two
8 days; is that right?
9 A. Yes, looking at that. Yes, perhaps my memory is not ...
10 Q. It is your memory that it took place over a shorter
11 space of time?
12 A. Yes. My memory is that it was the same day, but
13 possibly it was not.
14 Q. In any event, the operation of the reopening of the
15 chest is taking place on the ITU and Mr Wisheart came to
16 you afterwards and explained how it went?
17 A. Yes, that is right.
18 Q. Did he explain whether or not Amy was out of the woods,
19 or were there still further problems?
20 A. No. He said that the blood pressure at that stage was
21 still low, so they were still keeping an eye on it. He
22 mentioned that because of the low blood pressure, there
23 was a possible risk to her kidneys because they were not
24 getting enough blood. So again, they were keeping an
25 eye on that.
0038
1 Q. What did Mr Wisheart then do?
2 A. Over the next couple of days they were just keeping an
3 eye on it, really. The blood pressure began to improve
4 over the next few days. But the kidneys, there appeared
5 to be something wrong with them and the urine output was
6 not what it should be.
7 Q. What had to be done as a result of that?
8 A. She had the dialysis, the peritoneal dialysis.
9 Q. What was Mr Wisheart's role in this at this stage?
10 A. He came in, really, every day to see her, probably
11 a couple of times a day, and he was really overseeing
12 her sort of care and what was happening to her.
13 Q. Did he have any interaction with you and your wife?
14 A. Yes. I mean, whenever he came to see Amy, he sort of
15 explained what was going on and what was going to happen
16 next. So, yes, he had discussions with us.
17 Q. What impression did you make of him?
18 A. Just really that he was a very caring person, that he
19 understood what we had been through and he seemed to go
20 out of his way to explain what was going on.
21 Q. What about the nursing staff, then? What was their role
22 in Amy's care at this stage?
23 A. She had a dedicated nurse with her really all the time,
24 on a rota basis, and again, they were very sort of
25 caring and supportive of us as parents, and -- yes,
0039
1 I mean, really, we were just there -- obviously the main
2 purpose was to look after Amy, but also supporting us.
3 Q. What did they do to support you, Mr Wagstaff?
4 A. Really explaining what was going on with all the
5 machines, and when alarms went off, obviously, it was
6 a sort of worry, but they also encouraged us to do
7 things like washing her mouth out and things like that,
8 so we could actually sort of contribute to her care,
9 really.
10 Q. Did you feel they succeeded in that?
11 A. Yes, yes. We felt sort of very happy with the nursing
12 care.
13 Q. How did Amy proceed, then? What happened to her after
14 the clot had been removed and she had been on peritoneal
15 dialysis?
16 A. She was on dialysis for a few days. Her temperature was
17 high as well, which again caused concern, so she had ice
18 packs put around her. She was in ITU I believe for
19 about 10 days after the operation, and then she was
20 returned on to the children's ward at the Royal
21 Infirmary.
22 Q. How did the atmosphere or the environment at the
23 children's ward in the Royal Infirmary compare with that
24 in the ITU?
25 A. Vastly different, really. It was a dedicated children's
0040
1 room and with children's nurses. Obviously further
2 recovery, once she was out of ITU, she seemed to recover
3 more quickly on the ward.
4 Q. When you say they were children's nurses, were they
5 different staff from those who had been involved in ITU,
6 or not?
7 A. Yes. From what I recall, there were dedicated ITU
8 nurses and dedicated children's nurses.
9 Q. So Amy was moved initially out of ITU into the
10 children's side ward?
11 A. Yes.
12 Q. Then finally what happened to her?
13 A. Then, after, I think just about over a week or so, she
14 was then released from hospital.
15 Q. She went home?
16 A. Yes, that is right.
17 Q. So that was about how long after the operation in total?
18 A. I believe it was about three weeks in total.
19 Q. How soon did she recover?
20 A. Very quickly, really. When we first saw her in ITU, you
21 could immediately see the difference in her skin colour
22 from obviously the increased blood flow, and, yes, she
23 really went from strength to strength after that.
24 Q. Did she need any follow-up after she had left the Royal
25 Infirmary?
0041
1 A. We came back for a check-up back at the Children's
2 Hospital, I believe it was two or three weeks later, and
3 saw a Registrar, I believe.
4 Q. Was she being managed on any drugs for any period of
5 time?
6 A. Yes. She was on various drugs to start with. I believe
7 mainly related to sort of fluids, getting rid of fluid,
8 really.
9 Q. For how long was that necessary?
10 A. I think -- I cannot remember, to be honest.
11 Q. A matter of months, weeks or years?
12 A. Months I would say, probably 6 months.
13 Q. If we could just look at medical record 237/5, if you
14 could just show the whole page, please, down from --
15 first of all the date at the top. Do you have that on
16 your screen now?
17 A. Yes.
18 Q. That is a letter dated 23rd August from Dr Joffe?
19 A. Right.
20 Q. That is the record of a follow-up visit, is it not?
21 A. Yes, that is right.
22 Q. That you have obviously had with Amy?
23 A. Yes.
24 Q. It says there that "Amy attended today for review.
25 Parents are delighted with her progress."
0042
1 A. Yes.
2 Q. Is that a statement you would agree with?
3 A. Yes, certainly.
4 Q. What is the current situation today, Mr Wagstaff?
5 A. Amy is very well. She is fine. We are now on a sort of
6 check every 18 months, so, I mean, as far as her heart
7 is concerned, she seems to be progressing very well.
8 Q. Is there any suggestion that there may be any need for
9 any future operation?
10 A. No, the indications are at the moment that there should
11 be no further surgery required.
12 MISS GREY: Thank you very much, Mr Wagstaff. Could you
13 wait there in case the panel have any questions?
14 Examined by THE PANEL:
15 MRS HOWARD: Mr Wagstaff, there was some confusion with
16 regard to the operation day and your recollection of
17 when the procedure to open Amy's heart took place. Can
18 you recall whether it could have been over the midnight
19 period?
20 A. Yes. I mean, I can remember, really, Mr Wisheart being
21 there until about sort of 1 o'clock in the morning, but
22 from my memory, the opening of the chest was early
23 evening, 7/8ish. My recollection is that it was the
24 same day.
25 MRS HOWARD: Thank you very much.
0043
1 THE CHAIRMAN: Is there any re-examination?
2 MR SHARP: Sir, I do not think so, thank you very much.
3 THE CHAIRMAN: I am grateful.
4 MISS GREY: Thank you very much. You are free to go.
5 THE CHAIRMAN: Thank you very much for coming. We are very
6 grateful. As I said to other witnesses, this need not
7 be the last time you get in touch with us. If there is
8 anything else you think will help, please let us know
9 and we will take it.
10 MISS GREY: Chairman, may I suggest we pause for some 20
11 minutes? There are some matters that need to be dealt
12 with and this is a natural break.
13 THE CHAIRMAN: I think that is a good idea. Let us break
14 now and reconvene at 11, when we will hear Mr Parsons.
15 Thank you.
16 (10.39 am)
17 (A short break).
18 (11.10 am)
19 MR LANGSTAFF: Sir, thank you for the additional time.
20 There were matters which Mr Parsons wanted to discuss
21 with me in advance, and as I indicated yesterday,
22 I would hope that Counsel to the Inquiry are always
23 going to be accessible to witnesses. I know that you
24 are concerned that breaks should be kept to 15 minutes
25 strictly, but you will understand the reason why on this
0044
1 occasion there was an exception to that rule.
2 THE CHAIRMAN: Yes, of course.
3 MR LANGSTAFF: May we please have Mr Parsons?
4 Mr Parsons, I think you wish to affirm. We have
5 developed the practice of standing to take the oath so
6 if you would not mind standing, the oath will be
7 administered.
8 MICHAEL JOHN PARSONS (Affirmed):
9 Examined by MR LANGSTAFF:
10 Q. Mr Parsons, you are Michael John Parsons and you would
11 like to be known as Mick?
12 A. Yes, please.
13 Q. Before you came here today, I think you had understood
14 that your role would be to read out the statement which
15 you had provided in writing to the Inquiry?
16 A. Yes, sir.
17 Q. Can we please have on the screen witness 10/1.
18 If you look to your right, is that in fact your
19 statement?
20 A. Yes, it is, sir.
21 Q. Do I understand it right: that you spent a considerable
22 time psyching yourself up to read out your statement so
23 people knew what you had to say?
24 A. Yes, indeed. I was under the impression that I would be
25 coming here to read my statement.
0045
1 Q. So what we shall do, Mr Parsons, is, we will go through
2 your statement paragraph by paragraph, and you will
3 understand that I will ask you questions about it?
4 A. Yes, sir.
5 Q. I think you pointed out that you may be in the same
6 position as a number of parents who may not have been
7 here yesterday and who themselves may think that what
8 they will have to do when they come to give evidence is
9 come and read through their statement, rather than be
10 asked questions about it?
11 A. Yes, that is correct, yes.
12 Q. So it will help them if I mention at this stage that, of
13 course the usual procedure will be that they will be
14 asked questions based on the statement, and if I make it
15 clear that everyone's formal statement is already part
16 of the evidence and it will be published when everyone
17 gives evidence.
18 A. Yes, I am satisfied. Now seeing the system, you know,
19 the fact that the statement is on the screens, I find
20 that that is reasonably satisfactory.
21 Q. As you can see, everything has a witness number, all the
22 witnesses who give evidence have their witness
23 statements scanned in, and they will, of course, be
24 available to the press.
25 Let me ask you this: I think you first contacted
0046
1 Tozers solicitors, who act for the Action Group, in July
2 of last year?
3 A. That is right.
4 Q. That was after the GMC hearings, was it?
5 A. It was after the Panorama programme.
6 Q. So that is what made you contact them?
7 A. It was the Panorama programme which made us aware of the
8 situation.
9 Q. Really, in many ways you are your own man. You do not
10 feel particularly comfortable being part of one group or
11 another?
12 A. No, sir. You could say my feelings are split both ways,
13 within the middle of both the groups, and I am my own
14 man as such and I have not joined any group. I have
15 been independent.
16 Q. Can we do what I promised and go through your
17 statement.
18 If we look at your first paragraph, it sets out
19 your age and you are married to Pauline Parsons. She is
20 "Leen", hence Pauline?
21 A. Yes.
22 Q. You have two children and you had a child Mia, who was
23 born on 19th May?
24 A. Just to correct, it is actually Mia, old English for
25 May.
0047
1 Q. Mia was born in Treliske in May. If we scroll down to
2 paragraph 2, we can read that. You ran a kite shop in
3 Penzance. Would you rather I read it out?
4 A. It is fine as it is.
5 Q. You had no fixed address and you lived with Leen in
6 a van which was parked in the car park of Cape Cornwall
7 Golf Club and you then found accommodation over a shop
8 in Swansea which you opened as a new kite shop and you
9 went into business making kites for traction, and you
10 still do this full-time from your new address near
11 Carmarthen?
12 A. Yes.
13 Q. You have moved around a bit?
14 A. Yes.
15 Q. We may see that is a matter of importance when we come
16 to deal with what happened at the GMC. One of your
17 complaints is that the GMC did not make contact with
18 you, although they used the details of Mia's life and
19 death?
20 A. That is right, yes.
21 Q. Then paragraph 3, you deal with Leen's pregnancy, and
22 Mia's birth. You say you were with her during the birth
23 and left about 3 o'clock in the morning. You slept in
24 the van and drove back to work. You left the delivery
25 ward and believed everything was satisfactory. At some
0048
1 time in the afternoon after the birth, you received
2 a telephone call at the shop. That would be 12 or so
3 hours later, would it?
4 A. It was about 1 o'clock in the afternoon, just after
5 dinner.
6 Q. You were asked to return to the hospital because there
7 was a problem. You were told they were not prepared to
8 tell you over the telephone what that problem was, but
9 they wanted you to go back to the hospital. You asked
10 if it was a medical emergency. You were told it was
11 not, but you should go back as soon as possible. You
12 did, and you went to Leen. She was in a private room
13 and you waited with her for the consultant.
14 Paragraph 4, the bottom of the first page. We can
15 see there what you say is that on arrival he came into
16 the room and asked if you were aware that there was
17 anything wrong with your daughter. Leen said that you
18 thought there was something wrong, you did not know what
19 it was and the doctor replied that she had Down's
20 syndrome. You set out your reaction. If we go to the
21 next page, please, let us expand it so people can see.
22 You had not been prepared for that result. It took some
23 time to come to terms with it.
24 Over the next three months or so, you learned to
25 cope with Mia. During that period, she had a number of
0049
1 tests to check her condition.
2 Shall I read out what you say, and then ask you
3 questions about it?
4 A. As you wish.
5 Q. Would you prefer me to do the reading, or would you
6 rather do it yourself?
7 A. To actually read the statement, as I requested? I would
8 obviously prefer that, yes, please.
9 Q. Would you like to do it?
10 A. Shall we go from 5?
11 Q. If you take us down to the end of paragraph 4, and then
12 stop there, because I may have some questions to ask you
13 about it.
14 A. Okay:
15 "Over the next 3 months or so, we learned to cope
16 with Mia. During this period she had a number of tests
17 to check her condition. I believe it was some 3 months
18 after her birth that Dr Jordan confirmed to us that Mia
19 had a heart problem and would require surgery. Although
20 we were not told at the time, I can see from a letter
21 dated 12th February 1993, sent by Graham Taylor, the
22 consultant paediatrician at the Royal Cornwall Hospital,
23 Treliske, to Dr Agarwal, consultant paediatrician at
24 Singleton Hospital, Swansea, that the doctors were aware
25 from a very early age that Mia had a heart murmur. This
0050
1 was something that was not disclosed to us until
2 Dr Jordan confirmed it at some three to four months of
3 age".
4 Q. You must have seen Dr Jordan some time in the August for
5 the first time, Mia having been born in the May?
6 A. That is right, sir, yes.
7 Q. So some time between the end of paragraph 4 and the
8 beginning of paragraph 5, which takes you on to
9 25th October, you had seen Dr Jordan?
10 A. That is right.
11 Q. I think you may have seen him on at least two occasions
12 before the events which you go on to talk about on 25th
13 October?
14 A. It would have been twice, yes, sir.
15 Q. One of those occasions -- may we move from the statement
16 and have a look on my screen, please, medical report
17 1792/37.
18 This is a letter which I think you have seen
19 subsequently?
20 A. Yes, once we got her medical records.
21 Q. Of course you did not see it at the time?
22 A. No, sir.
23 Q. I can tell you that it is from Dr Jordan. He talks
24 about reviewing Mia again in the paediatric cardiology
25 clinic, the first word. He describes what he found.
0051
1 If we go down to the second paragraph, please:
2 "I have discussed things further with the parents
3 and we have agreed that Mia should come up to Bristol
4 for cardiac catheterisation, probably in about a month
5 from now [which would be October]?
6 A. Yes.
7 Q. Or possibly November, "-- so we can assess her with
8 a view to surgical treatment.
9 "They are aware that there is a small risk
10 attached to the investigation and a fairly substantial
11 risk is likely to be attached to the operative repair of
12 the defect. However, they realise that if we do not
13 offer surgery the problem is going to remain with Mia
14 and result in a considerable reduction in her life
15 expectation, both in terms of years of life and also
16 quality of life, so that the balance is generally fairly
17 strongly in favour of advising operation."
18 How accurate a summary of your discussions with
19 Dr Jordan is that, do you think?
20 A. Well, you know, as parents, we were obviously very
21 concerned. In our memory, we were not told the actual
22 specifics of what was wrong with her and it was
23 actually -- we were concentrating more on the cardiac
24 catheterisation to find out what was wrong with her. So
25 when we left our meeting, we were not aware, actually,
0052
1 what was wrong with her. We were aware that she was
2 going to go for the catheterisation to find out what was
3 wrong with her.
4 Q. Tests to find out what was wrong?
5 A. That is right.
6 Q. Is it right, you understood there was a small risk
7 attached to the investigation?
8 A. That is right. We were not aware as to what operation
9 would be required after the catheterisation, in the
10 aspect of where it states, you know, "a substantial risk
11 is likely to be attached to operative repair". We
12 understand all operations have a risk, but we were
13 certainly not aware of any specific operation or any
14 specific risk.
15 Q. At that time?
16 A. At that time.
17 Q. Can we go back to your statement, witness 10/2,
18 paragraph 5?
19 You had better read it.
20 A. "After confirmation of the defect, we attended the
21 Bristol Royal Infirmary on 25th October 1992 with a view
22 to Mia having a cardiac catheterisation. At this time
23 Leen and I were still unaware of the exact details of
24 Mia's medical condition. On our arrival at Bristol, Mia
25 was placed in a ward and we were given accommodation
0053
1 next to that ward. On the following morning,
2 26th October, Mia was given a sweet pre-med sedative and
3 within 15 or 20 minutes she was soundly asleep. Shortly
4 after that, she was taken to the theatre and we
5 accompanied her until she was handed over to the
6 anaesthetist. We had been seen the day before by
7 a doctor whose name I cannot remember. We were given
8 a very thorough explanation of what they intended to do
9 to Mia. We were told that they were to do a cardiac
10 catheterisation which would allow them to measure the
11 pressures in Mia's heart and the blood flow and that
12 that would give them a much better idea as to the actual
13 condition that she was suffering from. We were told
14 that there was a risk associated with the operation,
15 although we were informed that it was a very low risk.
16 "After delivering Mia to the theatre, Leen and
17 I left the hospital and walked around Bristol for
18 a couple of hours. I do not know who suggested that we
19 should leave the hospital, but it was a suggestion that
20 we should go and use up our time like that rather than
21 hanging around worrying about what was going on. We
22 returned about two hours later to find Mia had already
23 been returned to the ward, and we were told that
24 everything had gone well. Mia stayed in the ward for
25 the rest of that day and we left in the evening and
0054
1 returned home. We had at that stage not been informed
2 what her condition was or what the results of the
3 catheterisation had shown.
4 "After the cardiac catheterisation, both Leen and
5 I realised that we were approaching decision time with
6 Mia. Although we were not aware of the actual heart
7 defect that she had, we both felt that some surgery was
8 going to be recommended. Nobody had explained the
9 surgery which could have been given, and we felt we were
10 in the dark. We therefore contacted the Bristol Heart
11 Group during the period between the catheterisation and
12 the visit to Mr Wisheart in January of 1993. As
13 a result of our contact, I obtained a book from the
14 Heart Group called 'Heart Children'. This book was
15 extremely informative, and I think I must have read it
16 20 or 30 times. I was keen to master all of the
17 possible problems that Mia might have."
18 Q. Pause there. You say nobody had explained the surgery
19 in the middle of that paragraph. After the
20 catheterisation, did Dr Jordan or anyone speak to you
21 about what they thought they found?
22 A. No, sir.
23 Q. When was it that you understood that Mia was suffering
24 from what we might call an AVSD?
25 A. When we went to see Dr Wisheart at the Bristol Royal
0055
1 Infirmary in January.
2 Q. So not until then?
3 A. No, not until then. We did not know the actual
4 condition, although we knew obviously she had a heart
5 problem, which was one of the reasons I read the whole
6 book and all the different types of problems, so I could
7 understand more fully. I mean, it is a long time ago,
8 and when you are in a situation such as that, when you
9 see doctors, it is well possible that in all honesty
10 they might have told us things, but you are in shock and
11 it does go in one ear and out the other as such, but we
12 certainly were not aware as to her heart condition, the
13 specific heart condition, until we saw Mr Wisheart, and
14 then he told us what it was.
15 Q. You knew she had gone in for tests. That was the
16 purpose of the catheterisation, the operation with the
17 small risk?
18 A. That is right.
19 Q. So some people might think it would be natural to ask
20 the doctor, "Well, what did you find?" or "When will
21 I find out?"
22 A. After the catheterisation, we, you know, basically, we
23 left that evening. We were given no results.
24 Q. Did you have a GP?
25 A. Yes, sir, in --
0056
1 Q. Did you contact him or her to say, "Well, what is Mia's
2 condition, have you heard?"
3 A. No, I did not. Again, it was a long time ago and my
4 wife and I have talked about this. I think it was
5 possible that we were waiting for the meeting, or the
6 expectation was to find the result when we met
7 Mr Wisheart.
8 Q. But in the meantime, you were so concerned about it that
9 you read a book which had all sorts of conditions in it,
10 without knowing which one was Mia's?
11 A. Without knowing which one, which is why I had to read
12 them all, because I did not know which specific one it
13 was, or even if it was actually in the book.
14 Q. So I think what you say, just to sum that up, is that
15 nothing prevented you asking, but you assumed you would
16 be told in due course in January when you met the --
17 A. We knew as a fact we were going there to find out.
18 Q. That leads us on to paragraph 7 in your statement. You
19 might like to read that out to us?
20 A. "On 20th January 1993 we went to the Bristol Royal
21 Infirmary and were met by a carer and shown to
22 Mr Wisheart's post-operative day surgery. We were also
23 shown the ward where Mia would be staying, the family
24 room, the kitchen and finally the ITU. We waited in
25 a corridor where Mia played happily with an activity
0057
1 bear and she was extremely happy. Eventually we were
2 called into Mr Wisheart's office. There were several
3 people there including Mr Wisheart. I went in clutching
4 the book and I can recall being concerned that I might
5 damage it because I was holding it so tightly.
6 "On going into Mr Wisheart's office, Mia was
7 extremely active. Mr Wisheart played with her and
8 I felt there was a degree of bonding between us. After
9 a short period of time, he asked me how she was getting
10 on with her medication. I replied "What medication?"
11 and it was obvious that he was surprised that she
12 was taking no medication at all. He then drew a heart
13 on a piece of paper --
14 Q. Can you stop there? I think you know why. Can we, in
15 the other half of the split screen, show witness 10,
16 page 19, and see how good this is on reproduction. Can
17 we try to enlarge the right-hand side, so we can keep
18 the text? Go back to the left. Can we please enlarge,
19 if we can, what is, I think, a diagram of a heart which
20 is shown there. It has not come out very well on the
21 photocopying, has it?
22 A. No.
23 Q. It is the photocopying which has been scanned in. If
24 you just scroll up a little bit, the words at the top:
25 those particular words are in the heart book, are they?
0058
1 A. Yes, just, you know, to correct you, you interrupted me
2 a little early, because he started to draw on a piece of
3 paper. I then asked him to do it in the dedicated pages
4 at the rear of the book and that is where the page that
5 you have shown comes from.
6 Q. Which is why it has at the top of the page, page 94 of
7 the book, obviously. We have that at the bottom of the
8 page. It was designed to help a parent understand and
9 a surgeon to explain?
10 A. Yes, sir. It was a very good book, in fact.
11 Q. The various arrows and the diagram of the heart, can we
12 just go back to that? This is something which you must
13 have taken home and looked at and thought about
14 afterwards?
15 A. Yes, sir. I did not really understand it at all,
16 although we knew this particular drawing was the results
17 of the catheterisation, the pressures.
18 Q. Although you did not understand it, Mr Wisheart was
19 trying to explain it to you?
20 A. Yes, he did explain it very well, as far as he could to
21 a layman, sir.
22 Q. So he did his best to explain it?
23 A. He did, sir.
24 Q. You did your best to understand it, but I think the
25 impression you are giving me is that you were a bit
0059
1 shell-shocked by it all?
2 A. We were, and one of the reasons why we were keen to have
3 this book, because on previous occasions, as I stated
4 earlier, when you go in to see doctors you are under
5 stress and when you leave the information tends to
6 disappear. Even only an hour afterwards, you are asking
7 each other, "What did he say?", "What was this?", "What
8 was that?", which is why it was very important for us at
9 this stage to leave with it written in our possession,
10 because, you know, a piece of paper, scribbled on and
11 then thrown away, will be forgotten within minutes.
12 Q. That was not, I think, the only page?
13 A. No, sir.
14 Q. If we can go to the next page, 10/18, still on the split
15 screen -- it is the page before; it is the other way
16 round in my bundle. It is headed:
17 "Questions for my child's doctors". Can we just
18 look at the bottom two-thirds of that page. Who drew
19 that?
20 A. Dr Wisheart.
21 Q. What is your understanding of what it shows?
22 A. Well, as a final picture, it looks more confusing. He
23 did it layer by layer. If you look, the little lines
24 that show the valves which he showed us first, and the
25 actual circles is in the end, if you like, was somewhat
0060
1 simplified, as to the area of the heart that he would be
2 working on. So, if you like, that drawing would be in
3 three layers as such.
4 Q. He was saying, was he, that there was a hole in the
5 middle of the heart?
6 A. Yes, sir.
7 Q. Did he use those words?
8 A. Yes, he did, yes, sir.
9 Q. So that the blood communicated between the right atrium,
10 the RA, the left atrium, LA, and left ventricle, LV and
11 the right ventricle, RV?
12 A. Yes, he did his best to explain.
13 Q. Did he say what he was going to do about the problem?
14 A. Yes, sir, he did explain in some detail as to what he
15 was going to do. The large circles were almost at the
16 end where he was saying that was the area he was going
17 to be working on, which does confuse the diagram in
18 a way.
19 Q. The two bits at the bottom left-hand side, if you just
20 go down and enlarge that, please, what does that relate
21 to?
22 A. That is the risk of mortality, and the lower one is, he
23 is explaining when she was older, it is possible she
24 might have needed a pacemaker if her heart became
25 erratic.
0061
1 Q. That is even after the operation?
2 A. This would be after the operation. It would be
3 possible, not necessarily possible, but if her heart
4 became erratic, she might need a second operation for
5 a pacemaker.
6 Q. So he was telling you that the risk of death as a result
7 of the operation immediately was 1 in 5?
8 A. Yes, sir.
9 Q. And that there was a further risk that if she survived
10 the operation, she might need a pacemaker in later life?
11 A. Yes, sir.
12 Q. Can we remove the split screen and go back to your
13 paragraph 8?
14 Do you want to go on reading it? I think you got
15 as far as drawing a heart a piece of paper?
16 A. "I then produced a book I had brought and asked him to
17 draw his explanation on the dedicated pages that were at
18 the back of the book. He readily agreed to this and
19 commented that he thought that it was a good book.
20 Whilst he was drawing in the back of the book he was
21 explaining to us firstly what the problem exactly was
22 with the blood crossing over, secondly, what he was
23 doing to put the defect right. If you look at the
24 drawing you will see a circle on the drawing which is
25 where he said that was where he was going to do the
0062
1 operation. Annexed to this statement at enclosure MJP1
2 is a copy of the drawing that Mr Wisheart did".
3 Q. That is the drawing we have seen?
4 A. Yes, sir. "At this stage we did not ask any questions
5 about what he was saying, as in all honesty we didn't
6 really have much of a clue what he was talking about.
7 We just let him carry on and listened.
8 "Mr Wisheart then dealt with the question of
9 risk. I am not sure in which order the information came
10 out, but he informed us that there was a 20 per cent
11 chance of mortality and wrote that figure on the diagram
12 which is contained in the book. He also went on to
13 mention that she might need a pacemaker at some stage in
14 the future. He told us that without the operation Mia
15 would die. He did not say how long she would have, but
16 we were left thinking it would not be long and she would
17 decline during that period. He said the operation must
18 be done during her first year of life, because after
19 that her condition will become inoperable.
20 "I then asked Mr Wisheart what was the prognosis
21 in so far as Mia's quality of life after surgery,
22 providing it was successful. Mr Wisheart said, taking
23 into account her Down's syndrome, she would be able to
24 live a normal life, in that she could run and jump and
25 play like any normal child."
0063
1 Q. Pausing there, can we go split screen again, please, and
2 can I have on the other half of the screen, on my screen
3 only for a moment, medical report 1791/31.
4 Can we enlarge that, please? Can we enlarge it
5 a bit more? It is going single screen. I do not know
6 if you have seen this letter since. You have had the
7 medical records?
8 A. In the medical records, yes, sir.
9 Q. It is written on 26th January, which is a few days after
10 you saw Mr Wisheart. It is addressed to two
11 cardiologists, Dr Jordan and Dr Joffe. It deals with
12 your daughter:
13 "Thank you for asking me to see Mia whom we
14 discussed in the joint meeting a few weeks ago. She has
15 Down's syndrome, an atrioventricular septal defect,
16 bilateral SVCs and a bad right subclavian artery and
17 mild hypoplasia of the aortic isthmus".
18 This is the bit I want to ask you about: "I have
19 advised the parents that total correction should be
20 undertaken and we had the usual discussion of the
21 potential risks and benefits involved.
22 "They have accepted this advice and her name has
23 been placed on the waiting list ..."
24 You can't say what Mr Wisheart's usual discussion
25 of potential risks was or was not?
0064
1 A. No, sir.
2 Q. But if the risks which you have quoted, which he quoted
3 to you which you wrote on a piece of paper, were part of
4 his usual discussion, that would fit with this letter?
5 A. If you say so. I had not seen this letter, so it would
6 only be a presumption on my part.
7 Q. It says you have accepted the advice. You did that?
8 A. We did, sir, yes.
9 Q. At the meeting?
10 A. Yes, sir, we did.
11 Q. On what basis did you decide that it was right to go for
12 a complete repair of the atrioventricular septal defect?
13 A. The basis was to save her life, sir.
14 Q. Would you like to go back to your statement now, please,
15 and let us have witness 10/4 back on the screen:
16 paragraph 10.
17 A. Shall I carry on?
18 "Sheila Forsyth, who was the carer who showed us
19 around, told us whilst she was doing that that we were
20 really in the hands of the best surgeon so we agreed to
21 the operation proceeding on the basis of the percentages
22 which we had been given on the basis of her life
23 expectancy and on the basis of Mr Wisheart's
24 reputation."
25 Q. You told me a moment ago that of those three matters,
0065
1 the percentages, the basis of her life expectancy, and
2 thirdly Mr Wisheart's reputation, it was really the life
3 expectancy that decided you?
4 A. It would be the percentage risk, which is their main
5 consideration at that time, yes, sir.
6 Q. What sort of percentages would have undecided you?
7 A. Well, it is very difficult to say, but because we had
8 read quite a bit, we understood, you know, what the
9 risks in a way were going to be, and we felt that 30 per
10 cent was our figure that we would have refused. This
11 was our -- we decided to divide it by three as such.
12 Q. So anything over a third?
13 A. Anything over a third and we would have to have made
14 different decisions and possibly referred.
15 Q. You say possibly referred?
16 A. Well, again, we are surmising on an event that did not
17 happen. When we went in there, we did have the risks in
18 our mind very strongly and we decided that 30 per cent
19 was the maximum risk we were going to be taking in
20 regards to Mia. If the risks were higher than that,
21 then we would have to get more information and
22 investigate further as to what the correct path would
23 be, or whether to actually let her lead a natural life.
24 Q. So what you are saying is that anything less than
25 a third and you go ahead with whatever operation you
0066
1 were going to be told about; anything more than that,
2 you would have to think more about it?
3 A. Absolutely, yes, sir.
4 Q. Without necessarily knowing what in the end you would
5 do?
6 A. Yes. We do not know what we would have done.
7 Q. You say in your paragraph 10 that you agreed on the
8 basis of Mr Wisheart's reputation. What did you know
9 about that reputation?
10 A. Nothing initially. When we were first shown around the
11 day surgery by Sheila Forsyth, she was, if you like,
12 giving us a sales job on the unit and on Mr Wisheart,
13 and, you know, she obviously had great respect for
14 Mr Wisheart, and so it did become obviously of our
15 overall decision, that we were happy she was in the best
16 hands and in fact we felt, you know, it was a privilege
17 for us to be there.
18 Q. Was there anything apart from what Sheila Forsyth said
19 to you that made you think that Mr Wisheart was a man of
20 significant reputation?
21 A. I actually, on a personal level, felt very comfortable
22 with Mr Wisheart, and I felt that, as I said earlier in
23 the statement, that we actually bonded very, very well,
24 and we felt very happy to put our trust into
25 Mr Wisheart.
0067
1 Q. So it was not just a question of what other people said
2 about it, it was a question of the way you found him as
3 a person?
4 A. I think you could look at it, when you go into
5 a situation like this, that it is never one particular
6 thing; it is an overall perception you are gaining from
7 the hospital itself, the people you need, the nurses,
8 the doctors. The meetings you have, you could have
9 a bad meeting or a good meeting, or you could not get on
10 with people. It is the whole thing which gives you the
11 confidence to carry on. If you were in doubt, for
12 example, if the buildings were old and decrepit and the
13 equipment was bad, you start having doubts. But as we
14 all know, Bristol is a very modern hospital and is
15 a specialised centre, and, you know with the meeting --
16 first of all, Sheila Forsyth, before we met Mr Wisheart,
17 we were, you know, told that he was one of the best and
18 we had seen all the outpatients with all the people
19 playing and we talked to people, and it was actually
20 quite a pleasant experience. So we were very confident
21 when we went in, and primarily in our minds, I must say,
22 because of the books and the risk, it was risk that we
23 were mainly looking at. The risk was the crunch. Yes,
24 we were happy with the centre and we were confident with
25 Mr Wisheart, but it was the risk side, obviously, you
0068
1 know, life is like that. We have to weigh the odds and
2 if the odds are acceptable, you then take a risk. And
3 even acceptable odds are a risk. I class 1 in 5 as
4 a very high risk. It is not to be taken lightly,
5 because my wife is very young and we have no history of
6 Down's syndrome and the doctor said it was a 1 in
7 a million chance to have Mia. If we can have a 1 in
8 a million chance, 1 in 20 is a very high risk, so it is
9 not done lightly.
10 Q. I think you go on to make that point in paragraph 11.
11 You might want to read that out now to us?
12 A. "Before I go on, I feel it is relevant at this point to
13 go into both my and Leen's state of mind and the
14 concerns that I had prior to the interview with
15 Mr Wisheart. With a Down's syndrome baby, risk becomes
16 an everyday reality. As I have said, the weighing of
17 odds became a daily affair, as it affected everything we
18 did, whether in a major or minor way. Having read the
19 Heart Children, a practical handbook for parents
20 booklet, I felt we were fairly well prepared in regards
21 to our decisions that we had to make in relation to the
22 corrective surgery that Mia was going to need. I had
23 formulated several questions which I was going to ask
24 prior to our meeting with Mr Wisheart, amongst which
25 were what was wrong with Mia's heart, what was her life
0069
1 expectancy without surgery, was surgery possible, what
2 was her life expectancy after the surgery and finally,
3 if surgery was undertaken, what were the risks and side
4 effects? I can say that our state of mind was positive,
5 although concerned and worried. However, as I have
6 said, what we were told by Mr Wisheart put us at ease
7 and we made the decision as a result of that."
8 Q. You say, going back to the very bottom of the previous
9 page, if we can do that just for a moment, the very last
10 paragraph, that you formulated several questions which
11 you were going to ask. That might suggest you did not
12 actually ask?
13 A. Yes, we did. I was very concerned and my wife was very
14 concerned as to actually the quality of life which she
15 would expect after the surgery. That was very, very,
16 you know, important for us, because obviously we wanted
17 to make the right decision, and if she was suffering any
18 further, we would be very worried, that, you know, she
19 might continue suffering and for us, we wanted to know
20 what she could do. It was very important to us how
21 active she would be, you know, whether she could walk or
22 run, you know, or -- and obviously, whether -- this is
23 after surviving the surgery. This was quite important
24 to us.
25 Q. Let us go to the next page, paragraph 12, and pick up
0070
1 your story there?
2 A. "The next we heard was a letter giving us an appointment
3 for Mia's surgery, which I believe initially was for
4 some time in April. Unfortunately, I had to be out of
5 the country when the surgery was proposed and it was
6 therefore changed to 6th May 1993. I should say that
7 during the period leading up to Mia's operation, she
8 stayed well without infections or any medication and was
9 slowly gaining weight. In any event, when we arrived,
10 Mia was admitted to ward 5A at the Bristol Royal
11 Infirmary. Leen and I were again shown around and spent
12 some time in the ITU so that we could prepare ourselves
13 for the post-operative environment. We stayed with Mia
14 on the ward throughout the day, and it was some time in
15 the early evening that Mr Wisheart came into the ward to
16 see us. Mr Wisheart told us that all the tests which
17 had been undertaken on Mia during the day had proved to
18 be clear and the operation was set for tomorrow.
19 I vaguely remember him saying that it was to commence at
20 around 7 am. Mia was full of beans and had spent the
21 entire day running up and down the ward in a newly
22 discovered baby-walker and seemed very well. Whilst
23 both Leen and I were anxious, Mia's behaviour was such
24 that we got through the day well. Leen and I slept in
25 the ward with Mia and we were ready at 6 am for the
0071
1 pre-med to take place, as the operation was due to start
2 very early. In truth, neither I nor Leen slept that
3 night".
4 Q. Before we go on to 13, can we go to a full screen, on my
5 screen only, please, 1791/52.
6 What you are looking at here is again something
7 which you have had, I think -- you may not have looked
8 at closely. It is part of the nursing notes in relation
9 to what I think is the 5th or 6th of May 1993, looking
10 at the top of the page, the nurse has entered, the one
11 whose handwriting you can read, at any rate:
12 "For theatre on Thursday", so it is plainly
13 written before the Thursday. "Settled well. Mum will
14 stay by the bed tonight as she is demand feeding.
15 Dad ..." and it is not very clear.
16 Then we go down. There is an entry we cannot
17 read. In the clearer writing:
18 "Settled day. Mum and Dad seem quite happy. They
19 will be in Wiltshire room tomorrow. Mum has our breast
20 pump and knows how it works."
21 The Wiltshire room was a room down the corridor
22 from the ward, was it?
23 A. I have no knowledge of the Wiltshire room, sir.
24 Q. Did they find a room for you to sleep in?
25 A. I slept in a bed opposite and my wife slept on the floor
0072
1 next to Mia.
2 Q. The day after, was any arrangement going to be made for
3 you to stay overnight?
4 A. We had a room in the hostel.
5 Q. The reason for my asking, we may subsequently hear that
6 the Wiltshire room was a room very close to the ward,
7 but you were never in fact accommodated in a room close
8 to the ward, were you?
9 A. No, sir.
10 Q. Can we go back to your statement? It is 10/5,
11 paragraph 13.
12 A. "The first thing that happened that day was in relation
13 to the pre-med. The nurse who was to give Mia the
14 pre-med came over to us and asked if we would give the
15 medication to Mia. The reason she asked us this was
16 because she was going off duty. I insisted that the
17 nurse give Mia the pre-med for three reasons: firstly
18 because we were both stressed; secondly because Mia was
19 still breastfeeding and, because she was not allowed to
20 have any milk, she was agitated with Leen, and thirdly
21 and the most important reason for us, was that the
22 pre-med had been so beautifully executed at the
23 Children's Hospital that I wanted a nurse to do it
24 again. Sadly, the pre-med turned into a very difficult
25 time. Mia squirmed a lot and it was obvious the nurse
0073
1 just wanted to go home. Mia did not take all the
2 medication and a portion of it dribbled down her chin.
3 Unfortunately, Mia did not go to sleep, but was content
4 to cuddle in my arms. I must say that I deeply regret
5 my decision to ask the nurse to do it."
6 Q. Pausing there, the ward that Mia was on, ward 5A, were
7 there many children there?
8 A. No, sir. We were on our own in the ward.
9 Q. And did you have a look at ward 5 at all?
10 A. No, not that I can remember.
11 Q. Did it strike you as being a children's room, or not?
12 A. Yes. There was plenty of toys around and pictures. It
13 was a pleasant room.
14 Q. Paragraph 14?
15 A. "We remained in the ward until about 7 am when the care
16 worker Helen Strachan came for us and took us down to
17 the operating theatre. I carried Mia all the away to
18 the operating theatre. I went into the pre-op room with
19 Mia while Leen stayed outside. I handed Mia over to the
20 anaesthetist who I later knew to be Dr Bolsin. They
21 prepared her for the anaesthetic. It was at that stage
22 that Helen Strachan said that if Leen wanted to see Mia
23 before she became unconscious, she should come in now.
24 Leen then came in and gave her a kiss. As they were
25 giving her the anaesthetic, Mia gave what I think is the
0074
1 loudest scream she had every screamed. For some reason
2 I said, "That's right, Mia, kick back at the bastards".
3 I do not know why I said that. I had no idea that
4 things were going to work out as badly as they did. It
5 was just a reaction. I know what I felt and that was to
6 say to her 'Fight'. It just came out the wrong way.
7 I did however know that both Leen and I were not just
8 anxious about the situation, we felt that something was
9 not right."
10 Q. So you were stressed?
11 A. I was stressed at that time. You could say the events
12 of the day were not working out right.
13 Q. Was that the pre-med?
14 A. It was the pre-med, yes.
15 Q. And obviously the scream, but you have no idea why she
16 screamed?
17 A. No, sir.
18 Q. Then paragraphs 15 and 16?
19 A. "Helen Strachan led us away from the operating theatre
20 and did her best to comfort us. This would have been
21 just after 7 am.
22 "We came out of the pre-op room and I walked
23 ahead. Helen Strachan said something like, 'You poor
24 things, that was awful'. I said something like, 'That
25 is another scar in my life'. She then said for us to be
0075
1 brave and that Mia would not have felt a thing. At that
2 stage I was deeply unhappy about what had gone on since
3 the pre-med. I said to her that it was all very well
4 for this modern liberal approach, but I felt that the
5 way it had been conducted was all wrong. I carried on
6 by saying, 'To take Mia from the ward when she was not
7 asleep and to allow us to go with her down into the
8 bowels of the hospital to a back room with all the
9 paraphernalia of the operation there and the smell,
10 whilst she was still awake and whilst we were distressed
11 was taking it too far'. After that both Leen and I fell
12 apart. By this I mean we just simply cried. Helen
13 Strachan then said to us that you do not want to stay in
14 the hospital or in the ward. She advised us to leave
15 the hospital and walk around. Helen then told us to
16 come back at about 2 pm and we then left the hospital.
17 We accepted that advice. We walked round Bristol and
18 came back to the ward at approximately 2 pm. On our
19 arrival back at the ward we were informed by a member of
20 staff that we were too early and that Mia had not
21 returned from surgery. We were advised that we should
22 go away again and come back later, and so we decided to
23 go to the staff cafe. We waited there for what was the
24 longest hour of my life and we went back to the ward at
25 approximately 3 pm."
0076
1 Q. Can I take you back to the end of the previous page,
2 10/6. You described there, really, how you were very
3 concerned and how quite naturally it affected you?
4 A. Yes. It was an unfortunate experience, sir.
5 Q. When you said to Helen Strachan that it was all very
6 well, this modern liberal approach, what was this modern
7 liberal approach that you had in mind?
8 A. I think that taking the parents and the child right down
9 into the, and I mean the bowels of the hospital. At
10 Bristol it is the very bottom floor at the back, maybe
11 I am right or wrong, it is a very sterile environment
12 and the smell is outrageous really for a layman. It is
13 a shocking experience. To hand the baby still awake to
14 the anaesthetist, in my view, was asking a lot. It was
15 unfortunate that Mia was still awake. If Mia was asleep
16 I think it would have been a bit easier for us, but
17 still a difficult journey and a long journey to make.
18 It was happening to us as such, so this is what I said
19 at the time, and I still feel the same way.
20 Q. I think what I am asking you about is you are really
21 saying this is all part of an approach here, and the
22 approach is, in your view, wrong?
23 A. I would not say it is wrong. I think, you know,
24 a balanced approach -- at the Children's Hospital, the
25 whole environment for us worked a lot better. We went
0077
1 out with Mia and she was asleep. We went out with her
2 as she was on the stretcher, and we said goodbye to her
3 in the lift going down as such, I believe. I am not
4 entirely sure, but it certainly was not as traumatic as
5 what happened to us at Bristol.
6 Q. Was there any discussion beforehand about what would be
7 expected of you?
8 A. We were told this was going to happen, yes, sir.
9 Q. You were told it was going to happen?
10 A. We were told we were going to be going down to take her
11 to the theatre.
12 Q. You were not asked whether you should?
13 A. No, we were told this is what was going to happen. It
14 was unfortunate that she was still awake. I think that
15 actually is very important, and, you know, if you asked
16 me, I know, what I would have preferred, if she was
17 asleep, then the whole series of events would not have
18 folded as is, especially her scream, because being
19 a Down's syndrome, she was a quiet baby, and at a very
20 specific point, when we were giving her to the
21 anaesthetist and handing the baby over, to have her
22 scream as loud as that was shocking.
23 Q. So what really went wrong with it from your point of
24 view was in particular her being awake?
25 A. Yes. The pre-med went wrong. The day started wrong.
0078
1 Q. We are back to the question of the pre-med and how that
2 was very casually administered?
3 A. It was. We had made our minds up the day before we were
4 going to get the nurse to give her the pre-med. We were
5 very strong on this.
6 Q. Shall we go back to page 7, paragraph 17?
7 A. "We were told to wait in the ward, which was ward 5A,
8 which had only been occupied by ourselves and Mia. When
9 we arrived at the ward there was another lady with
10 a girl who I think was about two years of age waiting in
11 the ward. Some time after we had been in the ward,
12 Helen Strachan came in and said 'I still do not have any
13 information. I will go down to the operating theatre
14 and check'. She then left us and returned about 15
15 minutes later. She simply told us at that stage that
16 there were some problems but that she was going to go
17 down and find out what was happening. We were at this
18 stage becoming seriously worried and very stressed. The
19 surgery had lasted for at least 10 and a half hours
20 (from 7 am to 3.45 pm). Helen Strachan was away for
21 quite a while, no-one else came to see us during that
22 period and the lady in the ward was getting distressed
23 because of the distress we were obviously showing. At
24 approximately 4.30 Helen Strachan returned and informed
25 us that Mia had died in surgery. The lady who was with
0079
1 us then broke down at hearing the news. Both Leen and
2 I felt very concerned about the lady, because we were
3 causing her great distress, and therefore we immediately
4 left the ward and closed the door behind us."
5 Q. You may be comforted to know that in their comments on
6 your statement, the Hospital Trust agree that it is
7 inappropriate that anyone should be told about their
8 child's situation in front of another parent on the
9 ward. That is one of the complaints, I think, that you
10 have?
11 A. Yes, sir.
12 Q. What was the other lady in with her daughter for?
13 A. We do not know, sir. Strangely enough, we hope that,
14 you know, things went well for her, because she was
15 incredibly anxious because she was waiting for an
16 operation. She had been admitted for an operation, so
17 she felt the way we did the day before, so we knew what
18 she was feeling like.
19 Q. So you had to get out of the ward; that is why you went
20 into the corridor?
21 A. Yes, sir.
22 Q. Tell us what happened in the corridor.
23 A. "We were therefore in the corridor with Helen Strachan,
24 'freaking out' is the only word I can use to describe
25 the condition we were in. At that moment, two of the
0080
1 nurses from the ITU came past. One of them asked in
2 a pleasant voice how Mia was. I replied that she had
3 died in the theatre and the look of shock and horror on
4 their faces was plain to see. One of them blurted out
5 in an angry voice "But she looked so well. We had
6 babies who looked like skeletons and still survive".
7 After saying that, they both turned round and left in
8 what seemed to be a very angry fashion. Neither Leen
9 nor I saw them again. After the encounter with the
10 nurse, Helen Strachan took us to Mr Wisheart's office.
11 We waited in the office for a little while and then
12 Mr Wisheart came in. I have to say that whilst he
13 looked extremely smart, he gave us the impression of
14 being upset. He said the operation had been successful
15 but that Mia's heart would not start independently after
16 being taken off the bypass machine. He said that they
17 had tried several times and her heart had started once
18 but had stopped again after a short period of time. He
19 continued by saying that her heart must have been too
20 badly damaged to carry on. We were shocked and dazed at
21 the news, but felt sympathy for Mr Wisheart, as he was
22 obviously distressed. We both thanked him for trying to
23 save Mia's life and left his office in a complete daze.
24 I do not believe that the meeting lasted for more than
25 5 to 10 minutes."
0081
1 Q. I wonder if we can go split screen to a late stage in
2 your statement, page 10/14. It is (vi), if we can
3 enlarge that.
4 If that is on your screen, you see that at a later
5 stage you say that you considered that the post
6 operation interaction was so poor that it exacerbated
7 the distress, grief and anguish that you felt. Had it
8 been handled differently with more respect for Mia and
9 yourselves, you think you would be far less hurt today
10 than you are. You say your memories of Bristol are all
11 of pain. You remember little that does not cause you
12 distress.
13 At the time that Mr Wisheart came to talk to you,
14 you must still have been shocked?
15 A. Yes, sir.
16 Q. But you thanked him for trying to save Mia's life?
17 A. Yes, we did. We felt we knew that he tried his best and
18 he was obviously distressed. I do not know why, in that
19 situation, at that time, we felt almost more concerned
20 with other people's stress than our own, the lady in the
21 ward and Dr Wisheart. Our hearts went out to them. In
22 all truthfulness, we did thank him for trying to save
23 her life.
24 Q. You have told us already you did not know of what was
25 happening at the General Medical Council until the
0082
1 Panorama programme last July. Until then, had you
2 thought that Mr Wisheart had indeed tried his best?
3 A. Yes, sir.
4 Q. So it was your hearing or seeing that on TV that made
5 you think rather differently about it?
6 A. Because we were not contacted, we did not believe that
7 it had anything to do with us. Once we found out it
8 had --
9 Q. I will come to that. But it was learning of that that
10 made you reassess what you thought Mr Wisheart had done,
11 was it?
12 A. Yes, sir.
13 Q. So until last July, you thought very much as you thought
14 immediately afterwards: that he had done his very best?
15 A. Yes, sir.
16 Q. Because that was the impression he gave you?
17 A. That is the impression that he gave us, yes, sir.
18 Q. Did you in fact some time after you had recovered from
19 the shock, if you ever do, did you write a letter to him
20 specifically to thank him?
21 A. Yes, we did, sir, yes.
22 Q. And you meant it?
23 A. And we meant it.
24 Q. So although aspects of the way that the Infirmary had
25 treated you you never liked, you did --
0083
1 A. We had no complaints against Dr Wisheart at that time
2 and the treatment that we complained about later would
3 not refer to the meeting we had with Mr Wisheart in that
4 office; it was conducted sensitively and professionally.
5 Q. I am looking ahead in your evidence. By all means, if
6 you would rather wait until we get there, but I think
7 your complaint about Mr Wisheart we will see: that he
8 did not quote you the right risks?
9 A. Basically, yes, sir, in the light of further expositions
10 as such.
11 Q. And obviously that depends on this Inquiry finding out
12 what the right risks actually were?
13 A. Yes, it does, sir.
14 Q. Can we go back to paragraph 19?
15 A. "Helen Strachan was waiting outside and she then led us
16 to a small box room which was full of all sorts of stuff
17 and had a small settee. It was effectively a junk
18 room. She asked us whether we would like to see Mia to
19 say our goodbyes. I said no, but Leen said that she
20 wanted to say goodbye. Helen explained that it would be
21 good to see Mia and say goodbye, as it would help us to
22 come to terms with her death. I therefore reluctantly
23 agreed to see her. But Mia was brought in wearing
24 a white baby-grow which was not hers. She was in
25 a Moses basket. Leen was upset at the baby-grow because
0084
1 it was not hers and she did not like white on Mia, but
2 in any event she picked her up and cuddled her. Helen
3 took a photograph and said that if we didn't want it,
4 that was okay, but if we did, we were to ring her. She
5 also took a small lock of her hair and took a hand and
6 foot print. She then left us with Mia. After a short
7 time, she returned and said that it was best if we went
8 home. We actually said we would prefer to stay in the
9 little room at the hospital, and I think in all honesty
10 it was because we did not want to leave Mia. In
11 addition, we were both exhausted, confused and terribly
12 distressed. We had no sleep the night before and for my
13 part, I hoped to stay and talk about the operation and
14 say goodbye to Mia in my own time and in my own way.
15 I know that Leen felt the same thing, but wanted to
16 express and say goodbyes in a different way.
17 Q. The junk room, you say it was not a junk room, it was
18 something more than that, was it?
19 A. There was, you know, medical equipment as such, tissues
20 and boxes and a settee in there, such that it was
21 a general purpose room, very small.
22 Q. And there were just, what, the three of you?
23 A. The three of us, yes, and Mia.
24 Q. Can you help us with the room: was it one which had
25 a window high up in the wall, do you remember?
0085
1 A. If you went down the ward towards the Intensive Care
2 Unit, it would be two-thirds of the way down on the
3 right. The Intensive Care is on the left.
4 Q. The Trust in their comments on your statement have
5 suggested this is probably the relatives' room which had
6 a settee and did not normally have any other furniture
7 apart from easy chairs?
8 A. There would not have been room for easy chairs. The
9 settee would fill a considerable -- it was a small
10 room. There was not much room. There was, if you like,
11 stock in that room.
12 Q. When you say extraneous items: stock?
13 A. Tissues, boxes, bandages, big plastic bags.
14 Q. So it gave the impression of being a room that was used
15 for more than one purpose?
16 A. Our impression is that it was a junk room with a settee
17 in there. It was a small room. If that is the family
18 room, well.
19 Q. You were going to go on and say, well --
20 A. If that is what they call a family room, so be it.
21 Q. You did not think a lot of it?
22 A. No. We had not seen or been shown that room before.
23 Q. Had you been shown any room to wait in before?
24 A. When I heard mentioned recently the family room,
25 I presumed that was where the kitchen was. There was
0086
1 a room with, you know, like catering facilities at the
2 other side of the ward. If you go to the cross
3 corridor, it was opposite, across the corridor, which
4 I presume is what people were calling the family room.
5 We were not shown this room before.
6 Q. The room you had been in before, the room with the
7 kitchen: were other families or parents using it?
8 A. At that time, the actual whole ward was very quiet as
9 far as we were concerned. We did not really talk or see
10 any other patients. There were patients in there when
11 we were first admitted, but they all left.
12 Q. So I suppose, really, the use of the family room would
13 depend on who was admitted during the day?
14 A. Yes. We did not actually use the family room, or what
15 I would say was the kitchen as such. We did not use any
16 of those facilities. We were not there long enough.
17 Q. If you were going to say your goodbyes to Mia properly,
18 you would need to be there on your own, would you not?
19 A. I must say, at that time, one could say we were not
20 stable, but we were, you know, put on our heels in the
21 aspect of the room itself, because it was so small, and
22 messy, and it seemed to me, and I can visualise the
23 room, as I say, I can describe where it is, that it was
24 a junk room with a settee in it.
25 Q. The question I think that I am asking you, to invite
0087
1 your comment, really, is this: that if there is a family
2 room with a kitchen where families may go, there is
3 something public about it?
4 A. Yes.
5 Q. You found it distressing, quite understandably, to be
6 told of Mia's death in a small ward shared with another
7 parent?
8 A. Yes. In ward 5A we were told of her death.
9 Q. You wanted to say your goodbyes to Mia, and Helen
10 Strachan can speak for herself, but it may very well
11 have been she thought you would be better doing that
12 privately, so you could express your private grief and
13 goodbyes?
14 A. Yes, sir.
15 Q. There must be a limit on the number of large
16 well-equipped rooms which can be made private in a busy
17 hospital, perhaps?
18 A. Yes, there would be.
19 Q. So your complaint about it, really, is the impact on
20 you, is it?
21 A. The day started wrong and finished worse. The events
22 that followed the announcement of her death, which meant
23 we had to go into the corridor, it was just rolling on
24 in a chaotic fashion, and then, to go into this room,
25 which, to me was not an appropriate room, and even at
0088
1 that time, I was, you know, not happy, and that the
2 Moses basket was, you know, placed on the settee.
3 Q. The Moses basket was hers, was it?
4 A. No, it was not her Moses basket.
5 Q. The white baby-grow certainly was not?
6 A. Certainly not.
7 Q. Did she have baby-grows of her own there?
8 A. Yes, and her own Moses basket.
9 Q. The Trust had commented that white baby-grows were used
10 when the children's baby-grows were, and I quote, "not
11 to hand". Were baby-grows for Mia available to hand as
12 you recollect it?
13 A. From our end, yes, sir. It was just, you know,
14 unfortunate that it was white and Leen hated her in
15 white.
16 Q. So it is the colour rather than the fact that it was not
17 hers?
18 A. If she had been in a surgical dress as such, it would
19 not have been so hurtful for Leen. She was very upset
20 at that time, because it was white.
21 Q. I am sure that you accept that aversion to white is not
22 perhaps a common reaction, understandable as it may be?
23 A. No, sir. It was just unfortunate.
24 Q. If we can go on to paragraph 20, and please, as we put
25 the image up, scroll over to the next page, the bottom
0089
1 of the page. If you would like to take up the reading?
2 A. "In any event, Helen insisted that we would disrupt the
3 ward if we stayed and that getting back to our home
4 environment was the best thing that we could do. At
5 this stage I became extremely stubborn. The whole
6 sequence of events that had transpired since we had been
7 told of Mia's death was deeply upsetting. There was
8 firstly the fact that another lady and her young child
9 were present in the room; there was the incident in the
10 corridor; there was being placed in a junk room where we
11 were expected to say goodbye to Mia, and finally, I got
12 the distinct impression that we were being rushed out of
13 the hospital before we were ready to go. I was also
14 concerned about the drive to Swansea. I must stress
15 that all this took place in the box room and Mia was
16 still lying in the Moses basket.
17 "We were persuaded out of the box room and Helen
18 insisted that we go and collect our stuff firstly from
19 ward 5A and then from the hostel. We had not stayed at
20 the hostel but we had actually dumped some of our stuff
21 there. Throughout this time, I was making it quite
22 plain to Helen that we did not want to go. Eventually
23 we found ourselves at the door of the Bristol Royal
24 Infirmary completely distressed and dazed. I cannot
25 remember if we were escorted out or left after being
0090
1 told to go, but I know that I had made it quite plain
2 that we did not want to leave. This would have been
3 around 6 pm".
4 Q. You spoke about being stubborn, making it plain you did
5 not want to go. How did you do that?
6 A. I said I wanted to go and she said we would upset the
7 ward. By this time my wife really was very, very upset
8 and we really wanted more time. It was all happening so
9 fast. As I say, I mean, we were out on the doorstep at
10 6 pm and it was at 4.30 we were told she had died, and
11 that includes the visit to Dr Wisheart, the period in
12 the corridor, the period in the box room, was only an
13 hour and a half. We had no time in any way to come to
14 terms with what was happening. Although I initially
15 reeled back in horror, really, at being asked whether
16 I wanted to see Mia, it was really more of a shock of
17 the whole thing all happening so fast, so I needed more
18 time, to come to -- it takes years to come to terms with
19 it, but we were not stable at that time, we were in
20 shock and we needed more time.
21 Q. Leen was crying?
22 A. Leen was crying.
23 Q. What about you?
24 A. I was getting angry at this point. I was angry because
25 I wanted to stay and I knew that leaving the hospital,
0091
1 I was not fit to do so. We were not in control; we were
2 in shock and we were exhausted. We did not have time to
3 say goodbye. It was all too quickly.
4 Q. Do you think you expressed your anger before you were
5 asked to go?
6 A. After.
7 Q. The Hospital Trust had commented that it was normal
8 policy for parents to be given time to come to terms
9 with their loss and not hurried in any way and notes
10 that parents did frequently stay an additional night, as
11 you and Leen would have preferred. They say it is not
12 possible to know why that did not happen in your case in
13 the short time available before comments were required,
14 and plainly, they are at liberty to comment further
15 later.
16 If that was normal policy, to what extent, as you
17 saw it, did Helen Strachan appear to be following it?
18 A. It was not what occurred to us.
19 Q. You say you were persuaded out of the box room and Helen
20 insisted that you go and collect your stuff. What
21 reasons did she give for saying, "Well, really you ought
22 to go home", or you ought to go?
23 A. Because we were disturbing the ward, which I agree, we
24 were.
25 Q. So that was the crying and the shouting?
0092
1 A. Yes, sir.
2 Q. But the disturbing of the ward could not have been the
3 reason she first asked you to go, because you were not
4 then shouting, you say?
5 A. I would not say we were shouting as such, but we were
6 not agreeing, and I was -- the situation was out of my
7 control, and --
8 Q. Just so I understand that, when you say out of your
9 control, you mean you were out of control?
10 A. No, we were being hassled.
11 Q. And you reacted to that?
12 A. Yes, I did.
13 Q. And you reacted to that?
14 A. I did, but not strong enough.
15 Q. The persuasion out of the box room, what form did that
16 take?
17 A. I asked to stay, could we stay another night. Helen
18 said that it would be much better for us to be able to
19 go home, and we, both Leen and I asked, that we wanted
20 to stay that night to collect ourselves and to say
21 goodbye to Mia our own way. I cannot say how she got us
22 out of the room. To this day we do not know, but it was
23 like waking up from a dream. We were at the doors of
24 the hospital and suddenly we were out of the doors of
25 the hospital; we were persuaded out. Whether she
0093
1 escorted us all the way out, I cannot remember. We were
2 in shock.
3 Q. I do not mean to suggest any criticism at all of you,
4 but when you say, well, you said you wanted to stay the
5 night, did you put it quite so pleasantly as that?
6 A. I was not annoyed -- Helen, I must say, worked very,
7 very hard and had a very difficult job to do. I was not
8 aggressive as such. You could say we were stubborn. We
9 were not shouting. And when -- we were in her hands, in
10 a situation that is alien to us and when people say it
11 is best to leave the ward because we are disturbing the
12 ward, it is true, we were disturbing the ward and we
13 were -- we had already upset a lady in ward 5A, we had
14 already had a situation in the corridor. The problem we
15 were in in the box room, and I agree we were disturbing
16 the ward, all I could think was that I wanted to stay
17 another night. That was my prime requirement. She said
18 it was best for us to go home and is a professional
19 carer, and with more experience than us, and being in
20 shock, I would say that she had her way.
21 Q. Paragraph 22.
22 A. "On leaving the hospital I went to the hostel. I was in
23 such a state that I left many of my belongings there
24 which were subsequently lost. We were unable to find
25 our camper van and we were walking in the streets of
0094
1 Bristol openly crying. People were staring at us. By
2 the time we found the camper we were totally
3 distraught. All I could think of doing was making
4 a strong coffee and then we drove from Bristol to
5 Swansea. I can only say that the drive was a nightmare
6 and suited the day we had suffered."
7 Q. Were you able to concentrate on the driving at all?
8 A. No, sir. It was a bad drive.
9 Q. Paragraph 23.
10 A. "The first contact that we had after Mia's death was as
11 a result of Leen telephoning her GP Dr Law, to obtain
12 tablets to dry up her milk. This was obviously very
13 distressing for her and Dr Law did well. It was about
14 a month later that we received a letter from the Bristol
15 Royal Infirmary stating that if we would like to have
16 a talk with Mr Wisheart, we could do so. By that stage
17 we had cremated Mia and we decided it would do us no
18 good, but we should look forward and try to rebuild our
19 lives. At that stage, which would have been somewhere
20 in June 1993, we had no knowledge that there were any
21 problems at Bristol and we simply tried to get on with
22 our lives."
23 Q. Can we have the next page, please? Do you want to go
24 on?
25 A. Yes, please.
0095
1 "Leen and I lead a fairly isolated life at our
2 residence in West Wales and we had seen no publicity
3 whatsoever concerning the Bristol Royal Infirmary and
4 its problems until the very end of the General Medical
5 Council disciplinary hearing involving Mr Dhasmana,
6 Mr Wisheart and Dr Roylance. On the Thursday or Friday
7 before the showing of the Panorama programme on
8 27th June 1998, we saw the reports on television, but so
9 far as we were concerned, we did not believe it could
10 affect us or Mia, because we had not been contacted by
11 anybody. Had it affected us, we assumed that we would
12 have been called because Mia had been operated on. In
13 any event, Leen and I watched a Panorama programme.
14 This was on the Monday. Towards the end of the
15 programme, there were specific references to timespans
16 and operations which were AVSDs on children under one
17 year old. This, to us, was very close to the mark --
18 Q. Can I stop you there? Mia was just under one, was she
19 not?
20 A. Yes, two weeks, shortly.
21 Q. I am sorry, would you like to go on?
22 A. "This to us was very close to the mark, but we still did
23 not think that it would possibly apply to us because we
24 had not been contacted. As a result of the programme,
25 Leen and I discussed it at length that evening, and we
0096
1 came to the conclusion that we should check to see
2 whether Mia was one of the children who were subject to
3 the GMC investigation.
4 "I eventually contacted Messrs Tozers who were
5 unable to give me any information. I contacted the
6 Bristol Heart Children's Action Group who initially were
7 not able to assist me but I subsequently spoke to
8 somebody who seemed to have a list of the people that
9 were involved. Initially she informed me that Mia was
10 not on the list but after requesting further information
11 from me concerning her date of birth and date of death,
12 she told me that there were certain children on the list
13 that were not named. It was not up to her to tell me,
14 she said, but she thought that Mia could have been the
15 subject of the Inquiry. She actually gave me the number
16 W12, and that was the first time that I had heard that
17 number. I therefore resolved to contact the General
18 Medical Council direct. I obtained the number from
19 directory enquiries and telephoned them. I gave all my
20 details to their press officer, who said that she would
21 pass those on to the solicitors who would get back to
22 me. They returned to me within 30 minutes of my call to
23 the GMC.
24 "The solicitors confirmed to me that Mia was
25 W12. Even having been told that, I still did not
0097
1 believe it and asked them to put that in writing. They
2 subsequently wrote to me and confirmed that Mia was
3 indeed W12. During the telephone conversation, I asked
4 the solicitors why they had not contacted me. They said
5 that as a result of their limited remit, they had simply
6 sent three letters to my last known address and one to
7 my last doctor. I assume that they had had no reply.
8 I find this totally unacceptable. They obviously had my
9 GP's address in Cornwall, the notes of the family
10 including Mia's GP notes were transferred from one GP to
11 another. They could therefore have easily traced Leen
12 and myself, and we would therefore not have been placed
13 in such an invidious position. I also pointed out to
14 him that all our previous addresses had been family
15 addresses, and therefore I find it very difficult to
16 understand why he could not contact us.
17 "I fully appreciate that whether I found out in
18 1995 or 1996 or 1998 as I did, the distress and trauma
19 would have been the same. However, I feel extremely
20 aggrieved that had the GMC taken any reasonable steps
21 that they would have been able to find my whereabouts.
22 They could have traced my medical records, they could
23 have contacted my previous address by telephone, and
24 they would have found myself and my wife. I could then
25 have given evidence to the General Medical Council. As
0098
1 it turns out, I had evidence which was of the utmost
2 importance to the Inquiry because there was considerable
3 debate about the levels of percentage success that were
4 being quoted by Mr Wisheart. I had documentary evidence
5 to prove what he was quoting. In addition I understand
6 that Mia's case was pivotal, and it would have done both
7 myself and my wife a great deal of good to have been
8 able to have taken part in the exercise and seen justice
9 at least tried to be done."
10 Q. Could I just stop there. Let us look at a letter which
11 was sent to you by Veale Fisher Waterhouse who were
12 acting on behalf of the General Medical Council. It is
13 page 24, on my screen first, please. Can we scroll down
14 to where it begins "Dear Mr Parsons", removing the
15 address at the top. This is a letter which I can tell
16 you was dated 12th June 1998. You have seen it. It is
17 to you and it confirms in the middle of the page that
18 Mia is shown in the document as patient W12?
19 A. Yes, sir.
20 Q. That is the confirmation you spoke about. If you just
21 look at the very last paragraph which talks about
22 contact, this is your complaint about the General
23 Medical Council:
24 "During the first half of 1997 we made extensive
25 efforts to contact the parents of all the patients named
0099
1 in the schedules to the enclosed charges. Some we
2 already knew. However, we sought to contact others
3 through addresses last known to the hospital, and
4 failing that, through the last known GP. You were one
5 of those that we sought to contact in this way. The
6 address we had for you was 15 Western Street, Swansea,
7 which you tell me was only a temporary address."
8 You had had a telephone conversation, then, with
9 Mr Ryder on 12th June, had you?
10 A. Yes, sir.
11 Q. One of your addresses had been, had it, 15 Western
12 Street, Swansea?
13 A. Yes, sir.
14 Q. Did you tell him that it was only a temporary address,
15 that it had been only a temporary address?
16 A. Yes, sir.
17 Q. The point that he might perhaps wish to make is that you
18 had only a temporary address at the time, it might have
19 been difficult for him to get in touch with you. What
20 do you say about that?
21 A. If that is simply the case, then I would agree with
22 that. We were referred to Bristol Royal Infirmary from
23 Treliske Hospital in Truro, so the address and the
24 doctor there were actually in Penzance, which was
25 a family address, so there was a route through that
0100
1 way. Halfway through our proceedings we moved to
2 Swansea --
3 Q. Let me stop you there. The route would be what, to the
4 GP?
5 A. Yes, or to our previous address, which Truro Hospital
6 would have had.
7 Q. If your previous address had been contacted --
8 A. Yes, it was a family address.
9 Q. Who was living there?
10 A. It was my wife's family, an extended family in Cape
11 Cornwall. In fact, they own Cape Cornwall and the Golf
12 Club there and we are in constant contact.
13 Q. And they knew where you were?
14 A. They knew very well where we were.
15 Q. So that is what you say they should have done?
16 A. Yes, sir, plus also our records were forwarded from the
17 GPs, as well from Western Street to Dyfed, Wales.
18 Q. Can we go back to your main statement, 10/11, the bottom
19 of the page. This is where you begin to comment in
20 relation to the running and staffing of the Bristol
21 Royal Infirmary, and you make a number of comments. You
22 say that you make no apologies for the fact that your
23 knowledge is retrospective, as you have very fairly
24 acknowledged this morning, and you say in the light of
25 the evidence you have seen, you believe the comments are
0101
1 both fair, balanced and irrefutable?
2 A. Yes.
3 Q. So these are your comments?
4 A. Yes.
5 Q. You are saying they are based on evidence which you have
6 seen?
7 A. Yes, sir, in the light of the 2-year General Medical
8 Council Inquiry.
9 Q. And it follows that the evidence is something which you
10 got from other people?
11 A. Yes, sir. It is retrospective.
12 Q. So ultimately, it will be for this Inquiry to decide
13 what it makes of that?
14 A. That would be what we would hope.
15 Q. Would you like to deal with what you see as the
16 problems?
17 A. The referral to Dr Wisheart:
18 "I find it incomprehensible that Dr Jordan should
19 refer Mia to Mr Wisheart for surgery, knowing that his
20 results were far worse than those obtained by
21 Mr Dhasmana with the same staff and the same amenities
22 and that the results were even further adrift from the
23 national statistics. In addition, Dr Jordan must have
24 been aware of the claims made by Dr Bolsin after the
25 publication of the figures in 1992. It was criminal for
0102
1 Dr Jordan to continue, given his personal knowledge and
2 information received from Dr Bolsin. Had Leen and
3 I been aware of the real statistics, or had Dr Jordan
4 told us the truth, we would never have accepted the
5 referral."
6 Q. Pausing there, that all depends on what Dr Jordan
7 actually knew, or actually did not know.
8 A. Yes, sir.
9 Q. "Consent: I find that when I deal with the question of
10 consent that I become both angry and emotional. When
11 I received my daughter's medical records I read through
12 them and when I came to the consent form and saw my
13 signature on that form it brought home to me what I had
14 done. I fully appreciate that in view of the
15 information given to me by Dr Jordan and Mr Wisheart
16 that when I signed the form I believed that I was doing
17 the correct thing by Mia. However, in retrospect I know
18 that I did not. The information given to me by
19 Mr Wisheart and written in his own hand on the diagram
20 in the back of my book, to which I have already
21 referred, that the mortality rate was 20 per cent, I now
22 know to be fiction. Regardless of the exact statistical
23 evidence, such as that referred to in Mr Henderson's
24 opening at the GMC Inquiry, it is plainly obvious to me
25 that Mr Wisheart's mortality rate was far more than
0103
1 either Mr Dhasmana or the national average for AVSD.
2 Judging by GMC statistics, the risk seems to have been
3 at least 50 per cent. Had I been given the true figures
4 by Mr Wisheart, that is Mr Wisheart's own success rate,
5 I can categorically state that I would never have
6 allowed the operation to proceed. When I went into the
7 meeting with Mr Wisheart on 20th January, I had read and
8 re-read my book. I knew that there was a percentage
9 risk, and I was aware that around 50 per cent was an
10 unacceptable risk.
11 "I would never have allowed the surgery to
12 continue and would have insisted that Mia be moved
13 immediately to another paediatric hospital, rather than
14 to take what I would have considered then, and certainly
15 consider now, to be an unacceptable risk with her life.
16 I therefore maintain that my consent to this operation
17 was obtained by giving me deliberately false
18 information. This, in my view, is criminal. I would
19 like to quote from page 1-60 of Mr Henderson's opening.
20 The quote comes from between paragraphs a and b.
21 "Sir, if that is an implied assertion that
22 Mr Wisheart was well aware of his own AVSD results and
23 of their comparative quality ... his judgment in
24 continuing is then open to grave criticism".
25 Mr Wisheart has caused heartache to my wife and me
0104
1 and to many other families."
2 I am not going to ask you any more about that,
3 because we dealt with that earlier in your evidence, and
4 I appreciate it is something you feel very bitter
5 about. That is a fair description of the way you feel
6 about it, I think?
7 A. Yes, sir.
8 Q. Do you want to go to number 3?
9 A. "Post-operative interaction. The way in which my wife
10 and I were treated after the death of Mia was inept,
11 unfeeling and thoughtless. In the main body of my
12 statement I have detailed how Helen Strachan tried to
13 help and she no doubt thought that she was behaving
14 correctly. However, a number of things were allowed to
15 happen that increased the distress of my wife and myself
16 to a level that we could never have imagined. To break
17 the news of our child's death in the same ward as we had
18 last seen her alive was wrong. It was doubly wrong
19 because in the ward at that time was a mother and child
20 who was shortly to have surgery. Her distress was
21 self-evident and my bungled attempts to make her feel
22 better only made her and me feel worse. I believe that
23 we should have been taken to a designated area where we
24 could have been given the news in private."
25 Q. Can I stop you there: your bungled attempts to make her
0105
1 feel better. What did you try and do or say?
2 A. I said that Mia was very ill and that I am sure she will
3 be, you know, her daughter will be fine, in such words.
4 "(ii) After we had been told we should have been
5 allowed, as a right, to spend as much time with Mia
6 saying goodbye as we wished. To be forced to deal with
7 the situation and our goodbyes in a room full of junk
8 under pressure from the authorities to leave the
9 hospital caused incalculable distress.
10 "(iii) The presentation of our daughter after
11 death was something which thought should have been given
12 to. I appreciate that the hospital could not have been
13 aware that my wife disliked seeing Mia in white.
14 However, they could have made sure that when she was
15 presented to us she was at least wearing something which
16 was either hers or was obviously the hospital's. In
17 addition, when we were shown Mia, she was terribly
18 bloated and did not look like our child. We should have
19 been forewarned that as a result of the operation, there
20 would have been physical changes; because the shock of
21 seeing her in that condition added to our grief. We
22 were rushed out of the hospital and this gave us the
23 impression that they simply wanted to wash their hands
24 of us. No counselling was offered, no thought was given
25 to our condition or the grief we were feeling and no
0106
1 communication was made to our local doctor, social
2 services or bereavement counsellor who could have
3 assisted us in our plight".
4 Q. Pausing there for a moment, you are obviously looking
5 beyond the day of the death here, you are looking into
6 the weeks which followed immediately?
7 A. Yes, sir.
8 Q. And it is right, is it not, that the hospital wrote to
9 you at some stage to ask if you wanted to come and see
10 Mr Wisheart?
11 A. Yes, sir.
12 Q. That was reasonably soon?
13 A. A month.
14 Q. A month after the death. So far as counselling is
15 concerned, what did you understand Helen Strachan to be
16 there for?
17 A. To assist us through the stresses and strains of the
18 operation, and the hospital environment.
19 Q. And when you say no communication was made to your local
20 doctor who could have helped you in your plight, were
21 you registered with a GP?
22 A. We were, yes, sir.
23 Q. Was there anything which would have prevented you going
24 to see the GP, for instance, if you needed sleeping
25 tablets?
0107
1 A. There was nothing to prevent us doing so, and in fact we
2 did.
3 Q. So you did actually get the help?
4 A. Yes, we had to, because my wife was in great pain,
5 physical pain, because Mia used to take a lot of milk
6 and she was, you know, full of milk and in great pain.
7 Q. So what actually happened was very shortly afterwards
8 you went to see the GP?
9 A. Yes. I would say -- no, we did not see the GP. We rang
10 him up and he came to see us, maybe a day or two after
11 we got home.
12 Q. So that was within three days of the death?
13 A. Yes, within three days. I cannot remember if it was the
14 next day or the day after, but very soon, because my
15 wife was physically distressed.
16 Q. Did he tell you where you might get counselling
17 services?
18 A. No, sir.
19 Q. Did you ask him?
20 A. Not that I remember.
21 Q. Could you have done, if you had thought about it at the
22 time?
23 A. If I had thought about it at the time, yes, sir.
24 Q. Would you like to go on to (v)?
25 A. "The hospital were aware that Leen was still
0108
1 breastfeeding Mia. They did nothing by prescribing or
2 referring her to her GP to assist her with her problems
3 of giving milk. Until we sought help ourselves for that
4 problem, it was a constant reminder of the loss that we
5 both had suffered.
6 "I consider that the post operation interaction
7 was so poor that it exacerbated the distress, grief and
8 anguish that we felt. Had it been handled differently,
9 and with more respect for Mia and ourselves, then I
10 think we would be far less hurt today than we are. Our
11 memories of Bristol are all of pain and we remember
12 little that does not cause us distress."
13 "Retention of tissue: at the time of giving this
14 statement, I cannot say how Leen and I are going to feel
15 if Mia has had organs or tissue retained. All I can say
16 at this point is that so far as I am concerned, I never
17 gave consent for any organs to be removed. I consented
18 misguidedly to the operation being performed, but
19 nowhere on the form or in any explanation given to me,
20 did anyone point me to the fact that by signing an
21 operation form then organs which belonged to my daughter
22 could be removed. In addition, whilst I accept that
23 a post-mortem can be ordered by a Coroner, that does not
24 mean that organs need to be removed or indeed should be
25 removed. I would like to have the opportunity of
0109
1 commenting on this at a later date when I have been able
2 (a) to find out what our position is and (b) to have
3 given it more thought".
4 Q. You have now found out, I think, have you not?
5 A. Yes, we have.
6 Q. I wonder if we could have, on my screen please, 10/20.
7 Can we please go below the address to where it says:
8 "Dear Mr and Mrs Parsons... ."
9 I can tell you that this comes on a headed piece
10 of paper headed the United Bristol Healthcare NHS Trust
11 from the Director of Children's Services. It is
12 addressed to you at what I think is your present
13 address. Perhaps in fairness we ought to look at the
14 second paragraph first:
15 "According to our records which we have checked
16 and rechecked in each individual case, a post-mortem
17 examination was undertaken on 7th May 1993, following
18 Mia's death, on the instruction of the Coroner. I would
19 confirm that it is standard practice throughout the NHS
20 to retain tissue following a post-mortem examination.
21 "In the case of Mia, I confirm that her heart is
22 still retained by the hospital following her post-mortem
23 examination. The reason for retaining the heart is that
24 due to its small size and complexity, it cannot be
25 properly examined during the post-mortem procedure
0110
1 itself. Further, more detailed examination is required
2 to ensure that the diagnosis of the heart condition was
3 correct and to study and learn from the surgery that was
4 undertaken. This process has contributed significantly
5 to the major advances that have been made in paediatric
6 cardiac surgery over the years.
7 "I do appreciate how distressing this information
8 will be to you, and I am sorry if the factual tone of
9 this letter adds further to your distress. However,
10 I feel that it is essential to be absolutely clear
11 regarding Mia's individual circumstances.
12 "I would like to assure you that the Trust will
13 retain Mia's heart until you have notified us of your
14 wishes. A number of possible courses of action exist
15 and I will write to you again as quickly as possible
16 asking you to indicate your wishes in this matter in the
17 light of more detailed information I will also enclose.
18 We will of course be able to arrange for Mia's heart to
19 be returned to you, bearing in mind the legal
20 obligations that the return of organs and other tissues
21 places on both the Trust and yourself, and also taking
22 into consideration the requirements of the Public
23 Inquiry. We are currently seeking clear guidance on
24 those obligations. Although we have no further
25 information to give you at present, the help line
0111
1 continues to operate ..." it gives the number and it
2 expresses the wish, signed by Mr Barrington, that there
3 is a hope that the information is of help. "Sorry for
4 the additional distress that may have been caused by the
5 recent media publicity surrounding this issue."
6 Have you responded to that letter?
7 A. No, sir.
8 Q. Do you have it into mind to respond?
9 A. Yes, sir.
10 Q. Now that you know what the position is with Mia's heart,
11 how does that resolve the feelings that you expressed --
12 if we can go back to page 14 of your statement -- at the
13 bottom of that page?
14 A. I understand that this is a national issue, not
15 specifically to do with Bristol, and the pressure put on
16 by the BRI has led to this disclosure, so it has to be
17 a concern to everybody that has a post-mortem carried
18 out by the National Health Service, so it is going to
19 cause distress to a large number of people.
20 As a family being involved in this matter it has
21 caused us a lot of distress, and one could say that this
22 has added insult to injury. I had no awareness that we
23 did not bury all of Mia and would like to have been
24 asked.
25 Q. Although it is retrospective, suppose that a week or so
0112
1 after the shock you had been asked if you would agree
2 to -- even before then -- you would have agreed to Mia's
3 heart being retained after post-mortem, what would you
4 probably have said?
5 A. My wife is adamant that she would not agree because she
6 believes heart and soul. In the light of things that
7 have gone on, I cannot say what I would have said now,
8 because of all the other incidents, so I cannot say what
9 I would have said. My wife is adamant that she would
10 not have allowed Mia's heart to be removed.
11 Q. Although it is very difficult to say in hindsight, and
12 I am sorry for pressing you, is it likely that her view
13 would probably have prevailed, do you think?
14 A. Yes, it would have. She would have prevailed.
15 Q. Can we go on, then, to page 15 of your statement? You
16 did not complain at the time, you say, because you were
17 unaware of the true situation at Bristol. Do you want
18 to take it up from there?
19 A. "I did not complain about the treatment of my wife after
20 the death of Mia, because we were too distressed and it
21 would have done us no good. However, if I had one
22 central complaint, it is simply to ask the question, why
23 was Mr Wisheart allowed to continue after 1992? Why do
24 I place the question in 1992? I place it there for
25 these reasons --
0113
1 Q. I am going to stop you there, because here you are
2 beginning to argue, are you not, the case in the light
3 of whatever the history might actually be. It is as you
4 understand it, obviously?
5 A. It is as I understand it from the information that
6 I personally have acquired since our knowledge of the
7 GMC Inquiry.
8 Q. The one matter which I do want to ask you about, if you
9 can cast your eye down after the six matters which you
10 mention, you say Mr Wisheart chose to continue to
11 operate, was not stopped by his colleagues. Would you
12 just read on from there?
13 A. Will we go back to the --
14 Q. If you wish to, but you appreciate that what I have
15 asked you, these are arguments which you have, people
16 can read them and see them. Unless you wanted to read
17 them out specifically, we can move on to the
18 paragraph where there may be more to ask you.
19 A. Okay.
20 "Mr Wisheart chose to continue to operate and was
21 not stopped by his colleagues, the hospital authorities,
22 the Regional Health Authority or the Department of
23 Health. This, in my view, is criminal, bearing in mind
24 that all of these bodies and individuals knew of the
25 problem by 1992, they must all take a share of the blame
0114
1 for allowing the surgery to continue. I have been told,
2 although I have no direct evidence, that it was known
3 throughout the United Kingdom that there was a problem
4 with paediatric cardiac surgery at Bristol."
5 Q. It is that that I want to ask you about. You say you
6 have been told. By whom?
7 A. Bob Black for the Down's Syndrome Association in West
8 Cornwall referred to conversations in hospitals in
9 Cornwall and Devon referring to Bristol as the "killing
10 fields", and I also personally know plastic surgeons --
11 Q. Can I ask you to come on to that in a moment and deal
12 with what Black has told you, which you are repeating to
13 us, when Bristol was known as the "killing fields".
14 What time? When?
15 A. The information he gave me, that it was known from 1990.
16 Q. From 1990?
17 A. Yes, I believe that is the information. I did actually
18 provide a copy of the letter sent to me.
19 Q. You did. To whom was it known as the "killing fields"?
20 A. This was conversation between surgeons and doctors in
21 South Cornwall and Devon hospitals.
22 Q. So the hospitals which would refer children to Bristol,
23 possibly?
24 A. Or did not.
25 Q. Some doctors there called Bristol the "killing fields"?
0115
1 A. Yes, sir, and some of the hospitals refused to refer
2 children to the BRI.
3 Q. But you accept that although you have given us the
4 source of the information and you appreciate that
5 enables us to make further enquiries if we should wish,
6 that this is, so far as you are concerned, something you
7 have heard from somebody else?
8 A. Yes, sir.
9 Q. And you have no independent means of knowing whether
10 that is true or not?
11 A. Of course not.
12 Q. You were going to go on to say, that is one reason, one
13 person or one source of my information, and you were
14 going to go on and deal with other sources?
15 A. Yes. Obviously, you know, which everybody must have
16 read, there are articles in papers, in Private Eye,
17 which I personally did not see. We know some plastic
18 surgeons in Wales who said that it was a source of
19 conversation at cocktail parties for quite a long time,
20 as to the problems the Bristol Royal Infirmary --
21 Q. Can we put a period of years on the "quite a long time"?
22 A. No, I cannot.
23 Q. So it may well be before 1990; it may well be after
24 1990?
25 A. It may well be.
0116
1 Q. Do you have any other source of hearsay?
2 A. Only the media.
3 Q. Do you want to go on with, "I do not know why no action
4 was taken...
5 A. "I do not know why no action was taken and I hope that
6 the Public Inquiry will be able to shed some light on
7 this issue. I believe it is the single most important
8 issue that the Public Inquiry must deal with. I firmly
9 believe, as I know many parents believe, that had the
10 individuals shown a personal conscience and the
11 authorities accepted their collective responsibility,
12 many lives would not have been lost. It was, and is, an
13 added insult that Mr Wisheart was created Director of
14 Surgery in 1992, notwithstanding problems with his
15 work. It is this failure of management which I perceive
16 to be the root cause of all these problems and it is my
17 opinion that had Mr Wisheart ceased dealing with
18 children suffering from AVSD that much of the heartache,
19 distress and anxiety which we all now feel would never
20 have happened.
21 "Mr Wisheart carried on operating in the arrogant
22 belief that matters would get better. In my view,
23 Mr Wisheart had dug a hole for himself and by 1992 had
24 got to rock bottom and unfortunately for us, continued
25 to dig."
0117
1 Q. Before you turn to your final matter, you have told us
2 those last two paragraphs are based on your
3 understanding of what the facts will show once the
4 Inquiry has explored them and come to its conclusions?
5 A. From the evidence that I have gathered, namely from the
6 GMC hearing.
7 Q. You talk about the failure of management which you
8 perceive to be the root cause of all the problems?
9 A. Yes, sir.
10 Q. The previous page -- we do not need to go back to it --
11 you talk about individuals needing to show a personal
12 conscience. In your own view, and it is only your view
13 I am asking for, is it an individual matter or
14 a collective matter, or both, as you see it?
15 A. It was certainly an individual matter that this affair
16 came to light, with the efforts that Dr Bolsin made to
17 try to correct the situation.
18 Q. You are going to comment on the history here, really.
19 I do not think I need to explore that further with you.
20 Do you want to turn to your final matter and read that
21 out to us?
22 A. "I have one final matter which I would wish to bring to
23 the attention of the Public Inquiry. This is a very
24 personal matter and one which has left my wife and
25 I feeling ostracised to a certain extent, and which is
0118
1 why I am grateful to be given the opportunity for making
2 this statement. Mr Henderson, the QC for the General
3 Medical Council, in his opening page, 1-38c, makes
4 reference to the length the GMC solicitors went to make
5 sure that everybody was contacted. In our case those
6 efforts were a farce. All the GMC solicitors had to do
7 was to ask our former GP in Cornwall where he had sent
8 our GP notes. That GP had our address. If the GMC
9 solicitors had undertaken that simple task, then my wife
10 and I would not have discovered that Mia was W12 by way
11 of a Panorama programme and our subsequent
12 investigations. I think it should be incumbent on
13 everybody that holds confidential information and needs
14 to use it, whether for public or private good, to go to
15 all the lengths that are necessary to make sure that
16 anybody who is to be involved in an Inquiry, whether
17 disciplinary or otherwise, is aware of the circumstances
18 before it starts. There can be no excuse and no reason
19 for any other conduct."
20 Q. Just two questions about that. First, I think it is
21 obvious from your evidence today that you have given
22 consent to this Inquiry to deal openly with Mia's case?
23 A. Yes, sir.
24 Q. Secondly if they had made proper efforts and had got in
25 touch with you, and I know you say they did not, is it
0119
1 at least acceptable that the GMC should have referred to
2 your daughter's case by calling it W12, rather than by
3 using your name and her name publicly without your prior
4 knowledge?
5 A. Yes. Without our knowledge, I think they would have to
6 not disclose the name.
7 Q. No-one else, other than you and Leen, would know that it
8 was Mia, would they?
9 A. No.
10 Q. That is all I am going to ask you, Mick. Is there
11 anything you think I should have asked you about which
12 I have not, and which you would like to add?
13 A. At this point, I think we have covered quite well.
14 MR LANGSTAFF: I do not know if the panel have any
15 questions?
16 Examined by THE PANEL:
17 THE CHAIRMAN: May I just ask one question: you talked of
18 Mia's scream. Did I understand you as saying you
19 thought the reason for that was being taken away from
20 you when she was still alert and awake?
21 A. She screamed when Dr Bolsin injected her.
22 THE CHAIRMAN: I see. I am grateful, thank you. Is there
23 any re-examination?
24 MR LISSACK: No, thank you.
25 THE CHAIRMAN: I am grateful.
0120
1 MR LANGSTAFF: You are free to go or stay as you wish.
2 Thank you very much indeed for coming.
3 THE CHAIRMAN: Mr Parsons, I echo that, thank you. I know
4 how difficult it was and I am very grateful. If you do
5 have, and you reflect in your statement you might like
6 to reflect on something and then get in touch with us
7 again, please understand that you are free to do so for
8 as long as we are sitting. Thank you very much indeed.
9 (The witness withdrew)
10 MR LANGSTAFF: Sir, it is now, I think, time for a second
11 short break. This time I would expect a quarter of an
12 hour. Mr McLorinan has had an advantage of speaking
13 already to Miss Grey who will ask him the questions to
14 be asked.
15 THE CHAIRMAN: I am very grateful, Mr Langstaff. We were
16 just talking here, perhaps 20 minutes, to reconvene at
17 1.30. Thank you very much indeed.
18 (1.10 pm)
19 (A short break)
20 (1.30 pm)
21 MISS GREY: Thank you, Chairman. I think we were hoping to
22 hear from Mr McLorinan this afternoon, so if I could ask
23 him to come and give evidence?
24 THE CHAIRMAN: Thank you.
25 MISS GREY: Mr McLorinan, if you could start perhaps by
0121
1 standing whilst you take the oath, please.
2 THE WITNESS: Sir, could I just say, no objections to taking
3 the oath, it is not something I take lightly, but I have
4 this to aid my memory. It says I have not consulted the
5 medical notes. My wife and I made three drafts of that,
6 and it is our sincere belief of what has happened, but
7 we have not checked Joe's medical notes. We have not
8 had an opportunity.
9 THE CHAIRMAN: I am grateful to you. I quite understand.
10 There is no impediment for you in taking the oath in so
11 far as you reasonably believe it is the case.
12 MR JOHN STEPHEN McLORINAN (Sworn):
13 Examined by MISS GREY:
14 Q. Thank you, Mr McLorinan. So I could repeat that, the
15 point you were making to the Chairman is that you
16 provided a statement to the Inquiry which was made
17 without access to the medical records?
18 A. That is correct, yes.
19 Q. But it was true to the best of your knowledge and
20 belief?
21 A. Yes. Myself and my wife collaborated.
22 Q. You will be giving evidence in exactly the same spirit
23 here and now?
24 A. Yes.
25 Q. So is your full name John Stephen McLorinan?
0122
1 A. It is.
2 Q. And are you a retired head teacher?
3 A. I am.
4 Q. Again, just so everyone knows what you have there, is
5 that a copy of the statement that you put forward to the
6 Inquiry, in front of you?
7 A. Yes. We made three attempts at the statement. This was
8 the final one, there was just a minor mistake in the
9 last sentence, so it is not the exact copy of that.
10 Q. Do you want to tell us what that mistake was, just for
11 the sake of the record?
12 A. On page 11, three lines up from the bottom.
13 Q. If you hold on for a moment, can we have on the screen
14 witness 122/11, so everybody can see what you are
15 referring to. Which paragraph is it?
16 A. This is paragraph 23.
17 THE CHAIRMAN: You want that up on the screen?
18 MISS GREY: Yes, could I have that up on the screen. Four
19 lines up from the bottom, it says:
20 "He does however remain susceptible to infections
21 and we therefore need to be careful. (b) I believe that
22 not only Joe as a patient but also the parents", that is
23 something that appears over here so it has been taken
24 out.
25 A. That is something that escapes my memory. It was
0123
1 a technicality, not a fact.
2 Q. Substantially you are happy with the contents of the
3 statement?
4 A. Yes, I am not challenging that at all, I am sorry.
5 Q. Not at all. Going back to the beginning, Mr McLorinan,
6 perhaps if you would like to refer to the statement if
7 you need to, to refresh your memory, but perhaps as best
8 as possible if you would like to tell us what happened
9 in your own words, that would be helpful to everyone's
10 hearing. Is it right you are married?
11 A. I am, yes.
12 Q. You have a wife called?
13 A. Gillian, Gill.
14 Q. She is a music teacher?
15 A. Yes.
16 Q. You have three children: Martha, Hannah and Joseph?
17 A. Yes.
18 Q. How old is Joseph?
19 A. Joseph will be 10 this November. He is 9 at the moment.
20 Q. When was he born?
21 A. He was born on 29th November 1989.
22 Q. Where was he born?
23 A. He was born in Southmead Hospital.
24 Q. In which town?
25 A. Bristol.
0124
1 Q. Immediately following the birth, did you discover
2 whether or not there were any problems?
3 A. Straightaway, yes. I should point out that my wife has
4 trouble in childbirth. The two girls were emergency
5 Caesarean sections up north with eclampsia and
6 pre-eclampsia, so when we came down here, we had
7 a marvellous GP here and she sent Gill for tests and she
8 found out it was physically impossible for her to have
9 a natural birth so we elected her to have a Caesarean.
10 They put Joe under the heater thing while the
11 paediatrician examined him, giving him a whiff of
12 oxygen, and I said "Put him back under the heater"
13 because he was the wrong colour and wrong shape and he
14 was gasping for breath, a typical boy, slow to start.
15 They said no, no, and took him out and had another
16 look. They said take him down the corridor. I started
17 walking nonchalantly down the corridor and then
18 I realised I was sprinting to keep up with them.
19 Q. What were you told about the nature of the problems that
20 Joe had?
21 A. That is all we were told straightaway. Into a room and
22 I must have waited, it seemed a long time, about an
23 hour, and nurses kept coming in with cups of tea and
24 that. The lady who -- a consultant had done the
25 delivery, but a very senior gentleman came in called
0125
1 Spyde or Spice or something like that, and he explained
2 Joe had profound difficulties with his heart and lungs
3 and things were not looking very good at all. I said
4 "Things are quite black then, aren't they?". He said
5 "I have not finished yet. He is a mongol, he has
6 Down's syndrome. The position is very grave indeed".
7 One of the staff offered to come with me to explain to
8 Gill what had happened, so we went up and explained to
9 my wife.
10 Q. Can you explain to us for a moment, who used the term
11 "mongol"?
12 A. It was this gentleman, Mr Spicer or Spyde, something
13 like that. I think he was one of the senior people
14 there.
15 Q. After that, was the term "Downs syndrome" used?
16 A. That was the only time it was used. "Down's syndrome"
17 was used after that.
18 Q. So Joe has Down's syndrome and he also has a heart
19 defect, you were being told?
20 A. Somewhere in the immediate aftermath of that, we found
21 out he had Hirschsprung's disease as well.
22 Q. Was Joe in a fit state to go home?
23 A. No, we expected him to die at any moment. He was
24 immediately put into an incubator with tubes and lines
25 and things all over the place.
0126
1 Q. That was at Southmead Hospital. Did he remain there for
2 long?
3 A. That was at SCBU at Southmead. I think I am right in
4 saying he was born on a Wednesday and he moved from
5 there on Thursday, after discussion with Dr Joffe.
6 Q. Where was he transferred to?
7 A. He was move to SCBU, St Michael's Hill, Bristol.
8 Q. Before he was moved to St Michael's Hill, had you met
9 any doctor who had particular care of him?
10 A. Initially we met the staff at Southmead. They more or
11 less stabilised Joe, but they said they wanted an expert
12 to come from the Children's Hospital. That was on the
13 Wednesday. On the Thursday, Dr Joffe came across to
14 Southmead and gave Joe a thorough examination. We were
15 not actually present when he examined him.
16 Q. If I can stop you for a moment, you are going a little
17 fast for the stenographer, so if you could slow down?
18 A. I am sorry.
19 THE CHAIRMAN: Do not apologise at all, so we make sure we
20 have everything you say, the lady there has to type it
21 out.
22 THE WITNESS: Do slow me down, if you have to.
23 MISS GREY: You were saying whilst still at Southmead
24 a Dr Joffe from the Bristol Children's Hospital came to
25 see you and he was identified as a particular
0127
1 specialist?
2 A. Yes, as a cardiologist.
3 Q. What sort of speciality did he have?
4 A. He was a heart specialist.
5 Q. A cardiologist, would that be right?
6 A. I believe so, yes.
7 Q. Was he experienced in children or adult cases or both,
8 do you know?
9 A. I am not sure. I think he was a paediatric specialist.
10 I am not sure he has dealings with adults.
11 Q. He came to see Joe. Did he examine him?
12 A. I believe so. I was not present.
13 Q. Did you meet him after any examination?
14 A. Yes, he came up to the room Gill was in.
15 Q. Were you there at the time?
16 A. Yes.
17 Q. Can you tell us what he explained to you about the heart
18 problem that Joe had?
19 A. Yes. Well, he came in, I think he perched on the end of
20 the bed and he was very calm and soothing and very
21 professional, and he explained very carefully that the
22 initial diagnosis was correct and that Joe did have
23 profound heart problems, and he explained that there was
24 a hole in the middle of the heart and the valves were
25 not working properly and blood was sort of slushing
0128
1 around and not doing a proper job and that was affecting
2 the breathing and everything else.
3 Q. Did he give any particular name to the hole or chambers
4 in the heart at that stage? You cannot remember?
5 A. I cannot honestly remember. We were so familiar with
6 the term "AVSD", I do not know where we picked it up.
7 He explained it very thoroughly. Probably he explained
8 what it was there and then, and so we grew into the
9 term.
10 Q. That is the term you are now familiar with for Joe's
11 condition at the time?
12 A. Yes. I think it was severe enough to be obvious as soon
13 as he had done his examination.
14 Q. He explained about the condition of the heart. Did he
15 go on to explain the options for Joe's management and
16 treatment?
17 A. Yes, he did. He made it quite clear that there were
18 three options. I was quite furious at the time.
19 Q. Would you like to tell us why you were furious at the
20 time?
21 A. I think it was because of my perception of doctors
22 diving in and automatically saving life and doing what
23 was best for the child and, looking back, I can see
24 there was a definite policy they have to follow which
25 was very professional, so we had the choice of letting
0129
1 Joe go, or he said there was this other possibility that
2 he could be sort -- I am not sure whether it was to do
3 a banding there pretty soon or just take him on with
4 drugs.
5 Q. Just stopping you there, you said that you were talking
6 about why you were angry and what your expectation of
7 how doctors would behave was?
8 A. Yes.
9 Q. You then went on to talk about the first option, which
10 was that of letting Joe go?
11 A. Yes.
12 Q. Was that related to the fact that you were angry in any
13 way?
14 A. I suppose, I am not sure that "anger" was perhaps the
15 correct word. I suppose I was just dead anxious for
16 somebody to take Joe away and fix him, put him all
17 together. There was this child in need and somebody was
18 saying "Perhaps you have the option of letting him go".
19 Q. So if the first option was to let Joe go, what was the
20 second one?
21 A. The second option was, if possible, given all the
22 hurdles and ifs and buts, that it was possible, without
23 doing major heart surgery, he could have been jollied
24 along until the age of about 10 or 11, at which stage it
25 was explained he would become increasingly breathless
0130
1 and would eventually die because everything would pack
2 up and he would not be able to cope.
3 Q. If that required jollying long, that second option, what
4 made the difference between letting go and jollying him
5 along?
6 A. I am sorry about the phraseology. Certainly it was made
7 clear to us there would be a regime of drugs. I put in
8 the statement about banding. I am not sure if that was
9 mentioned then or at a later date. Obviously before you
10 go to the third stage, if the pressures are being shot
11 through it is no good and you have to have a banding.
12 Q. Can I stop you again. For the sake of clarity, is it
13 right that at some stage you understood that banding was
14 part and parcel of what you might call the second option
15 for Joe's care and management?
16 A. That is as I understood it, yes.
17 Q. Tell me about the third option.
18 A. The third option again, these things obviously went in
19 stages, the more hurdles there were the further we went
20 on with this, but the possibility was suggested that
21 eventually, if we wanted to, we could be referred to the
22 heart surgeon who would open the heart up and do a full
23 repair, put it all back together again. But right from
24 the outset, it was explained all sorts of hurdles and
25 difficulties and dangers and it was looking so far ahead
0131
1 and in fact Joe was so ill at the time we were looking
2 almost an hour or a day ahead.
3 Q. So the third option was the one that involved long-term
4 repair?
5 A. Yes.
6 Q. But it might take some time before Joe was in a fit
7 state to get to that stage. And possibly, if you were
8 only looking an hour or so at a time ahead, he might not
9 get to that stage at all is that a fair summary?
10 A. Yes. We had very much in mind that there was a sort of
11 optimum stage fairly on in life, not say before an early
12 age, but because he was small anyway he had to be as big
13 as possible without things getting too pressurised in
14 his lungs.
15 Q. What did you understand about the second option,
16 jollying Joe along, would mean in terms of his long-term
17 prospects?
18 A. I think his long-term prospects, certainly the best
19 option, I suppose, for those long-term options, would be
20 for him to last to about the age of 10 or 11 if things
21 were good, and he would obviously not be able to do much
22 running and leaping about and ordinary sort of life.
23 Q. So the only option, is this fair, that allowed him to
24 survive beyond the age of 10 or 11 was the corrective
25 surgery, the third option; is that right?
0132
1 A. Yes.
2 Q. Can you tell us a little bit about how Dr Joffe was able
3 to explain those three options to you and to your wife?
4 A. We did not have any diagrams at this stage, as have been
5 mentioned for other people. He just sat there and
6 explained very slowly, very carefully and very clearly,
7 the various options and the problems. He was prepared
8 to repeat himself. He was prepared to answer questions
9 and he was very calm and he had a very good manner. His
10 clarity of expression and also his presence of calmness
11 and because we were so tense and panicking, almost,
12 I think it took a great deal of skill to be able to
13 communicate accurately with people in our situation, but
14 I think he successfully enabled us to make important
15 decisions.
16 Q. At the end of that discussion, then, did you feel you
17 had had a proper opportunity to ask him all the
18 questions you needed to?
19 A. Oh, yes, yes.
20 Q. What did you do to decide which of those three options
21 you wanted to progress with?
22 A. To be honest, we did not really consider any other
23 option than the full repair, because having brought
24 a child into the world, we thought we would "go for
25 broke", you know, it was not fair on Joe just to let him
0133
1 live a few months or a few weeks or whatever, he ought
2 to have the opportunity of as full a life as possible,
3 so we did not really consider either of the first two
4 options, in all honesty. We wanted to go for it.
5 Q. Did you understand anything about the risks that such
6 corrective surgery might bring with it?
7 A. Well, indeed. In fact, we understood that he might not
8 even get as far as corrective surgery. It was in many
9 ways, talking to Dr Joffe, and people later on, in many
10 ways it was depressing, because they were saying, "But,
11 if, it might not, we have not got there yet, there is
12 this problem". So they were very good at calming us
13 down, "There is this problem, there is that problem, we
14 cannot guarantee this".
15 Q. If Joe did survive long enough to be ready for surgery,
16 was anything said about the risks of that?
17 A. Yes, but I think surgery at that stage was so far in
18 advance and perhaps so indeterminate that certainly no
19 statistics were mentioned. We just knew it was a very
20 difficult time.
21 Q. So you have mentioned then that for you and your wife,
22 really, the only option was to try and aim for the third
23 option?
24 A. Yes.
25 Q. Even though it might take a long time to reach that
0134
1 point, and Joe might never reach it?
2 A. Yes.
3 Q. So did you tell Dr --
4 A. I am sorry. I did not mean to interrupt, but I think
5 I should also explain that Joe not only had the heart
6 problem, we were also made very aware of the Down's
7 syndrome and that Down's syndrome people reacted very
8 differently to things and were more susceptible to
9 infection, and also he had this Hirschsprung's disease
10 which was a major problem as well. Apart from the
11 cardiac problem he was a whole mess as well and things
12 all piled on top of each other, so it was very difficult
13 to comprehend anything beyond an immediate fault. We
14 were just very, very aware of how delicate his life was.
15 Q. You decided from the point of view of managing the heart
16 problem, you wanted to try and take him to corrective
17 surgery if you could?
18 A. Yes.
19 Q. Did you tell Dr Joffe that straightaway, or what did you
20 do?
21 A. Well, he satisfied himself that he had explained things
22 to us and we did not want to ask anything else, and then
23 he said that he would leave us and go back to -- he had
24 pressing business in Bristol. He said "Discuss it
25 amongst yourselves and when you feel you are ready to
0135
1 make a decision, let the person in charge here know",
2 because if we decided to go for it, he would have to be
3 moved to St Michael's Hill, for Miss Noblett to get him
4 in for the Hirschsprung's.
5 Q. Did you do that?
6 A. We did and did not. Both of us, it went without saying
7 that we wanted to go for it, but I said to Gill, "Hang
8 on, if I go out of the door now and say we are going for
9 it, they will think we have not gone through it
10 properly", so we pretended to talk it through. We
11 nonchalantly went through the door and found the sister
12 and she said "We thought you would say that, I will make
13 arrangements for transfer".
14 Q. So arrangements were made to transfer Joe to the Bristol
15 maternity hospital, is that right?
16 A. Yes, the special care baby unit there.
17 Q. Were there any problems over the transport?
18 A. Yes.
19 Q. What were those?
20 A. Could I just say, I had another problem at the time as
21 well, in that my father, who was a marvellous gentleman
22 and had wonderful timing and never let me down at any
23 time in his life, took sick in the September before. He
24 was a sick man anyway, but he went into hospital before
25 Joe was born and he died on the Wednesday before Joe was
0136
1 born on Friday night.
2 Q. So you were coping with the distress of two difficult
3 events at the same time?
4 A. On the Thursday I went to see Joe and Gill in the
5 morning and then went to Shropshire. Gill had managed
6 to get to St Michael's Hill but Joe had not, because
7 there had been some sort of dispute with the ambulance
8 crews and the availability of vehicles, and the actual
9 transport was posing a problem. The lady that operated
10 on Gill said that if necessary she would personally
11 drive her there, but they got her there in two parts.
12 Q. Gill went first and then Joe went?
13 A. Yes.
14 Q. By ambulance?
15 A. Yes.
16 Q. Do you know what sort of ambulance crew was able to help
17 on that transfer or not or not?
18 A. No, because I was in Shropshire when it happened. There
19 were problems because apparently his bottom, they
20 realised he had this Hirschsprung's and it was not
21 supposed to work and it did, and made a bit of a mess,
22 and then he managed to knock the tube out which was
23 ventilating him so they had to sort that out and that
24 made a bit of a delay, and that made Gill even more
25 worried because she did not know what had happened, but
0137
1 eventually they both arrived there.
2 Q. When Joe was in the Maternity Hospital, did he have to
3 have operations for other conditions that he was also
4 dealing with at the same time?
5 A. Yes. The immediate problem was the Hirschsprung's
6 disease, because he was not able to pass food through
7 his alimentary canal. He was not able to take milk
8 naturally anyway, so he ended up on a bottle and was fed
9 by tube, but once the food was in him it would not go
10 anywhere, so in order for him to survive he had to have
11 the offending bit taken out and a colostomy bag fitted.
12 Q. What impact did that have on the timing of any treatment
13 for his heart condition?
14 A. The heart condition was sort of treated with drugs.
15 I think he was on Cysopride (?) and Frusemide, and
16 perhaps something else as well. He was in heart
17 failure, which we noticed on his records and panicked,
18 and one of the doctors came and explained what it was,
19 that we should not panic too much, but the operation on
20 his bowel was paramount, so he was immediately prepared
21 for that and again, as a measure of how ill he was, we
22 really expected that he might not be around for very
23 much longer, so we said to one of the staff there, "If
24 he does die, I do not suppose any of his organs will be
25 any good because he is Down's syndrome, is he not" and
0138
1 the person we spoke to, I think it might have been
2 Dr Bailwood, I forget, said "You want him to live.
3 There is going to be such a hell of a fight, if we lose
4 him, there is not going to be much left anyway", so we
5 were comforted to think they were all behind him.
6 Q. Did you get the impression from that that there was
7 a team fighting on Joe's behalf?
8 A. Very much so, yes. At this time it was being
9 co-ordinated by Dr Marlow, one of the chief
10 paediatricians there.
11 Q. Dr Marlow, Dr Fleming?
12 A. Dr Fleming, yes, he came to see Joe when Dr Marlow was
13 doing other things and they co-ordinated with
14 Miss Noblett and other people.
15 Q. Miss Noblett was looking after Joe's bowel and colon
16 condition; is that right?
17 A. Yes.
18 Q. At what point was Joe discharged from the Maternity
19 Hospital?
20 A. I have a feeling it was about six weeks.
21 Q. Was he able to stay at home for any length of time?
22 A. No, no. He was home for about a week, and then he
23 developed a severe chest infection which went to
24 pneumonia, and he was taken back to Bristol, to the --
25 not the Maternity Hospital, the Children's Hospital.
0139
1 Q. Which ward on the Children's Hospital, can you remember?
2 A. I do not remember the actual ward, but it was one of the
3 ones where they had an individual cubicle on their own,
4 and I think things soon deteriorated, he was soon in
5 ITU, anyway.
6 Q. What impression did you get of the Bristol Children's
7 Hospital from the point of view of being an environment
8 for children?
9 A. The Children's Hospital I found, after a time, we
10 regarded it as home, really, it was safe and secure.
11 The building itself creaked as you walked along it, it
12 seemed very Victorian, out of date and unsuitable, but
13 it seemed to contain a wonderful staff who more than
14 compensated for the building itself. They were
15 exemplary in every way; every member of staff was.
16 Q. What about from the point of view of you as parents:
17 were there any facilities that allowed you to stay with
18 Joe if you wanted to?
19 A. I suppose the best facility was a person called Mrs Jill
20 Gill, who was the social worker. She would come around
21 daily and she seemed very concerned as to the health of
22 myself and Gill, because we were travelling, we were
23 covering between 150 and 200 miles a day. We made sure
24 Joe got three or four visits a day, and she used to give
25 us money for petrol too. She was a wonderful person.
0140
1 There were rooms where you could go and buy things from
2 machines and that, and I think there were rooms for
3 parents to stay, but very often they were bursting at
4 the seams and I think Joe was so young at the time that
5 we spent most of the day there and there was just about
6 6 hours during the night when we were both at home.
7 Some parents could stay in hospital, but I do not think
8 there was accommodation for everybody. I think the
9 parents who lived furthest away whose children were most
10 ill had priority.
11 Q. How good were the nurses at involving you in Joe's care?
12 A. They were very good. We were virtually part of the
13 team, really. I think, certainly in ITU he had somebody
14 with him continuously all the time, and the thing is,
15 when we arrived, we sort of cross-examined the nurses as
16 to his progress and would look at his notes and go
17 through it and they would explain things and show us how
18 to use any instruments around and if he needed his mouth
19 moistening or cleaning. I was impressed because the
20 staff were so meticulous. He was monitored very
21 closely, the amount of fluid he was retaining, so they
22 could tell you how much fluid he lost in perspiration
23 during the day. Even the nappies had to be weighed
24 before and after to work out how much food he was
25 getting rid of, and we were involved in that. We were
0141
1 involved in every possible thing we could do.
2 Q. What sort of things did you do?.
3 A. Weighing nappies, changing nappies, cleaning his mouth
4 out, changing his colostomy bag, making him comfortable,
5 whenever possible picking him up for a cuddle. They
6 also were very good because the girls were not all that
7 old at the time and the nurses came along and helped the
8 girls through that. When it was appropriate, they got
9 the girls to help out doing things on the ward like
10 taking nappies around and sometimes they made mice out
11 of little bits of things for the girls, so they made
12 everybody a welcome part of the team.
13 Q. So Joe was in the Children's Hospital at this point for
14 really quite a length of time, I think?
15 A. Yes.
16 Q. He was in there on this particular admission from
17 25th January 1990 to 13th March; is that right?
18 A. Yes, I should think it is.
19 Q. During that time it is right, is it not, that he had to
20 deal with a number of problems, not merely the heart
21 defect which has been the focus of today's evidence.
22 You mention, I think, that he developed ascites; is that
23 right?
24 A. Yes.
25 Q. Because of the various difficulties that Joe was
0142
1 experiencing, what happened from the point of view of
2 deciding what management needed to be taken of his heart
3 condition?
4 A. Without sort of the benefit of the records, thinking
5 back, the thing that stuck in my mind most was that
6 Dr Joffe and his senior members of his team would come
7 around. We would always be there when they came round.
8 They took great pains to explain to us, he has taken two
9 steps forward, one step back.
10 Q. Can I stop you there, you need to speak up a little so
11 the Chairman can hear you. You were explaining Dr Joffe
12 would come round with his team?
13 A. They were explaining what was happening, one step
14 forward, two steps back. They were explaining the
15 different drugs they were going to use, but on the heart
16 business they were failing because the heart was not
17 able to shift the blood and fluid around the body, so it
18 was accumulating, getting worse and worse. The
19 situation was just deteriorating and they were in the
20 best possible way saying "We cannot do anything else"
21 sort of thing. We really got to the stage where we
22 thought we would be called into a discussion to say,
23 "Well, do we call it a day?", you know.
24 Q. You have mentioned that things were deteriorating. You
25 have also said you do not have the benefit of the
0143
1 medical records. Can I just ask you to have a look at
2 page 171 of medical record 2469, just on my screen
3 first.
4 If we could just enlarge the two central
5 paragraphs of that, if you could take it up so the
6 address is missing. If you could just take it from me,
7 Mr McLorinan, that is a record of a joint cardiac
8 surgical radiological meeting on 21st February 1990, and
9 that various individuals, including Dr Jordan,
10 Mr Wisheart and Mr Dhasmana, were all present at that
11 meeting?
12 A. Yes.
13 Q. There is a review, is there not, of a cardiac
14 catheterisation procedure that has recently taken place
15 and a discussion of how Joe is to be managed at the
16 second paragraph of that note.
17 A. Yes.
18 Q. Mention there that "in the light of Joe's poor progress
19 and difficulty being reined off ventilation, it was felt
20 that a palliative operation would be preferable to
21 attempting a complete correction, which is likely to
22 have a low likelihood of success."
23 Do you remember that advice being given to you,
24 Mr McLorinan?
25 A. Yes, and no. This is referring to the banding
0144
1 operation, is it not, and I think what actually happened
2 was -- I mean, to be honest, we saw so many doctors on
3 so many occasions it is very difficult to pinpoint it,
4 but I am very aware that one morning we rang up as we
5 usually did to see how Joe was and they said "Come on
6 in, it is more or less a crisis point, we want to do
7 this emergency banding", so that is what we did. When
8 we got there, I think it was Alan Smith, one of the
9 senior Registrars --
10 Q. Can I stop you there, you have talked about the
11 emergency banding operation. Can you just explain to us
12 what you understood was to be done in this procedure?
13 A. We understood there was an artery coming from the heart
14 and that Mr Wisheart would open Joe's chest up and put
15 a band on this artery to restrict the pressures on it,
16 to keep the pressures down so it did not damage the
17 lungs, and also ensure that there was a more efficient
18 working of the heart so it would improve Joe's
19 condition, and we also understood this ductus which was
20 mentioned which should have closed naturally did not,
21 and that that would be done as well. We did actually
22 get a little diagram from Alan Smith on that, a piece of
23 paper.
24 Q. Who explained all this to you?
25 A. This was Dr Smith, I think. Probably I would have said
0145
1 perhaps Dr Tizzard. As I said, we saw so many of them
2 so often, it is difficult to recall.
3 Q. Was Dr Smith Dr Joffe's senior house officer?
4 A. I believe he was, yes.
5 Q. They explained everything in detail to you?
6 A. Yes, and also the very great risk that was involved in
7 this procedure.
8 Q. What did they say about the risks?
9 A. There were very grave risks, but we knew that. We
10 understood Joe was in fact dying and there was nothing
11 that could be done with drugs, and this is something
12 which very likely would not work, but if it could work,
13 it would solve the problem for the time being.
14 Q. Did they put an exact percentage on the risks, or were
15 they simply discussed in general terms?
16 A. To be honest, I cannot recall any percentage. We just
17 understood it was very, very serious and we were more or
18 less prepared that he was going to die during the
19 procedure, because we knew that Mr Wisheart did not
20 really want to operate, but there was no other way round
21 it and that was a last desperate attempt in a way.
22 Q. So it was something of a last resort or chance for Joe?
23 A. Yes, I think it was his only chance, yes.
24 Q. Did Mr Wisheart explain any of this to you?
25 A. No, he did not. That was not the fault of Mr Wisheart,
0146
1 but we went to the intensive therapy unit and we saw the
2 staff, as I have explained, and somebody, I think it was
3 the sister on the ward, said that it will be best not to
4 hang around the hospital, but she found it better for
5 people to go walk about and do things. So Joe was taken
6 down and we thought, "Well, we will go", so we did. It
7 was not until afterwards that we found that Mr Wisheart
8 expected us to be there before the operation and he was
9 going to have a word with us, and he went absolutely
10 ballistic with the staff for letting us go, but it was
11 just a misunderstanding. As it was, we were perfectly
12 satisfied with the explanation we had off the other
13 members of staff, anyway.
14 Q. So it was Mr Wisheart, then, who carried out the
15 operation?
16 A. Yes.
17 Q. And you went for a walk around Bristol, did you, while
18 it was being carried out?
19 A. Yes, I am afraid that is one of the things, we popped in
20 the Cathedral and had a meal of fish and chips somewhere
21 and wandered around Marks & Spencers. It was
22 unbearable, the tension and the worry. Unless you have
23 been through it you do not know.
24 Q. Was it your idea to wander round Bristol?
25 A. No, I think it was one of the staff in intensive care.
0147
1 Q. Do you think there would be a better method of treating
2 this difficult period for you?
3 A. For myself, I think that was probably the best thing to
4 do. Being Christians we went to the Cathedral and had
5 a quick burst with the Lord. By nature I cannot sit
6 doing nothing, I think I am better employed wandering
7 around than sitting.
8 Q. So how did you find out the results of the operation?
9 A. Well, I think we were advised to come back about half
10 past 5 and we found ourselves going up the steps of the
11 hospital about 5 o'clock and there was a light on
12 upstairs which we took to be the operating theatre, and
13 I was full of gloom and despondency, not really wanting
14 to go in. As it happened, Dr Joffe was coming down the
15 steps, he was going home, and he stopped and said
16 "Hello, I have put my nose in and things seem to have
17 been going quite well", which was a relief, and then we
18 found it easier to go up to the intensive care there.
19 They were all set up waiting for Joe to come
20 back. There was somebody designated to be with him all
21 the time, as you would expect, and we came back and were
22 very relieved and surprised to see him.
23 Q. So did Mr Wisheart explain, then, how the operation had
24 gone?
25 A. He did explain. I honestly cannot remember how long it
0148
1 was after. I can remember him standing in the IT with
2 his hands in his pockets looking at Joe, and I was
3 leaping up and down saying "Great, this is it", and he
4 was saying "Slow down, there are many hurdles ahead and
5 it is all very dodgy", but he did explain, yes.
6 Q. You have talked about this being a difficult and
7 stressful time for you and I think you have mentioned in
8 your statement an incident which happened before this
9 episode, when Dr Joffe gave an explanation to you and
10 your wife about how the future for Joe might progress
11 over the next few months?
12 A. Yes. I think you will probably be referring to the time
13 when I went to get the car and came back and my wife was
14 not in the waiting room, yes.
15 Q. Can you explain that incident?
16 A. We had lots of meetings with Dr Joffe. We were by this
17 time looking forward to corrective surgery, hoping and
18 daring that it would come. On this particular occasion,
19 Dr Joffe in his usual way was very carefully and calmly
20 explaining things, and he was explaining that it was not
21 just automatic that corrective surgery could be done,
22 reminding us that beforehand he had to have this
23 catheter and investigations to see whether in fact
24 corrective surgery was possible, and I was thinking,
25 "Oh, good, if he can get through that we can get on to
0149
1 the real thing", and so we discussed all sorts of things
2 and again we were very happy with the interview and the
3 examination of Joe, so we came out and Joe was very
4 small and had got this tube up his nose and his
5 colostomy bag and various other things. I went to get
6 the car. When I came back the waiting room was packed
7 and Gill was not there. I thought "This is funny", and
8 then one of the nurses came up and took me to what was
9 virtually a little cupboard with shelves inside and
10 stuff, and there was Jill inside, crying. She was
11 cuddling Joe and pointing out that the catheter and the
12 investigations might rule out the possibility of
13 surgery, and she thought that was the end. I said "It
14 is not that bad, there is a possibility, we have not
15 lost it yet". It struck home to us very much the
16 importance of listening carefully and the fact we tended
17 to select what we wanted to remember. We were in such
18 a state of tension --
19 Q. Can I just stop you there. You said that the lesson was
20 that it was important to listen carefully and also that
21 one tended to select different things from what you were
22 hearing said by a speaker?
23 A. I think so, yes.
24 Q. What do you mean? Is that a feature of the way in which
25 you and your wife listened to people on a number of
0150
1 occasions, that you might take different things from --
2 A. No, what I mean is, I think that we were both in such
3 a state of worry and anxiety, it had gone on for so
4 long, and we were so desperate for Joe to get fixed,
5 that we were there listening and just by chance the
6 brain would snatch on to one pieces of information, it
7 might be a good piece or a bad piece, but just the sort
8 of things that stuck.
9 Q. What sort of pieces was your wife taking and what sort
10 of pieces were you taking?
11 A. On this occasion, the fact that some children had
12 catheters and had echos, and it proved there was no
13 point in operating, the operation was not possible, it
14 would not work, so she was convinced that Joe would be
15 one of these people and that would be the end. I on
16 that occasion was more optimistic, saying "He will sail
17 through that, pass the tests and have the operation".
18 Q. Is it fair to say on this occasion your wife had picked
19 up the difficult or gloomy pieces of news, and you had
20 picked up the opposite?
21 A. Yes. That is why we always went together, but I made
22 certain whilst I was in town we would both go and
23 discuss things fully, and discuss things together
24 afterwards, as well.
25 Q. We have talked about the operation that Joe had for
0151
1 banding of the pulmonary artery and repair of the
2 ligation of the ductus. That was a successful
3 operation?
4 A. Yes, yes. There were problems afterwards because --
5 I think it was afterwards, the pericardium kept filling
6 up with fluid.
7 Q. I think it is right to summarise, is it not, that he
8 came home with you initially, but then had to be
9 readmitted within a week or so because of that problem?
10 A. Yes. I think, again, I said we had a brilliant GP.
11 I think it was the health visitor that lent us
12 a super-sensitive set of scales for weighing him,
13 because there was a problem with feeding and we noticed
14 his weight was increasing, but it was the fluid
15 collecting.
16 Q. During all of this period, how close to death was Joe
17 regarded as being?
18 A. I think very close to death. I may be melodramatic, but
19 I remember on one occasion I counted about seven times
20 when we could have lost him. Talking about this problem
21 with the pericardium, when he was in hospital he would
22 be drained and I think there was one occasion the nurse
23 told us that I think Dr Joffe and Dr Smith were down
24 there preparing to drain Joe and the nurse said, "Can
25 you stop talking and hurry up, please, I think Joe has
0152
1 arrested". I think it was that dodgy.
2 Q. If Joe was at that time very unstable, in a very
3 dangerous state, what impact did that have about how his
4 heart condition could be managed and taken forward?
5 A. Well, it was -- I suppose again it was day-to-day
6 management. I think he was by this time on perhaps one
7 diuretic, after the operation, or maybe -- I am not
8 clear about that. That had made a significant
9 improvement, but still we were looking forward to just
10 a day, a bit at a time, controlling it and hoping he
11 would stabilise and trying to build him up to this
12 optimum size in order to get through the catheter and
13 the echo and to have this big operation. But we were
14 very pessimistic at times about whether he would make
15 it.
16 Q. What sort of risks did the medical staff consider to be
17 acceptable from the point of view of getting Joe to the
18 stage when that operation could be undertaken?
19 A. I am not sure. Are you talking statistics here and
20 percentages?
21 Q. Did they talk about what would be an acceptable risk for
22 Joe to undergo that operation?
23 A. Very generally, I have a vague recollection when he was
24 first in SCBU at St Michael's Hill, somebody said he had
25 about a 20 per cent chance of survival, and I think the
0153
1 aim was to get him up to about 50:50, but we will
2 probably talk about statistics later.
3 Q. I get the impression of a number of procedures being
4 taken, continued at any one time, echoes, continued
5 catheterisations, all in order to manage Joe and to get
6 enough information to build up to the point where he
7 could undertake corrective surgery. Is that a fair
8 summary?
9 A. Yes. I think it is, yes. Everybody did as much as he
10 or she possibly could to stabilise him, to get him to
11 progress, to build up to the surgery, yes.
12 Q. Did there come a time when it was thought that it was
13 appropriate for Joe to have that surgery?
14 A. Yes, there was. My wife attended a session with
15 Mr Wisheart and Joe and Gill Gill, the social worker,
16 was at a big meeting. At that time I was working in
17 Yorkshire so I could not go, but I was quite happy for
18 Gill to go. I spoke to her that night on the phone.
19 Q. If I could ask for medical record 2523/50 to come up on
20 my screen, and just if you could enlarge it so the two
21 substantial paragraphs only are showing, can we get rid
22 of the address at the top, please?
23 If you could show that on the screen, please, that
24 a letter from Mr Wisheart, if you take that from me,
25 dated 10th October to Mr Joffe at the Bristol Children's
0154
1 Hospital. He is reviewing there the results of the most
2 recent catheterisation and the fact that some
3 reassurance about Joe's left ventricular function and
4 therefore presumably his cardiac output has been
5 provided by that catheter insertion. He is then
6 discussing there a discussion with Joe's mother, your
7 wife, about the possibility of corrective surgery, on
8 the basis of risks being 50:50, and he says there:
9 "There has been a full discussion of all the
10 potential risks and benefits involved."
11 Can you just tell me, tell the Inquiry, what your
12 wife reported about that discussion with Mr Wisheart?
13 A. If I may, I think to go back a little before that,
14 I think when, it would probably be, Dr Joffe did the
15 catheter and echo and that, and he reported to Gill it
16 was not straightforward, that Joe was borderline on the
17 possibilities of having it, but he said if he was a bit
18 more borderline I would have been really worried, but we
19 really got the impression that Mr Wisheart was not at
20 all happy about undertaking the operation. It was
21 something he did with great sort of qualifications and
22 reservations. I remember Gill saying to me on the
23 phone, he had even said to her, "It is all very fine
24 having a Down's syndrome boy at Joe's age, but having
25 a Down's syndrome teenager is a very different thing."
0155
1 I think he was very, very reserved about going into the
2 operation.
3 Q. Can you just explain to us a little bit more: what
4 impact did the fact that Joe was Down's syndrome have on
5 any reservations that Mr Wisheart may have felt?
6 A. I think that first of all I would like to say it was not
7 in any way a discrimination against Joe because of his
8 Down's syndrome, but I think he was trying to explain
9 that the needs of a Down's syndrome person are vastly
10 different from an ordinary person, in that they do have
11 special needs. Even now Joe is at a special school, but
12 even medically now, if he has problems -- at the moment
13 he has a chest infection, it is something you have to be
14 vigilant for, and as soon as he gets an infection, we
15 ring up the GP and they say there are no appointments
16 this week, and we say it is Joe McLorinan and they say
17 bring him. We have that special arrangement.
18 Q. Was that something Mr Wisheart was keen to explain to
19 you?
20 A. Yes, I think so. I do not know if it is appropriate to
21 say -- I was going to say something about Bristol and
22 Down's syndrome. It is probably not appropriate.
23 Q. If we could just talk about Joe's case here, what
24 I would like to ask you is whether you can tell us what
25 reservations Mr Wisheart had about corrective surgery.
0156
1 You have mentioned one, the fact that --
2 A. I think the actual AVSD itself and the state of the
3 heart was a problem, and also the fact that as Joe did
4 have Down's syndrome, I think we were very aware that
5 any procedure, anything at all that Joe had in the
6 hospital, there was an added risk because he was Down's
7 syndrome.
8 Right at the very beginning, when they introduced
9 drugs to him, they deliberately did not introduce the
10 amount of drugs they thought he needed, they started him
11 on a small amount in case, because of his Down's
12 syndrome, he had an unfavourable reaction. He was very
13 cautious about that. If you mentioned to any of the
14 anaesthetists that Joe needed anaesthetising, they
15 practically crawled up the wall because he was Down's
16 syndrome; his arteries and veins are so small it is
17 impossible to get a line in, and there are all sorts of
18 added problems and complications.
19 Q. Were you aware at any stage of any reluctance to give
20 Joe operative assistance or treatment throughout his
21 stay because of Down's syndrome?
22 A. Not because of Down's syndrome as such, no, because of
23 the problems that Down's syndrome brought, people were
24 saying because he is Down's syndrome, there are extra
25 risks, but the fact that he had Down's syndrome itself
0157
1 did not make any difference whatsoever.
2 Q. What then ultimately was Mr Wisheart's position in the
3 advice he gave to you and your wife about the
4 appropriateness of corrective surgery?
5 A. I think we were very well aware of the fact that even
6 though Joe had had the banding, he was not doing
7 particularly well and obviously his prognosis of life
8 was not very good, and we realised that to make
9 a success of Joe's life and any sort of permanency of
10 life, we would have to have the surgery done. We have
11 these figures here, 50:50, and these percentages, that
12 is a big thing. I suppose our understanding of the
13 statistics -- we are both teachers and I sort of
14 specialised in statistics and psychology in my final
15 year -- we are very much aware of statistics as
16 something you can use one way or another without
17 co-efficients of validity and reliability and all that.
18 You spend years studying these things in education, and
19 they say statistics do not mean very much anyway. By
20 50:50, we understood that Mr Wisheart, through the
21 totality of his experiences and his skill -- we
22 understood there was as much chance of Joe succeeding in
23 the operation as failing. Putting it crudely, it was on
24 the toss of a coin, but we wanted him to have that
25 chance and we were confident.
0158
1 Q. Did you ever at any stage wonder whether he would have
2 a better chance at any other centre?
3 A. That is an interesting question. We did and we did
4 not. The problem was, you see, I had been appointed as
5 a head teacher up in Yorkshire and I had been appointed
6 before Joe was born. Then he was born. So
7 I immediately got them to put off my move. I was
8 fortunate in getting a term's work down here to be with
9 Joe in the immediate crisis. Then I went up and took up
10 the job and commuted back and forth at weekends.
11 There were all sorts of rumours going on about
12 reforms in the NHS and we were hearing stories and that,
13 so we realised which hospital we would have been under
14 had we moved up north. Our belief was that there was
15 nobody up there with sufficient skill to perform these
16 sort of operations; they would not have been offered.
17 People in that situation were told, "I am sorry, it is
18 inoperable".
19 Q. Can I just ask you, you said that your belief was that
20 there was nobody who had sufficient skill to carry out
21 that operation up north?
22 A. Yes.
23 Q. On what was that judgment based?
24 A. I believe there was somebody appointed at a later date
25 in this hospital who was in fact trained under
0159
1 Mr Wisheart in Bristol.
2 Q. Well, you were making a judgment at that time?
3 A. Yes, at that time, we were told --
4 Q. At that time you were told by whom?
5 A. As I said, Gill was a bit worried about this, so she
6 asked Dr Tizzard, I think she was part of Dr Joffe's
7 team. She made enquiries and came back and said, yes,
8 she understood it would not be possible.
9 Q. Was that because nobody had enough skill to operate up
10 north, or was it because --
11 A. That is what we believed: that they did not do that
12 operation in that particular place.
13 Q. That may be two different factors: one is that nobody
14 has the skill to carry it out; the second factor, which
15 perhaps you mentioned, was that nobody would want to
16 carry it out?
17 A. Yes. I think there are two quite distinct issues here,
18 and I think that is one of the reasons why I actually
19 gave up the job and moved back down here. Certainly
20 I believe that the information was correct that they
21 were not doing that operation there, but secondly, as
22 the previous witness said, this is Downs Heart Group,
23 and we were members of the Downs Heart Group. The Downs
24 Heart Group obviously were promoting the support of
25 children with Downs, with heart problems, and they were
0160
1 doing research and coming up with alarming statistics,
2 that people with Down's syndrome were not being offered
3 equal chances of these operations.
4 Q. So from that, you thought there might be a problem in
5 persuading another hospital to offer Joe this
6 operation? Is that a fair summary?
7 A. We were certain of that, and we were also certain that
8 we would not get a better surgeon, a better team; we
9 could not do better anywhere else. Quite apart from the
10 actual operation itself, the follow-up afterwards.
11 Q. If you were certain that you could not get another
12 hospital to do the operation up north, is that because
13 of the information you had had from the Down's Syndrome
14 Group, or what was it based on?
15 A. It was primarily on Dr Tizzard's enquiries, but also it
16 was reinforced by the Down's Heart people.
17 Q. You then went on to mention a second factor: that you
18 had great confidence in the team in Bristol; is that
19 right?
20 A. Yes, because we had really got to know them. Joe had
21 spent, I suppose, a greater part of his life in and out
22 of hospital by then anyway.
23 Q. So is the upshot that you made some enquiries as to
24 whether a hospital close to where you thought you might
25 move would take Joe, but you never made any other
0161
1 enquiries about different hospitals in the UK, London or
2 other large towns, for instance?
3 A. We were certain we would not have got Joe operated on
4 where we would have ended up. Liverpool comes to
5 mind -- I am not sure whether they would or would not.
6 We did vaguely look into other places, but the place we
7 were going to would have been Yorkshire, so it would
8 have been difficult to go anywhere else. We were so
9 confident in Bristol that we had got the best, anyway.
10 Q. So it comes down to the fact that you had a relationship
11 of trust and confidence in the hospital in which you
12 were already placed; is that right?
13 A. Yes. We were very worried that we should not lose our
14 chance in Bristol, yes.
15 Q. So Mr Wisheart had had a discussion of moving ahead to
16 the full corrective operation on the basis of a 50:50
17 chance of success. Did you decide to go ahead with
18 that?
19 A. Yes.
20 Q. When was the operation planned for?
21 A. Again, the dates escape me, but by actual coincidence
22 it was planned for the time when the Gulf War started,
23 and --
24 Q. What was the effect of that?
25 A. Because of the Gulf War, the hospital was told to stop
0162
1 taking people in in case there were casualties from the
2 war, that they would have to be brought back here to be
3 treated.
4 Q. So that postponed Joe's operation, did it?
5 A. Yes, and we were frantic and our GP letters and we
6 kicked up a fuss, but it was just -- you know.
7 Q. How long was it postponed for?
8 A. I cannot remember, but the Gulf War did not last all
9 that long. It was not very nice at the time because we
10 had this optimum time and if we had missed it through
11 Joe's illness or whatever, obviously the chances would
12 deteriorate, and missing it by however much would have
13 taken our chances away completely.
14 Q. So eventually, or in a short space of time, perhaps, the
15 Gulf War ends. At that point was the operation --
16 A. We were given a date. I remember it very well, because
17 I had taken time off school, official leave, and I was
18 walking round the house with Joe on my shoulder about
19 seven o'clock the night before and telephone rang and
20 I thought it was somebody selling double-glazing or
21 something like that. When I focused, it was a voice
22 saying, "It's James Wisheart here. How is Joe?" He
23 said, "I am very sorry, but please do not bring Joe in
24 tomorrow. I have an emergency so I do not have the bed
25 or the staff. I know it is very difficult and I know
0163
1 you have been looking forward to it, and please
2 understand things will be all right, but please do not
3 bring Joe in until you hear from me, because I just
4 cannot take him." I said, "Fair enough, if you have an
5 emergency, you have an emergency."
6 The arrangement was that we did not take Joe in
7 until we heard. Then the next day the ward rang after
8 10 o'clock asking why we were not in. We explained.
9 There was some slight discrepancy between myself and my
10 wife: I thought it was a day or two; she thought it was
11 just a day, but we heard to bring Joe in eventually.
12 Q. So there was some question as to whether or not another
13 operation, the need for the beds, would delay Joe's
14 operation, but it was only for a couple of days?
15 A. Yes. At this time it was the special bed and the
16 nursing staff, the facilities.
17 Q. He went in, then, on 14th February 1991?
18 A. Yes, he did.
19 Q. Before the operation took place, was there any further
20 discussion with Mr Wisheart about the --
21 A. Yes. I mean, first of all we were received by a nurse,
22 who very thoroughly went through Joe's history. It is
23 funny how things stick in your mind. One of the last
24 questions she asked was, "Has he got a favourite toy he
25 likes playing with?" I said, "You stupid woman, we are
0164
1 dicing with death. Why are you asking questions like
2 that?" But she was only ensuring the very best for Joe,
3 which was fair enough. We had the opportunity of
4 visiting various ITUs, but we lived in various ITUs so
5 we did not take it up. Then we saw Mr Wisheart and went
6 through things with him. He said he was not absolutely
7 sure, it might be Joe or a geriatric patient, it
8 depended on the availability in the morning of beds and
9 staff and all the rest of it, so both of them were
10 prepared. As it happened Joe was taken. He fully
11 explained it.
12 Q. Did he explain the nature of the operation that was to
13 take place?
14 A. Oh, yes, yes.
15 Q. What about the risks that again were linked to the
16 operation?
17 A. Again, we understood it was a very, very serious
18 operation with a very high risk. We were aware of
19 little marks on Joe's notes saying that he was at very
20 high risk, even from anaesthetic. Again, we have this
21 thing of 50:50 and tossing a coin, but Mr Wisheart quite
22 plainly said what he was going to do, it was a bypass,
23 a very intricate operation, and even if everything went
24 well and he took him off the bypass for some reason,
25 some of these operations did not work. They had not got
0165
1 far enough in advance of understanding why these things
2 did not work. He said sometimes it is one of those
3 things that just does not work. He could not guarantee
4 anything.
5 Q. What did you understand was the alternative, for Joe, to
6 undergoing this operation?
7 A. There just was not an alternative because he was not
8 thriving. He would have died sooner or later.
9 Q. With that background, presumably you signed a consent
10 form for the operation; is that right?
11 A. Yes. You know, we were fully aware of the risks and
12 fully aware of the operation, but we signed it
13 willingly. We did not feel pressured. All the time we
14 got the impression that Mr Wisheart and the other staff
15 were putting forward all the alternatives, all the risks
16 and that, and we were making the choices, but we
17 desperately wanted to give Joe the chance. We thought
18 he might die, but it is better -- it is a horrible
19 thing -- for him to lose his life than die horribly
20 later on, and we had this wonderful chance of getting
21 him fixed.
22 Q. Thank you. So the decision was taken to go for the
23 operation. Joe has been admitted. What did you do on
24 the day of the surgery?
25 A. Gill stayed with Joe the night, and then I went in early
0166
1 the next morning and we helped get him ready and waited
2 and waited and eventually found out it was going to be
3 Joe. We went down with him to the theatre, just
4 outside, and I was conscious of about six very highly
5 qualified people gathering around and the anaesthetist
6 sort of gassed him down to start with. I held him.
7 I remember them holding something against my nose so
8 I did not get a head full of anaesthetic as well and
9 then, once he was under, we handed him over, wondering
10 whether we would see him again like that, whether it
11 would be successful or not. It was a very emotional
12 time. We sort of left in full confidence that the very
13 best was being done, and we just hoped and prayed that
14 he would pull through.
15 Q. So what did you do while the operation took place?
16 A. Again, we had been advised to go home this time, so we
17 went back home.
18 Q. How did you find out what had happened in the operation?
19 A. They advised us, I think they gave us a number --
20 I suppose it was about seven in the morning, it seemed
21 very early -- and they said, "Give us a ring about
22 three o'clock; we might know something then". I rang,
23 I think it was the ward at 3 o'clock, and it was this
24 dreadful feeling, ringing up and shaking. They said,
25 "We have not heard anything so it must be good news;
0167
1 things must be going all right. Give us another ring
2 about 5 o'clock". That prolonged the agony. They rang
3 again at 5 o'clock and said that everything was okay and
4 Joe was shortly up on the intensive therapy ward, so we
5 jumped in the car and hurtled into Bristol and I think
6 we saw Joe in a little room at the end of ITU, and
7 I think Mr Wisheart was there. I think Dr Joffe also
8 made a social call on his way home as well, which was
9 nice.
10 Q. Mr Wisheart was there when Joe had come back into the
11 ICU. Did Mr Wisheart explain how the operation had
12 gone?
13 A. Yes, again, I can remember he took time and explained
14 how things had gone. I cannot tell you now exactly what
15 he said, but the just of it was that things had gone as
16 expected and he had not met up with any major problems.
17 He pointed out there were two wires coming out of Joe
18 and he said there was a possibility that the heart might
19 need stimulating or pacing later on, so these were
20 already in place to save any further disturbance of Joe.
21 It was early days and the worst was over, but things
22 could still go wrong, but there was no evidence to
23 suggest that things would not be satisfactory.
24 Q. So the first hurdle had been overcome?
25 A. Yes.
0168
1 Q. What did you do at that time? Did you go home again?
2 A. No, we breathed a sigh of relief. By this time there
3 was room for both of us in the hospital for that
4 critical period, so we stayed with Joe. Again, we found
5 ourselves talking to the nurse and again we went through
6 all the machines and the monitors and the notes and
7 everything, and things were fine. Then -- I am not sure
8 at what time, but the very idea, about 11 o'clock at
9 night -- the alarm bells started going and machines
10 suggested things were not quite right. Then it must
11 have been Mr Wisheart's senior, the House Officer, came
12 and the wires were needed and they connected him up to
13 a pacemaker and did what was necessary. By this time
14 I was sort of in an advanced state of panic, pretending
15 to be calm, and I must confess, it is a dreadful thing
16 to say, but the gentleman seeing to Joe was not British
17 and he was not Mr Wisheart, and I thought "Why have you
18 got this man, not the boss?" But he did a perfect job.
19 It was just prejudice on my behalf. Then 20 minutes
20 later I turned round and there was Mr Wisheart. He
21 appeared out of nowhere.
22 Q. What time of day was that?
23 A. It was about 11 o'clock, very late.
24 Q. How often did Mr Wisheart drop into the ICU to see Joe
25 and other patients?
0169
1 A. It was very unpredictable. He had his regular rounds,
2 but you could be there at one in the morning or midnight
3 and see him wandering about. Sometimes he was dressed
4 as if he had been to the theatre, or sometimes
5 casually. I got the impression if he was passing he
6 would drop in to see people. He must have been an
7 impossible person to live with, because he spent large
8 amounts of time on the ward.
9 Q. So how frequent was your contact with him, would you
10 say?
11 A. Immediately after the operation it was quite frequent,
12 but then it sort of tailed off as the necessity tailed
13 off, but there were always members of his particular
14 team there. I was very aware of the anaesthetists
15 coming in, because they would do the same as
16 Mr Wisheart: first of all look at Joe, say this is
17 happening, that is happening, then look at the machines
18 and if the machines disagreed, say that machine is
19 dodgy, this is happening, that is happening. It was
20 incredible.
21 Q. What you are describing is a process whereby both
22 Mr Wisheart and the anaesthetist would look at Joe first
23 to see what the condition was, and then look at the
24 machines; is that right?
25 A. Yes, I think so. I got the impression that the machines
0170
1 were not superfluous, but they had this skill of looking
2 at Joe and by examining Joe they could tell exactly what
3 was really happening.
4 Q. So you have described Mr Wisheart wandering in at really
5 all hours of the day; is that right?
6 A. Yes, especially Mr Wisheart. He is immediately
7 recognisable because the anaesthetists worked in shifts,
8 but certainly, Mr Wisheart, it was not unusual to see
9 him there at any time. It was incredible.
10 Q. What about the paediatric cardiologists you knew from
11 the Children's Hospital. Did you see anything of them?
12 A. My memory is that we almost exclusively dealt with
13 Dr Joffe as the paediatric cardiologist and I think it
14 was more or less a social call he paid the day of Joe's
15 operation. I might be wrong, I am not sure, but I do
16 not think we saw him until we moved back to the
17 Children's Hospital. I might be doing him an injustice,
18 but I got the impression we were under the Wisheart
19 team. We certainly had every sort of facility afforded
20 to Joe by the BRI people there. I am not saying that
21 Dr Joffe did not come in. I do not remember him coming
22 in. I am pretty certain perhaps he did not.
23 Q. Can you describe the nursing care that Joe was receiving
24 at this time?
25 A. Yes. Again, there were obviously nurses who were
0171
1 especially trained in treating post-cardiac people who
2 were unconscious. They seemed to know the level of
3 unconsciousness and what was going to happen. They were
4 very skilled, and skilled in involving people such as us
5 in care as much as they could. We could not wish for
6 better staff.
7 Q. What sort of things were they involving you in?
8 A. There was not a great deal we could do to Joe to start
9 with. They encouraged us to talk to him, because they
10 said it was their experience that once people had been
11 brought out of the anaesthetic state, they could not
12 remember things, so they encouraged us to hold his hand
13 and do his mouth care and clean him up from time to
14 time, and then, as he got more conscious, we did more
15 things.
16 Q. You have described him being on the ITU initially when
17 he came out of the operation?
18 A. Yes. There was a special room at the end of ITU,
19 a small cubicle that Joe was in on his own.
20 Q. Initially he is in a little room at the end of the ward
21 on his own?
22 A. Yes, there was a separate door so you did not have to go
23 through ITU to get to it.
24 Q. How long was he in that room for?
25 A. I should think it is a matter of days. It is difficult
0172
1 to tell, because it is such a stressful time. He was
2 basically there once he was deeply unconscious, and once
3 he was conscious, I think they took the breathing tube
4 down when he was on the other part.
5 Q. Where did you move to after he came out of the small
6 room?
7 A. He came out and went to the big room where the adult
8 intensive people were.
9 Q. He moved to the big ward with adults and children?
10 A. Yes. They were assisting him. The further down that
11 you moved, the nearer you were to getting out of the
12 ward.
13 Q. How did the experience of being on a ward where there
14 were both adults and children strike you and your wife,
15 having had such a long time in the Children's Hospital
16 where there were just children?
17 A. I suppose in a way it was frightening. It was the big
18 world, reality --
19 Q. Could you repeat that again a bit more clearly, because
20 I think we are losing what you said?
21 A. I suppose in the children's ward one feels very much
22 supported and cushioned and cradled, and in the BRI,
23 where they have the heart cases, one was more aware that
24 people might die more often and things like that. It
25 was not really geared for children and families. It was
0173
1 a bit frightening and worrying like that, and obviously
2 the practical care of Joe was more difficult for the
3 staff, but I think the staff made every effort to
4 overcome that.
5 Q. What do you mean when you say that the practical care of
6 Joe was a bit more difficult for the staff?
7 A. I think I mean that the nurses were used to -- in the
8 children's area you had very much a designated area for
9 each child and the machines around it and the big sheet
10 that they recorded things on. It was very much their
11 domain and they could work around that, whereas in the
12 BRI it was much more a general ward room. It was much
13 less a designated space for Joe, his equipment and
14 things like that.
15 Q. So are you talking merely about a physical layout
16 problem, or ...
17 A. I think there was a physical layout problem, yes. We
18 felt less comfortable there, and I think it was probably
19 more difficult to nurse Joe there, but I do not think
20 there is any evidence in Joe's history to suggest that
21 he suffered because he was in that ward. I think people
22 made the extra effort to overcome whatever their
23 problems were. The staff did that little bit extra, or
24 whatever, and really pulled out the stops. I am not
25 saying that he would have been treated any better had it
0174
1 been in a special children's ward, although it was not
2 a special children's ward.
3 Q. How well did Joe recover after the operation?
4 A. He recovered, I think, in very quick time. I might be
5 wrong, but I think it might be the day they took the
6 breathing tube out or the day afterwards that they took
7 him up to the Children's Hospital. He was not very
8 long, once he was out of the little cubicle in the BRI,
9 he was not very long in the big one. He was transferred
10 up the hill.
11 Q. Up the hill, where was he nursed?
12 A. It was somewhere we were familiar with, we had been
13 before. I do not think it was intensive care, but he
14 obviously had all the attention he needed. I do not
15 think it was intensive care, I think it was just on one
16 of the wards.
17 Q. You said he was taken up the hill in an ambulance?
18 A. He was.
19 Q. Who accompanied him on that journey?
20 A. Well, we had one of the special nurses that was
21 responsible. She was asked to take him to the
22 Children's Hospital, and she said, "Well, I am not going
23 unless I have [I forget what the name of the piece of
24 equipment was] and also an anaesthetist", so they were
25 duly provided.
0175
1 Q. So she wanted a special piece of equipment and an
2 anaesthetist, and they were both provided?
3 A. Yes.
4 Q. With that, was the journey accomplished successfully?
5 A. Yes. We just went down, got in the ambulance and drove
6 up, and he was just instated in the other hospital.
7 Then the nurse and the anaesthetist went. The nurse
8 forgot the equipment, came back for it and went, and we
9 were duly handed over. We felt like we had come home,
10 in the Children's Hospital.
11 Q. How long did you remain there, before Joe was able to go
12 home?
13 A. I do not think we were there all that much longer,
14 because there were no complications. Dr Joffe came and
15 said everything was okay, so I think it was as soon as
16 it was obvious everything was okay. A matter of days,
17 I think.
18 Q. Was there any contact with Mr Wisheart during that
19 period?
20 A. I cannot honestly say that I remember. Again, looking,
21 I get the vague impression he was handed back to the
22 Joffe team then. I am sure the two of them liaised.
23 I am not actually sure whether Mr Wisheart came to see
24 Joe. I could not swear one way or the other.
25 Q. Recovery, I think you said, was uneventful after Joe
0176
1 came back from the Children's Hospital?
2 A. Yes.
3 Q. Was Joe eventually able to go home?
4 A. Yes.
5 Q. Speaking generally, how has he recovered from the
6 operation? What is his state of health?
7 A. Physically and heart-wise, he is wearing me out. He
8 dashes everywhere, runs and plays, plays practical
9 jokes. We have an annual visit to Dr Joffe just as
10 a sort of precaution. The last time we went was in
11 January, and it was just for an echo. We had an echo
12 and sadly the last record of the echo was not there
13 because Joe's notes were taken away for these enquiries,
14 but Dr Joffe said he could tell by the measurement he
15 got this time it could not have deteriorated from the
16 last time because it was so good.
17 Q. Is Joe still on drugs for his cardiac problems?
18 A. The only thing he is on, we have been giving him massive
19 doses of drug. His other problem is his insides, but
20 his heart, nothing. He has frequent uses of antibiotics
21 because he has one patch of his lung which is
22 particularly susceptible to infection.
23 Q. A few seconds ago you spoke about Dr Joffe talking about
24 the valve still being in a good condition. Is there any
25 need for further surgery?
0177
1 A. Around about the time of the operation it was vaguely
2 mentioned that some time, perhaps in Joe's 30s, it might
3 need looking at, but at the moment no-one has mentioned
4 anything; it seems fine.
5 Q. What is your overall assessment of the outcome of the
6 care he received for this particular cardiac problem?
7 A. I can honestly say I do not think we could have wished
8 for a better treatment or better outcome. It has been
9 marvellous.
10 MISS GREY: Thank you very much. We will see if the panel
11 have any questions.
12 THE CHAIRMAN: I do not, but may I ask Mr McLorinan: if
13 there are any matters that you would like to add that
14 you have not been asked, or any point that you have been
15 asked that you would like to clarify, please take the
16 opportunity, if you wish.
17 A. I feel quite sort of shell-shocked at the moment.
18 I would just like to reiterate, I feel that we were very
19 fortunate in being with Mr Wisheart because of the
20 condition Joe was in, he was so seriously ill, and
21 because of the Down's syndrome and all that that meant,
22 I think we were very lucky to get someone to take the
23 risk. It was not a flippant risk, but it was a risk we
24 were in on. Some surgeons might have said it was too
25 risky to go into, but -- I am not blaming Mr Wisheart.
0178
1 I am very pleased because of Joe's Down's syndrome,
2 because of his poor state of health and prognosis we
3 were still offered the treatment, and we were just
4 delighted with everything.
5 THE CHAIRMAN: Thank you. Is there any re-examination?
6 MR SHARP: Sir, there are just two questions, if I may.
7 Re-examined by MR SHARP:
8 Q. Mr McLorinan, just two points. The first is this: did
9 you, at any stage during the various decision-making
10 processes throughout Joe's treatment, feel that it was
11 anybody's choice but yours what decision was made?
12 A. No, no. I think I tried to make that clear from
13 Dr Joffe's first three options. It sort of refocused my
14 understanding of the role of the doctor, to almost be
15 the servant of the patient or the patient's guardians.
16 We were very much empowered to make the decisions.
17 We really felt we were given what we needed to make the
18 decisions, and it was our genuine free decision.
19 Q. That was true both of the Joffe team and the Wisheart
20 team?
21 A. Yes, and for what it is worth, the other team. We had
22 to sign consents for the draining of the heart and sign
23 consents for all the rest. Right down the line, it
24 seemed an excellent thing, in Bristol.
25 Q. The second point was, you mentioned at the end of your
0179
1 testimony a moment ago that last time Joe was seen there
2 was a problem with medical records?
3 A. I am afraid there has been, since the GMC first did its
4 procedure. One final point on it: we received through
5 the post a letter asking for our permission to release
6 Joe's notes for the GMC. That day my wife took Joe to
7 see Miss Noblett and she found it very frustrating that
8 Joe's notes had already gone, they were not available.
9 On subsequent occasions we have been back to see
10 Miss Noblett and now Miss Huskisson, because -- no
11 reflection on Miss Noblett, but Joe has had to have his
12 colostomy put back, and there has been some frustration
13 that the relevant part of the notes were not there. He
14 had to have some procedures done at the dental hospital,
15 and I think it was commented on by the anaesthetist that
16 the relevant parts of the notes were not there. Again,
17 when we went to see Dr Joffe in January, he wanted to
18 compare some information with something in the notes but
19 the notes were not there. The actual record of echo was
20 not there, and he could not compare it with the previous
21 one because the notes were not available.
22 MR SHARP: I am concerned about that, for obvious reasons.
23 I trust maybe the Inquiry will be able to do something
24 about it.
25 THE CHAIRMAN: I am very grateful to you, thank you.
0180
1 Mr McLorinan, thank you very much for coming in
2 and talking to us. This is not the last opportunity you
3 may have. If you want to get in touch with us again and
4 tell us anything else, please feel free to do so. We
5 shall be here for some time, and we will be happy to
6 hear from you if you feel you can help us more, but
7 thank you for coming this afternoon.
8 MR LANGSTAFF: Sir, that concludes the evidence which you
9 will hear today. Tomorrow there are two witnesses:
10 Mr Curnow, whose daughter Verity suffered from pulmonary
11 atresia, and Michelle Cummings whose daughter suffered
12 from a transposition of the great arteries with the
13 ventricle septal defect.
14 THE CHAIRMAN: Mr Langstaff, thank you. We shall reconvene
15 tomorrow morning at 9.30. Thank you very much.
16 (3.00 pm)
17 (Adjourned until 9.30 am on Thursday, 18th March 1999)
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0181
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2 I N D E X
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5 APPLICATION BY MR LISSACK .......................... 1
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7 MR PHILIP ANTHONY HENRY WAGSTAFF (Sworn)............ 9
8 Examined by MISS GREY.............................. 10
9 Examined by THE PANEL.............................. 43
10
11 MICHAEL JOHN PARSONS (Affirmed).................... 45
12 Examined by MR LANGSTAFF........................... 45
13 Examined by THE PANEL............................. 120
14
15 MR JOHN STEPHEN McLORINAN (Sworn)................. 122
16 Examined by MISS GREY............................. 122
17 Re-examined by MR SHARP........................... 179
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Published by the Bristol Royal Infirmary Inquiry, July 2001
© Crown Copyright 2001