Home Page Search Final Report Interim Report Evidence - Transcripts - Witness Statements - Submissions - CCNR Report and associated documents - Statistical Reports and associated documents - Background Papers - Expert Papers Inquiry Seminars About the Inquiry Help		Daily transcripts Hearing summary 9th June 1999   Dr John Roylance, former District General Manager of Bristol and Weston Health Authority and Chief Executive of United Bristol Healthcare NHS Trust (UBHT), concluded his oral evidence this morning with a re-examination by his legal representative to clarify several issues discussed yesterday and questions from the Inquiry Panel. He was followed by Mrs Margaret Maisey, former Director of Operations, UBHT, 1991-1996 and Director of Nursing UBHT to September 1997. She said that the Trust Board of UBHT’s aspiration was to deliver excellent care within the available funds. She went on to say that the role of the Executive Directors was to support and coach the Clinical Directors in meeting the organisation's aims. She then described her various roles within the NHS in Bristol, highlighting in particular the challenge of the changes brought in by the NHS Reforms in 1991, when she took on the role of Director of Operations. She discussed the levels of accountability within the Directorates and referred to monthly meetings which took place with Clinical Directors and with General Managers. Mrs Maisey was asked about her working relationship with Rachel Ferris, General Manager of Cardiac Services, UBHT, who will give evidence to the Inquiry tomorrow, and who has been critical of Mrs Maisey’s management style in her written statement. She concluded by discussing her amended role from 1996 as Director of Nursing, during which time she concentrated her efforts towards dealing with nursing issues.

FULL TRANSCRIPT

   1                       Day 26, 9th June 1999
   2   (9.30 am)
   3   THE CHAIRMAN: Good morning, ladies and gentlemen. Good
   4     morning, Dr Roylance. Good morning, Mr Langstaff.
   5   MR LANGSTAFF: Sir, as you will know, we finished the
   6     evidence in the questions that I wished to ask of
   7     Dr Roylance yesterday. There remains questions from the
   8     Panel and any re-examination.
   9   THE CHAIRMAN: Yes, thank you. Mrs Howard?
  10           DR JOHN ROYLANCE (RECALLED):
  11             EXAMINED by THE PANEL:
  12   MRS HOWARD: You have had vast experience both at District
  13     Health Authority and at Trust level, and I wonder if you
  14     have any comment to make about the role of non-executive
  15     directors, particularly now in the Trust Board
  16     situation?
  17   A. Yes. They were non-executive and they were meant to be
  18     the parallel of non-executive directors of a commercial
  19     company whose primary responsibility is to shareholders
  20     and profit. The primary responsibility of the
  21     non-executive directors was to patients, so it was their
  22     responsibility to do two things: bring lay information
  23     about the community and skills that they brought with
  24     them from their background. In other words, they were
  25     people with business experience to give us the benefit

   1     of a business approach to things, and they were very
   2     active. One of them in our case, behaved more like an
   3     executive Director because of his background, he chaired
   4     the Capital Monitoring and Commercial Services
   5     sub-committee of the Trust Board and I have to say, if
   6     a stranger came with no prior knowledge, they would have
   7     recognised him as one of the executive directors and as
   8     I said yesterday, the Medical Director as one of the
   9     non-executive directors.
  10        I hope I have addressed the question, but if not,
  11     please ...
  12   MRS HOWARD: No, thank you very much.
  13   THE CHAIRMAN: Professor Jarman?
  14   PROFESSOR JARMAN: Good morning, Dr Roylance. Margaret
  15     Maisey in her comments in Rachel Ferris's additional
  16     statement says, just for the record it is WIT 89/42, but
  17     I do not think we need that, I will just quote what she
  18     says:
  19        "The Trust Board are very proud of the cardiac
  20     services and Dr Roylance always referred to them as
  21     the 'jewel in the crown' of the UBHT."
  22        Do you remember saying that, or describing them in
  23     that way?
  24   A. I hope I did not describe it that way in front of the
  25     leaders of the other services in the Trust. Yes, I was

   1     very proud of the cardiac service. It was a regional
   2     service. It was the only one in the South West and
   3     I was proud of it. It was the second bit, the "jewel in
   4     the crown" implying we only had one jewel, and I would
   5     not have thought I would want to be quoted in that way,
   6     but I was certainly confident that it was a very good
   7     service.
   8        I was also certain that it was grossly
   9     under-funded.
  10   Q. And your views are roughly the same, are they, or have
  11     you changed your views?
  12   A. I do not know about the funding today. Since I have
  13     left I have seen drafts of new money coming in. Whether
  14     that is keeping up with the expanding demand, I do not
  15     know. I suspect the tension will be there, as it always
  16     was.
  17   Q. The second question related to when Mr Langstaff was
  18     questioning you about why the Medical Director only had
  19     two seconds: Mr Wisheart, and when Mr Ross started, and
  20     you spoke to him, you said that he would be wise
  21     strongly to reinforce the medical advisory machinery?
  22   A. Yes.
  23   Q. "The reasons why I gave him that were for (1) he was not
  24     a doctor", and I was just wondering, why did the fact
  25     that you were a doctor make a difference?

   1   A. I did not have to have explained to me what a neonate
   2     was, what an aortic replacement was, I understood the
   3     business we were in. If I had moved to ICI as their
   4     Chief Executive, I would have reinforced the
   5     professional advice about chemical manufacture. And
   6     I think that is true. I needed an awful lot of advice,
   7     but I did not need to be told what care in the community
   8     was. I could tell the difference between a psychologist
   9     and a psychiatrist, and so on. I actually knew the
  10     Health Service, so I did not need advice on what the
  11     Health Service was.
  12   PROFESSOR JARMAN: Thank you. The next question is, in your
  13     statement on page 20 you say:
  14        "I also considered the Royal Colleges had an
  15     overall responsibility for the maintenance of standards
  16     and that if concerns about such issues were made known
  17     to them, and a solution could not be found through their
  18     own good offices, they would notify me that appropriate
  19     management action was required."
  20        Does this seem to be putting quite a lot of
  21     responsibility on to them; what you say?
  22   A. I do not know what you mean by that. The whole purpose
  23     of a Royal College of Radiologists is to oversee
  24     standards in radiology, and they do that in a whole
  25     variety of ways. If they are not maintaining standards

   1     in radiology, I do not know what they are doing.
   2   Q. So you depended a lot on them?
   3   A. The expertise in whether the clinical work was up to
   4     standard lay within the profession and the profession
   5     was concentrated and represented and overseen by the
   6     Royal College.
   7        Let me, as an example, say that if there were
   8     anxieties about the quality of care, the professional
   9     performance of a specialist, normally that would be
  10     noticed first by other specialists, in this case we are
  11     talking of consultants, and their anxiety, they may wish
  12     to allay their anxieties or have something done by
  13     sharing it with their professional seniors who were in
  14     the Royal College.
  15        If they shared their anxieties with me, I would,
  16     when appropriate, ask for the advice of the Royal
  17     College, so it could go either way. It could be that
  18     management asked them for their expertise, or it could
  19     be that the profession asked them for expertise, but
  20     either way, if management action was required, they
  21     would have to define that to be so.
  22   Q. Thank you. The Royal Colleges have told us that really
  23     their main way of having an effect was the visits that
  24     they made to inspect training posts.
  25   A. Yes.

   1   Q. And we have heard previously on Day 12, page 118, line
   2     1, and also WIT 32/259, that at a visit done by the
   3     Royal College of Physicians in 1992, what they said --
   4     I am just quoting -- was that there are major problems
   5     due to increases in workload in emergency medicine
   6     without commensurate increase in resources.
   7        After a bit it goes on:
   8        "It seems probable that at times the quality of
   9     patient care may fall below safe standards. In my
  10     discussions with managers, it was clear that they were
  11     aware of these difficulties."
  12        Do you remember having --
  13   A. You said "medicine". Could you, just to help me, say
  14     what we are talking about?
  15   Q. This was a thing which has been mentioned before on
  16     Day 12 here. It was an exception by the Royal College
  17     of Physicians to inspect a training post, which they
  18     have told us is their main way of having any form of
  19     influence.
  20   A. Yes. I can talk in general, but unless I know which bit
  21     of Trust they were inspecting, whether it was --
  22   Q. Emergency medicine -- medicine; it was a medicine
  23     inspection?
  24   A. That was not uncommon of the Royal College and I think
  25     illustrates the Royal College's responsibility of

   1     maintaining standards. I expect the Royal College to
   2     say this was the main way because this was a major
   3     effort on their part and they were therefore constantly
   4     in, at intervals, and the intervals varied depending on
   5     the perceived problems, they were constantly in
   6     institutions which trained junior doctors. They were
   7     very experienced physicians in this case, who would
   8     interview them all privately and review the whole
   9     organisation and make constructive comments on how to
  10     sustain a proper training programme.
  11   Q. But their comment is that it seems probable at times the
  12     quality of patient care may fall below safe standards?
  13   A. Yes, well, that would have been taken very seriously and
  14     addressed. There is always a tension, I have to say,
  15     between professionals who want to do as much as possible
  16     for as many people as possible, and of sustaining safe
  17     standards. There are times when some would feel that
  18     poor care was better than no care. I do not expect you
  19     to share that view and I do not share that view, but
  20     that was a tension. This was a very helpful and
  21     I believe successful monitoring programme. If every
  22     report said "things are perfect", then everybody would
  23     have been wasting their time. They actually did pick up
  24     matters that were difficult.
  25        I believe that they are referring probably to

   1     a time when junior staff were working excess hours and
   2     it was becoming recognised that this was unacceptable
   3     and of course a major initiative was undertaken to
   4     correct that.
   5   Q. Thank you. The last question is, in your statement you
   6     say:
   7        "All consultants are expected to monitor their own
   8     performance and to be self corrective", that is on
   9     page 18.
  10        On page 22 you say:
  11        "There was no formal mechanism for disseminating
  12     information with regard to standards and outcome of
  13     clinical care."
  14        That is on page 22.
  15        Would you have any comment on putting those two
  16     things together?
  17   A. Yes. I think I could answer it most briefly by saying
  18     that the concept of clinical governance postdates the
  19     whole of the time we are talking about, and therefore
  20     I am absolutely right in saying that the concept that
  21     lay managers or non-experts could monitor the
  22     performance of experts was neither contemplated nor
  23     attempted. Therefore a lay Chief Executive could not
  24     make a judgment about the quality of care. Indeed, it
  25     was not part of his responsibilities. In the creation

   1     of Trusts and Chief Executives, clinical governance was
   2     not an issue. Corporate governance, as it became known,
   3     was an issue. The whole exercise was an attempt to
   4     correct the overspending and the overprovision of health
   5     care.
   6        The second part of that -- I mean, can I leave it
   7     like that? The idea that non-experts could monitor
   8     experts had not emerged and was unthinkable in the
   9     Health Service in those days.
  10        This business about communicating standards has
  11     two elements to it. The first is, there were no
  12     standards because audit, as we now understand it, was
  13     not taking place. There was no structure to communicate
  14     information, meaningful information, because the
  15     meaningful information did not exist.
  16        What did exist was a very tight interrelationship
  17     between the medical profession. If you talk to the
  18     average general practitioner, he or she will reassure
  19     you that they know to whom, which specialist, they would
  20     want to refer patients. You say how can that be? Well,
  21     they meet them frequently, they meet each other fairly
  22     frequently, and the knowledge of what is going on exists
  23     at that level. But there was no structured information,
  24     and I think the issue of audit was only just being
  25     introduced; there was no audit figure; there was no

   1     outcome figure that meant anything that could be
   2     distributed, and therefore, there was no formal
   3     mechanism to do so.
   4   Q. You said that there is no formal mechanism and doctors
   5     monitored themselves. I was just really wondering how
   6     they were meant to do that?
   7   A. How a consultant was meant to monitor himself?
   8   Q. How they would monitor?
   9   A. I would expect them to know the outcome of their
  10     treatment, the outcome of other people's treatment and
  11     when there are small volumes, the average outcome over
  12     a multi-centre review.
  13        Can I give you a specific example of cardiac
  14     surgery? If you divide up the types of surgery, the
  15     types of case in individual units, you get so many
  16     different ones and at different proportions with other
  17     units that you cannot average them across because that
  18     is adding unlike together. If you analyse them
  19     individually there is not enough there to be meaningful,
  20     so what was done is that all the results were sent
  21     centrally -- this was, in my lifetime, a fairly recent
  22     thing. They were sent centrally, summated and returned
  23     back with the overall figures with the individual
  24     recipient being able to recognise their figures amongst
  25     them.

   1   Q. The others were anonymised and they got the average of
   2     the lot and their own figures?
   3   A. Yes. That was of limited value because none of them --
   4     I think the technical term is "risk stratification" --
   5     none of them had the level of severity or what they call
   6     in educational terms the "unison improvement" was not
   7     there. So if there was a chap being referred all the
   8     very difficult cases and getting, what, a 50 per cent
   9     survival, he might be providing a much better service
  10     than somebody in another unit who was being given the
  11     simple cases who had a 90 per cent survival. So there
  12     are major difficulties in the information being more
  13     than just general information.
  14   Q. Did you expect that your medical people were doing that?
  15   A. I knew they were doing it. I did not know the results,
  16     and I have to say, if they had told me, I would have had
  17     even less idea what they meant, but I knew that cardiac
  18     surgeons centralised their outcome results in order to
  19     get some sort of idea, in order to get a big enough
  20     series to make a sensible suggestion.
  21   PROFESSOR JARMAN: Thank you.
  22   THE CHAIRMAN: Dr Roylance, I have no questions, but if you
  23     would just remain there, there may be some
  24     re-examination from Mr Francis.
  25           RE-EXAMINED BY MR FRANCIS:

   1   MR FRANCIS: Thank you, sir. Dr Roylance, I have just
   2     a few questions for you. Can I start, please, with the
   3     subject of Clinical Directors and the organisation of
   4     them.
   5        Firstly, you will be aware of the comments made on
   6     the number of Clinical Directors that you had, and the
   7     number of directorates that there were.
   8        In your view of the time, could you have managed
   9     with any fewer directorates, bearing in mind the size of
  10     the enterprise you had to deal with?
  11   A. No. If there had been an anxiety about numbers, the
  12     only managerial step I could have taken would have been
  13     to put an intervening level of management and put an
  14     assistant chief executive managing 6 seats, so to
  15     speak. There was no way I could put together two
  16     directorates and pretend they had a single interest.
  17   Q. If you had done that, would you have been at risk of
  18     knowing less about what was going on than you do?
  19   A. Yes. I think there is recognised in all management
  20     circles that the temptation to introduce a lot of levels
  21     must always be resisted.
  22   Q. You were asked by Mr Langstaff about the means of
  23     communication and it was in relation to a minute,
  24     UBHT 110/368.
  25        The point which was put was under "any other

   1     business". You can see there you were concerned that
   2     "there should be no misunderstanding that the
   3     Management Board should be a channel of advice from the
   4     Clinical Directors to the Trust Board."
   5        You were asked about communication the other way.
   6        There are other minutes of this meeting. Can you
   7     turn to page 365, please? Minute 102/91. There we have
   8     that it was agreed that the minutes of the group were
   9     extremely useful as a means of communication with
  10     Clinical Directors.
  11        To what extent was the management group used as
  12     a means of communicating the Board's policies and
  13     requirements to the directors?
  14   A. I think, please, could I say, if you scroll down, you
  15     will see that the meeting always started with a report
  16     from me to all the Clinical Directors.
  17   Q. You mean scroll up, I think.
  18   A. I am sorry, yes. I am demonstrating my competence
  19     level! It starts with the Chief Executive's report and
  20     that was the standard practice. We moved to a situation
  21     where we actually then used to start, because it was an
  22     emphasis, with not my report, which went at the bottom,
  23     but the reports from the Clinical Directors. I was
  24     forewarning them that in future I wished them, every
  25     time we met, to tell me and the other Clinical Directors

   1     of all issues that arose within or affecting their
   2     directorate.
   3        If you look at later minutes, you will find it
   4     starts with a report from the Director of Medicine,
   5     a report from the Director of Surgery. There was no
   6     priority order, we went around the table.
   7        It would be clearly unfair to say we would do this
   8     without forewarning them the next time I wanted them to
   9     have a concise coherent report of issues that should be
  10     reported.
  11   Q. These meetings took place I think monthly?
  12   A. Monthly, yes, halfway between the board meetings.
  13   Q. Were these meetings used as a means of co-ordination of
  14     any activity that involved more than one directorate?
  15   A. Yes, but not the sole means. I would expect
  16     directorates to collaborate together as necessary, but
  17     when there were issues and when there was perhaps doubt
  18     as to how many directorates wished to be involved, then
  19     those would be aired at this meeting.
  20        We would not resolve them there, we would decide
  21     who would go away and resolve them and report back what
  22     they had done.
  23   Q. Questions have been asked about the arrangements for
  24     audit or review, clinical audit or review, involving
  25     personnel in more than one directorate.

   1        To what extent would this board have been a forum
   2     in which any problems identified could be addressed?
   3   A. Well, we did discuss the problem of audit, because
   4     clearly, if you are going to have, shall we say, all the
   5     surgeons -- perhaps I ought to say all the
   6     anaesthetists, having an audit meeting, then it would
   7     not be very helpful for all the surgeons to pretend they
   8     were going to go on operating, so there was a pressure
   9     to have audit meetings simultaneously, but the snag with
  10     that is that the anaesthetists who ought to be at the
  11     surgical audit meeting and the surgeons who ought to be
  12     at the anaesthetic audit meeting had a problem, but most
  13     of the staff were accustomed to being in two places at
  14     once and these were addressed.
  15   Q. Can I ask you briefly about something Professor Vann
  16     Jones had to say? Can we have his WIT 115/2, and
  17     paragraph 7. I am not going to ask you to repeat in any
  18     way what you have given by way of answer to Mr Langstaff
  19     on this subject. I really wanted to ask you this. How
  20     did Professor Vann Jones, or how would he have had his
  21     task as a clinical director conveyed to him by you
  22     and/or the Board so that he, or indeed anyone in his
  23     position, would know what it was he had to do?
  24   A. I would have talked to him quite specifically and quite
  25     clearly, but I have to say that he had done it all

   1     before when he became Director, Clinical Director of
   2     Medicine. When he was invited to be Clinical Director
   3     of Medicine, the first thing he had to do was to define
   4     what was the Clinical Directorate of Medicine, and you
   5     can imagine there were one or two border disputes that
   6     went on from time to time as to what he could annex as
   7     his department and what another directorate would want
   8     to be them. So he was very experienced. I think it was
   9     four years he was Clinical Director of Medicine, a very
  10     big directorate, and that was why he was asked to do
  11     this one. He knew what it was. But I did tell him what
  12     my concepts were, and hoped he shared them.
  13   Q. Would any of this have been written down in a job
  14     description or a job plan, or a mandate or anything of
  15     that nature?
  16   A. No, because by the time we would write it down, it would
  17     have been a description of what had happened. If we
  18     knew exactly what was to be done, I would not have had
  19     to ask him to do it. He was, I think we used the term
  20     yesterday, Clinical Director elect for some considerable
  21     time, with a General Manager elect, discussing,
  22     negotiating and defining a clinical directorate.
  23        Then we could write down what it was he was
  24     managing.
  25   Q. In his statement, I will not take you to the passages,

   1     he identifies some of the problems about the separation
   2     of the bits and pieces of the service. Was this
   3     a problem in any other context you were aware he had
   4     experience of?
   5   A. Yes, when he develops his Directorate of Medicine, part
   6     of his directorate was not over the road, it was the
   7     other side of Bristol, in the Bristol General Hospital,
   8     so that these issues were well known and I have to say,
   9     health services evolve and if you try and impose
  10     a different management structure, you find it does not
  11     match, not if you are a big organisation.
  12   Q. Can I then turn from that to the issue of the split
  13     between the neonatal surgery taking place in the adult
  14     unit and the move to the Children's Hospital, and can
  15     I have UBHT 88/132, please?
  16        Can we scroll down a little bit, please?
  17        We see there in a report which is dated May 1994
  18     that the feasibility of the transfer had been
  19     investigated in the past, most recently in October 1990,
  20     and I summarise, but to date the costs have been thought
  21     to be prohibitive.
  22        Can you help as to how long so far as you are
  23     aware it had been argued by some that the transfer was
  24     a desirable thing to do?
  25   A. It was recognised as desirable, I will not say by

   1     everybody, but by the people within the service when
   2     I became a District General Manager back in 1985. There
   3     was some increasing recognition that children should be
   4     cared for in a children's unit.
   5   Q. When, if at all, did a consensus develop, not only
   6     amongst the professionals immediately involved, but the
   7     service in general, that this was a desirable thing to
   8     do?
   9   A. An effective consensus was -- it must have been in 1990,
  10     we were trying to do it then. I use the term
  11     "effective" consensus because in an organisation the
  12     size of the UBHT, total consensus was rarely achieved.
  13        But the decision that that is what we wanted to do
  14     would have antedated 1990. It says "investigated in the
  15     past". We did not investigate things unless we were
  16     desirous of doing it, but of course this was a quality
  17     move to make the service more acceptable in a sense, it
  18     was not a development, it was not an expansion, and it
  19     was very difficult for that to compete with all the
  20     other demands within the districts and then the Trust
  21     for the frugal amounts of money that were available to
  22     be allocated for expansion and more care.
  23   Q. You have already indicated in effect that the principal
  24     obstacle to implementation of this idea was the resource
  25     issue.

   1   A. Yes.
   2   Q. And in effect that it was a question of priorities?
   3   A. Yes.
   4   Q. When assessing this as a priority, where it stood in the
   5     list of priorities, what was the nature of the problem
   6     this was intended to or understood to solve? Was it
   7     a problem about an unacceptably low level of service, or
   8     was it about an improvement of a service which was
   9     desirable?
  10   A. As I understand it -- I think paediatricians may put
  11     a more extreme view -- it was about creating a better
  12     environment in which the care could take place; it was
  13     not about the success of that care. I mean, we were by
  14     no means the only unit which had a split between
  15     paediatric cardiology and paediatric cardiac surgery.
  16     Because of the way the specialty developed, that is the
  17     case, in a number of other units, I cannot tell you
  18     which ones, but I do know that that is not a unique
  19     situation by any means.
  20   Q. What effect on the timing of the implementation of this
  21     proposal did the plans to build a new Children's
  22     Hospital have?
  23   A. Well, the plan to build the new Children's Hospital had,
  24     as a part -- I will not say the sole function, but part
  25     of it was to achieve this coalescence. There were many

   1     other reasons why we wanted to replace the Children's
   2     Hospital, and it was hoped that with the development,
   3     this coalescence of the service would be achieved.
   4        That was hoped and it was expected, and I have to
   5     say that the Children's Hospital is alleged to be going
   6     to open next year; from my experience, that means that
   7     the decision was effectively made some time about 1986.
   8     It was not made formally in a documented form until
   9     a lot later, but that was what was hoped to be
  10     achieved. But it made it more difficult in that
  11     knowledge to then recommend that resources should be
  12     identified for a major structural change in a building
  13     which then had a very limited life.
  14   Q. Can I then go on, please, to something you were asked
  15     about, the letter from Dr Bolsin, PAR 1, file 8,
  16     page 5. I think in relation to that second paragraph,
  17     there was the suggestion that it was not clear that that
  18     paragraph concerned research.
  19        Would you like to comment on that? And your
  20     understanding of the letter when you received it?
  21   A. Well, this was at a time when the Chairman of the
  22     Medical Committee, who was a member of the project team
  23     of the Trust, was consulting with the medical staff, and
  24     amongst other things, they were consulting with the
  25     document "Application of Trust Status", which is in

   1     draft form there, with an Appendix. That had been
   2     created by the operational areas, not just doctors. It
   3     had to be a description of the Health Service that we
   4     were proposing should be contained in the Trust.
   5        Like everything else, it was almost like an annual
   6     report-come-advertising piece, and it was then put out
   7     for consultation throughout the whole staff.
   8        He owned to a particular index in the Appendix
   9     which related to the report on cardiac surgery. He took
  10     exception to the fact that they had said that research
  11     was going on which he had been unable to get funded and
  12     it is quite clear he thinks that it ought to be
  13     changed. You see at the end of that paragraph:
  14        "The sting must be seen at worst as untrue, and at
  15     best misleading."
  16        So that was a comment on a draft document being
  17     prepared for proposed Trust status and he is telling me
  18     it is wrong. He does not say, please will I go and get
  19     this equipment, he does not say it is disgraceful he
  20     does not have the equipment, what he said is that
  21     funding has not been identified by the management side
  22     and therefore the document should not say it had.
  23        Does that answer your question?
  24   Q. What, bearing the sentence you have just read, was the
  25     management responsibility for identifying such funding,

   1     if someone like Dr Bolsin said he wanted to do research
   2     into that area?
   3   A. There was very, very limited, if any, research money
   4     available through exchequer funds, which is what were
   5     managed by managers. Managers could occasionally
   6     distort the equipment replacement programme and buy
   7     something, tell me when I was allocating it that it was
   8     for a replacement of service equipment in order that
   9     somebody could do some research, so I do not pretend
  10     there was an innovative means of trying to identify
  11     things in that way. But research equipment was funded
  12     either from the special trustees who had an endowment
  13     fund, the Region research committees' funds or a major
  14     charity, and if I could put in perspective what it was
  15     possible to raise in those terms, you just have to look
  16     at the report of Gianni Angelini, who came along as
  17     a Professor and wanted to pursue a lot of research.
  18        But research was not funded from exchequer funds
  19     and should not be.
  20   Q. So if someone like Dr Bolsin thought that a particular
  21     piece of research of interest to his patients was
  22     required and he wanted to do it, was it the management
  23     responsibility to find the money for that, or was it in
  24     his own interests?
  25   A. His own, and he ought to be able to get very expert

   1     advice from his own Professor, unless of course his own
   2     Professor wanted the money and was a competitor.
   3   Q. Just finally on this letter, dealing specifically with
   4     this paragraph , because obviously we are coming back to
   5     other paragraphs in the letter at a later time, how
   6     typical, at around the time of 1990, was a complaint of
   7     this nature coming from a consultant?
   8   A. There were two halves to the complaint. There were
   9     a lot of, not complaints but constructive and sometimes
  10     destructive comments on the document which was out for
  11     consultation, so this was part of a massive response to
  12     our consultation on the formal Trust document.
  13        Apart from that, my life was full of people saying
  14     that their perception of what was the top priority of
  15     the Trust was so clear, why did all these other people
  16     not simply produce the money?
  17   Q. You have been asked about that, and indeed in your
  18     statement you describe to some extent your perception of
  19     the culture of the organisation. To what extent did
  20     demands for money for projects dear to practitioners'
  21     hearts form part of that culture?
  22   A. As I understand your question, totally. Everybody felt
  23     that what they wanted to do in a service sense, in
  24     a research sense, was the most important improvement to
  25     patient care that had ever existed and wanted it funded

   1     instantly.
   2   Q. Can I then turn to the subject of how the Trust and the
   3     Board dealt with problems about unacceptable practice,
   4     and complaints and how people could channel complaints
   5     about such matters.
   6        You were asked about the "three wise men"
   7     procedure. I will come back to that in a moment. That
   8     was a method by which someone could complain to one of
   9     the three wise men about matters of concern.
  10        Before I come to that in a bit more detail, would
  11     you have expected a member of hospital staff, whether
  12     medical or non-medical, to have had other means of
  13     raising concerns about unacceptable practice before
  14     getting to the stage of going to the three wise men, or
  15     one of them?
  16   A. I mean, there was a whole mosaic of routes that were
  17     available and were used and it is difficult to answer
  18     specifically unless I really hypothesise a situation,
  19     but shall we say, if a physiotherapist or an orthopaedic
  20     surgeon was not treating somebody properly and was a bit
  21     unconventional, that physiotherapist would be very
  22     likely first to talk to a physiotherapy colleague, first
  23     of all to reassure herself that her observations had
  24     some validity and so on and they might then make a joint
  25     approach to whoever they thought appropriate. It could

   1     be in Trust times somebody in the clinical directorate
   2     group. It would be very likely to be through their
   3     district professional adviser, and then to Margaret
   4     Maisey or me. The professional adviser would be to
   5     Margaret Maisey or me, but physiotherapists worked very
   6     closely with doctors and she might have shared her
   7     anxiety with a Senior Registrar in the orthopaedic
   8     department.
   9   Q. Taking your example, how would a new physiotherapist
  10     know that that was an appropriate or a possible approach
  11     to the problem facing him or her?
  12   A. Formally, there was an induction programme, I hope for
  13     all members of staff, tailored to their needs, not
  14     necessarily on Day 1, it was sometimes after they had
  15     been there a week or 10 days, but there was a formal
  16     induction programme. I was most associated with and
  17     knew best that for new doctors, but there were induction
  18     programmes, and there was a staff handbook that used to
  19     be called the "houseman's handbook" because it was given
  20     immediately to every knew houseman, but it existed on
  21     all wards and in all departments. It gave a great deal
  22     of information, and it was edited annually, of what was
  23     significant in the Trust. You can think of going, shall
  24     we say, from Bristol to Manchester, they are both big
  25     teaching hospitals, they both have the same services,

   1     but you needed to know who everyone was, where
   2     everything is and how things were run. It was all
   3     documented in the staff handbook. It changed its
   4     character over the years as different needs were
   5     perceived and things were dropped out. There was always
   6     an argument of what they ought to know and what they
   7     wanted to know, as you can imagine, but that was typical
   8     I think of the documentation that was available.
   9        If you say, was it a physiotherapist, the
  10     physiotherapist would have been shepherded by senior
  11     members of that department for some time, because they
  12     would need to know where the wards were and which is the
  13     quickest way to get there and the names of staff, so
  14     there was an enormous amount of introduction of new
  15     staff to this very big organisation.
  16   Q. One of the considerations that has been put to you in
  17     the context of the "three wise men" procedure was the
  18     potential difficulty of wishing to complain about one of
  19     the three wise men, being a senior member of the
  20     hospital.
  21        Before I ask you about that, can I ask you about
  22     the potential difficulty of a junior doctor or a member
  23     of the paramedical staff wanting to raise a concern
  24     about unacceptable practice in relation to a senior
  25     member within his or her own department, say a senior

   1     consultant surgeon in the Department or a senior
   2     physician, a person perceived to be in a position of
   3     some power.
   4        What would you have expected a person in that
   5     position to be able to do within the organisation?
   6   A. If they are very junior, it would be unusual if they
   7     were uniquely the only person who observed this, so we
   8     are having a purist hypothesis to start with, but let us
   9     for the moment say we have a very strong surgeon who
  10     leads a team of Senior Registrar, a Registrar and couple
  11     of SHOs and so forth, ward sisters and so on, there is
  12     a big clinical team and some new person comes along,
  13     a junior, and says, "I do not know quite what is going
  14     on". Let us hypothesise that. That person could share
  15     those anxieties in a whole variety of ways, and unless
  16     we put much more pressure on the thing, I will not tell
  17     you what they will do. They will talk to their peers in
  18     a horizontal way. They will talk to the next one up and
  19     if it was the consultant and what we are talking about
  20     is a new houseman, the houseman would presumably say to
  21     the Senior Registrar who is looking after him, "What is
  22     going on in the place? What is happening?"
  23        The likelihood would be that it was a faulty
  24     perception on the part of somebody in training and they
  25     could be suitably informed, but that family would have

   1     a number of people with whom they would like to
   2     communicate.
   3        If we keep putting obstructions and say "This is
   4     a big powerful surgeon", what else should you do? If it
   5     was a houseman they would talk to Bob Coles, who was
   6     a physician and then a retired physician, who acted as
   7     a mentor and a counsellor for junior staff with their
   8     difficulties. There were many difficulties and very
   9     rarely the one we are postulating.
  10        So what I am saying is that in the
  11     interrelationships within the organisation, there was
  12     what we would now term "counselling", people would be
  13     supportive and helping. This junior person might
  14     actually go and talk to the theatre sister. Theatre
  15     sisters do not usually have the inhibitions that you are
  16     mentioning about talking to senior consultant staff, and
  17     they are also very experienced and would know how to
  18     handle the situation.
  19   Q. Just pausing there, and I am sure you can produce other
  20     examples, it might be thought that some of the evidence
  21     suggests a complaint that there was not some sort of
  22     formal system in which this could happen, apart from
  23     perhaps the "three wise men" system. Do you have
  24     a comment to make on that?
  25   A. Well, there were formal systems. The trouble with

   1     formal systems is that they are constraining and
   2     limiting, and tend to inhibit rather than permit what
   3     goes on. There were grievance procedures, a whole
   4     series of procedures laid down on how to deal with
   5     things, but what we are actually talking about is
   6     somebody having an anxiety and wishing to have it looked
   7     into and be reassured or the problem corrected.
   8   Q. May I then turn to the three wise men procedure and some
   9     evidence you gave about it yesterday.
  10        In answer to one of Mr Langstaff's questions, and
  11     I am paraphrasing, you said that it was not really for
  12     the person bringing the information to the three wise
  13     men, it was not necessary for such a person to diagnose
  14     the problem in terms of whether it was a matter of
  15     ill-health or not, that was a matter for the three wise
  16     men.
  17        You went on to say that the three wise men could
  18     deal with the problem as they saw fit.
  19        To what extent were the three wise men, in terms
  20     of the procedure, as you understood it, constrained to
  21     deal only with cases when someone was indulging in
  22     misconduct or unacceptable practice through ill-health,
  23     which includes of course addiction of one sort or the
  24     other?
  25   A. I think I could best answer that by saying that that

   1     was a part of their function which had been formalised
   2     and was the subject of an NHS letter, a document that
   3     was circulated, so that that element of their function
   4     was documented and, if you like, statutory.
   5        Could I say that the "three wise men" in Bristol
   6     were the three most respected professional advisers at
   7     the time; they were the father figures; they were three
   8     people who all had been elected by the whole of the
   9     consultant staff to represent their interests, so
  10     I preferred -- I mean, I was quite happy to use the term
  11     "three wise men" because that was the responsibility
  12     they had to deliver.
  13        Part of that was laid down from on high, but the
  14     rest of their responsibilities were similar and were
  15     effected but were not the subject of the letter.
  16   Q. Would you have expected -- keep this to medical staff at
  17     the moment -- any member of the medical staff to have
  18     understood that if he had a concern about a colleague's
  19     practice which was unacceptable, but not related in any
  20     way to his health, that he could go to one of those
  21     three people?
  22   A. Absolutely. I mean, they were the lead figures of the
  23     profession, designated, publicly elected, known by
  24     everybody.
  25   Q. Do you recognise or accept that a person wishing or

   1     having such a matter of concern might be feeling
   2     inhibited about going to one of these three people if
   3     the concern he had was about one of them?
   4   A. I do not think they should have done. I cannot
   5     predict what everybody would do and if somebody had that
   6     anxiety, then I am sure that would be an anxiety they
   7     would share with somebody who would reassure them or
   8     take on the issue themselves. It was I think clearly
   9     understood that if the past Chairman was, what shall
  10     I say, suspected or criticised, they would talk to the
  11     Chairman. If the Chairman was criticised, they would
  12     normally talk to the past Chairman, because he had the
  13     experience. It was a very effective trio, all of whom
  14     were accepted, and of course the past Chairman had been
  15     coping and representing professional views for two years
  16     before he became past Chairman, so he was known. People
  17     would go. I cannot envisage any circumstance in which
  18     it was thought improper to go to any of the three wise
  19     men. If it had been, then there was, as I say, a mosaic
  20     of issues and if the Chairman of the Medical Committee
  21     was a surgeon and you were worried about him, then you
  22     could go via the University link, go and share your
  23     worries with a senior member of the University
  24     department, or you could share it with the Health
  25     Authority, me or anybody. There was no difficulty in

   1     sharing your anxiety with somebody who was in a position
   2     to take a mature approach to it.
   3   Q. Do you think it would have helped to have had some
   4     written guidance about that sort of problem or not?
   5   A. No, I think that would have restricted the situation.
   6     This is the way you have to do it. If you write written
   7     guidance, as I have told you, that you talk to an
   8     appropriate person, you would either have to have a very
   9     big document or it would narrow the field of with whom
  10     it could be spoken. There was so much variance, so many
  11     possibilities, so many issues, that to write down all
  12     the possibilities and all the ways of treating them in
  13     a document, I think, would have been unhelpful.
  14   Q. Now may I turn to the position of the non-medical,
  15     perhaps the paramedical staff? You recall you were
  16     asked yesterday about the letter from the NHS Management
  17     Executive about Beverley Allitt. Perhaps you can look
  18     at that for a moment, UBHT 115/113.
  19        Just going up a bit so we can see the date of it,
  20     it is 19th May 1995?
  21   A. Yes.
  22   Q. It appears to have attached to it a letter, I think,
  23     which -- it is there, but never mind for the moment.
  24        When you received that letter, was there a general
  25     reaction to the Beverley Allitt problem that you

   1     recall?
   2   A. I think, I mean, it made a big impact on everybody.
   3     When this happens somewhere, everybody wipes their brow
   4     and says "There but for the grace of God ... would we
   5     have done better?" People are very concerned about what
   6     happens.
   7        There was another time when a baby was stolen from
   8     a maternity unit and every maternity unit in the country
   9     looked inwards and said, how can we guarantee this could
  10     never happen here?
  11        So when anything like this happens, there is an
  12     immediate response, and there is -- I expect it was
  13     immediate, if our local regional manager --
  14   Q. You were asked yesterday about a minute UBHT 6/26 which
  15     was of 18th June 1993. Can I ask you, please, to look
  16     at UBHT 6/200, a minute of 21st May?
  17   A. Could you tell me the date on this one before we move?
  18   Q. We have there 21st May. Could you scroll down the page,
  19     please, and over the page. I am sure Mr Langstaff takes
  20     comfort he is not the only person this happens to.
  21     Page 206, please:
  22        "There should be an arrangement whereby any member
  23     of staff could express concern to a responsible person."
  24        You and Mr Wisheart and Mr Stone would meet to
  25     discuss the matter further.

   1        That was on 21st May. We have seen the minute of
   2     18th June. Can you actually recall what was done in
   3     relation to that issue?
   4   A. As I recall, we merely re-emphasised and reinforced
   5     what was already in existence. I cannot remember us
   6     changing anything, but we were nervous that in another
   7     institution where such matters should have been obvious,
   8     it had not worked.
   9        So I do not think we changed anything. I do think
  10     we re-emphasised, re-publicised and took advantage of
  11     the national feeling about the case to ensure our own
  12     house was in order.
  13   THE CHAIRMAN: Mr Francis, I do have an eye on the time.
  14   MR FRANCIS: I have one more subject to deal with.
  15   THE CHAIRMAN: We will talk later about the procedure and
  16     guidelines I have issued.
  17   MR FRANCIS: Were you thinking of a break, or asking me to
  18     stop?
  19   THE CHAIRMAN: I am just suggesting that you carry on
  20     conscious of the fact that normally in re-examination we
  21     are talking about 15 or 20 minutes. Many of the things
  22     that one needs quite properly to draw the Panel's
  23     attention to can of course be the subject of further
  24     written submission.
  25   MR FRANCIS: I appreciate that, sir. I am fully aware of

   1     that, thank you. Can I just ask one question, really,
   2     about the role of the Medical Director. Can we have
   3     Mr Baird's statement at WIT 75/101? Could we go to
   4     page 2.
   5        Very briefly, I just want to ask you this,
   6     Dr Roylance.
   7        Mr Baird describes a number of roles that he
   8     fulfills as Medical Director in paragraphs 3 to 7 on
   9     that page. I just want to ask you to what extent, when
  10     you were the Chief Executive, these roles were fulfilled
  11     by someone other than the Medical Director?
  12   A. Could I say, role 3 was fulfilled by my Medical
  13     Director, but would have been a much smaller role than
  14     it would be in the new arrangement.
  15        Role 4, I did. The Clinical Directors, as I have
  16     explained, were accountable to me and that was my job.
  17        The consultant appointments had always been
  18     medical, Chairman of the Medical Committee, and that
  19     James did, Christopher Dean Hart did.
  20        6, I do not have it all on here but I did all
  21     that. I chaired the meeting that allocated major
  22     medical equipment.
  23   Q. Bearing that in mind, to what extent would that have
  24     produced an increase in time required for the job over
  25     and above what your Medical Director did?

   1   A. If he spent the time I did, doing the things I did, it
   2     would have been a very substantial addition to his
   3     time. Supporting Clinical Directors was a very
   4     time-consuming occupation. My major role in operational
   5     management was to make them successful.
   6   MR FRANCIS: Thank you very much, Dr Roylance.
   7            DISCUSSION ABOUT PROCEDURES
   8   MR FRANCIS: Sir, can I make it clear, before I sit down,
   9     that in following your guidance there were questions of
  10     some considerable detail that we could have put on the
  11     subject of audit, and because Dr Roylance has been
  12     questioned in detail on the organisation and
  13     implementation of audit, both he and his advisors had
  14     anticipated he would deal with these in connection with
  15     issue M, as is made clear in his statement.
  16        As a result, and as was made clear in his evidence
  17     over the past few days, we have not as yet reviewed the
  18     documents and detailed history of the subject in a way
  19     which would have enabled Dr Roylance to give all the
  20     help he would like to give to you on this issue.
  21        I would emphasise, it is his view that his
  22     evidence given so far and in answer to the questions
  23     yesterday is not as thorough and as helpful as he would
  24     like it to be, but we think it would be more helpful to
  25     the Inquiry for him to reserve any further remarks he

   1     has to make on that topic until he has prepared and
   2     submitted a full statement on issue M, rather than to
   3     take up your time now in dealing with the subject
   4     piecemeal in re-examination.
   5        One final point in response to the invitation made
   6     to him yesterday: I would like to make it clear that
   7     there have been a number of comments about the lateness
   8     of Dr Roylance's statement. There was a reason for
   9     that. The reason was that it was hoped to be able to
  10     include in that statement references to the documents
  11     that Counsel to the Inquiry was to have comments on.
  12     Unhappily -- this is no criticism of anyone at all -- it
  13     was not possible, but that was the reason his statement
  14     was later than he, Dr Roylance, would have liked, and we
  15     hope that it has not obstructed the Inquiry too much.
  16     He is at all times wishing to assist this Inquiry in any
  17     way possible.
  18   THE CHAIRMAN: Mr Francis, I am greatly obliged for what you
  19     have said. As regards the last point, I think the only
  20     relevance of the lateness is for to us say how much
  21     admiration we have for all of those who have been
  22     helping us, that they have been able to respond
  23     nonetheless. Sometimes lateness happens. It is often
  24     times not the fault of anyone. We accept, and we know
  25     that, and we are only pleased that we were able to get

   1     the response we have.
   2        I understand and take your point about audit, to
   3     the extent that, if you have other things that you wish
   4     to put before us in a further statement which can not
   5     only say what you wanted to say initially, but also
   6     serves to, as it were, sweep up matters which have
   7     arisen so far, then we look forward to receiving that in
   8     due course, and we will be helped by it, I am sure.
   9   MR FRANCIS: Thank you very much.
  10   THE CHAIRMAN: Mr Langstaff, if I may, I would just say one
  11     or two things. First of all, to thank you, Dr Roylance,
  12     for coming and sharing your views with us. It has been
  13     a long two days for you, and of course for others, but
  14     we found your evidence very helpful, and we are obliged
  15     to you for coming. We will hear again from you later on
  16     another matter.
  17        I repeat again what I said a moment ago to
  18     Mr Francis: very sincere thanks from the Panel to all
  19     those legal representatives who so helpfully supported
  20     Counsel to the Inquiry, and therefore, through their
  21     questioning, enabled us to be helped in our
  22     understanding of Dr Roylance's evidence.
  23        That is what I would say, Dr Roylance, if you
  24     would bear with me one more moment while I just say the
  25     following: that I think it probably wise for us to take

   1     a break now, rather than start with the next witness and
   2     take a break. Before doing so, just to continue my
   3     conversation with Mr Francis, but not directed to him
   4     alone, I would draw attention once again to the
   5     procedural guidelines which we laid down on
   6     re-examination. Normally we would not expect it to go
   7     on for more than about 15 or 20 minutes, but, because of
   8     course we heard this witness for over two days, I was
   9     today somewhat flexible, and I think it was right to be
  10     so, but I would remind all legal representatives that
  11     the preferred option in many cases is to submit
  12     additional written statements which will help us, and
  13     can be ample, and we can read and we would read.
  14        So I would just draw the attention of everybody to
  15     that.
  16        Now I propose, Mr Langstaff, if I may, subject to
  17     anything you want to tell me, to take a break.
  18   MR LANGSTAFF: Two points, if I may, building on the
  19     constructive approach which Mr Francis adopted at the
  20     close of his re-examination: the first is to emphasise
  21     not only in the case of Dr Roylance but in the case of
  22     any other witness, that until the Panel has finished
  23     hearing evidence, it is open to receive evidence. We,
  24     for our part, look forward to receiving the more
  25     detailed and considered statement in respect of audit,

   1     and if questions need to be revisited, they can of
   2     course be revisited when Dr Roylance returns. It must
   3     not be thought that because at the time of his return
   4     the principal focus will be on other issues, that that
   5     excludes questions about issues which have already
   6     arisen in the course of the Inquiry.
   7   THE CHAIRMAN: Absolutely. I think it is very important
   8     for the Panel to say, we would expect that.
   9   MR LANGSTAFF: Secondly the point which Mr Francis raises
  10     in respect of the timing of the statement is one which
  11     is of more general importance, and of which I should say
  12     something for wider consumption. Certainly, it must be
  13     said, no particular criticism was intended of
  14     Dr Roylance, but the experience that the Inquiry staff
  15     have had in dealing with the particular problem that was
  16     thrown up, the natural desire of Dr Roylance and his
  17     advisers to have their attention directed to particular
  18     documents so that his statement might deal with them,
  19     and on the other hand the natural desire of the Inquiry
  20     to see what Dr Roylance would have to say upon what is
  21     after all a fairly detailed Issues List needs
  22     clarification.
  23        We know that there are, at the moment, some other
  24     witnesses, those of them who read these remarks on the
  25     Internet will know to whom I refer, who have not given

   1     us a statement because they wish to see the documents to
   2     which their attention should be directed.
   3        That is firmly, in our view, to put the cart
   4     before the horse. If they have had an involvement in
   5     issues and can say something about issues which are,
   6     after all, detailed in a list, then it is for them to
   7     say what they can and what they think they should, if
   8     necessary referring us to those documents of which they
   9     are aware. We, in the course of focusing upon that
  10     evidence, which is after all their evidence to the
  11     Inquiry, may wish to draw their attention to other
  12     documents upon which we would invite their comments.
  13     But that is the way that it works, and it does not work,
  14     it needs to be said publicly, by witnesses who are not
  15     prepared to put themselves on paper in the first place,
  16     saying "Show us the documents you have, and then we will
  17     comment".
  18        May I say, this does not apply to Dr Roylance
  19     and it should not be thought that it does, but it is
  20     a problem which needs to be addressed publicly at this
  21     stage, because it is one that is surfacing elsewhere.
  22   THE CHAIRMAN: So you are taking the opportunity to put
  23     down a marker, not specific to this particular witness.
  24   MR LANGSTAFF: As it happens, getting us rather nearer
  25     our usual break time.

   1   THE CHAIRMAN: Well, thank you for making that point
   2     clear. I repeat, Dr Roylance, thank you. We will now
   3     take a break for 15 minutes. That means that we will
   4     return at about 5 to 11 when we will hear from the next
   5     witness. Thank you very much.
   6   (10.42 am)
   7               (A short break)
   8   (10.55 am)
   9   THE CHAIRMAN: Mr Maclean, it may help -- please tell me if
  10     it does, and do not tell me if it does not! -- if
  11     I suggest what timetable we can observe for the rest of
  12     the day. I would have thought we now should go from
  13     what is effectively 11 o'clock to 12.15, and then have
  14     a break at 12.15 until 1, and then from 1 until 2.15,
  15     and then reconvene at 2.30 for a period of time to be
  16     discussed.
  17   MR MACLEAN: Sir, yes. Can we have the next witness,
  18     Mrs Margaret Maisey, please?
  19           MRS MARGARET MAISEY (SWORN):
  20            Examined by MR MACLEAN:
  21   Q. Your full name is Margaret Maisey?
  22   A. It is, yes.
  23   Q. And you were, until your retirement, latterly,
  24     Director of Nursing of the United Bristol Healthcare
  25     Trust?

   1   A. That is right, yes.
   2   Q. And you previously held various posts in the health
   3     authority which the predecessor of the Trust, and then
   4     when the Trust was established in 1991, you were an
   5     Executive Director of that Trust holding the title of
   6     Director of Operations?
   7   A. I was, yes.
   8   Q. Can we go, please, to WIT 103/1?
   9        Can we see that whole page, please?
  10        That is the first page of your statement to the
  11     Inquiry.
  12   A. It is, yes.
  13   Q. If we go to page 45, that is your signature, is it not?
  14   A. That is correct.
  15   Q. Have you read that statement recently?
  16   A. I have, yes.
  17   Q. Is there anything in it that is erroneous, anything you
  18     would like to change now?
  19   A. No, nothing.
  20   Q. I am not going to go through that statement page by
  21     page or paragraph by paragraph. The Panel have read
  22     your statement and we will take that as read. I want to
  23     develop, though, some of the themes that emerge from
  24     that statement.
  25        I should say, you have also helpfully supplied the

   1     Inquiry, I think, with a written comment on the
   2     statement of Mrs Ferris, from whom we will hear
   3     tomorrow.
   4   A. I have, yes.
   5   Q. Those are the two pieces of written evidence that you
   6     have so far submitted to the Inquiry?
   7   A. I have submitted comments also on Mr Boardman's
   8     statement, I think.
   9   Q. You are quite right, you have, yes. We may mention
  10     both of those as well.
  11        Could you just give me an overview, Mrs Maisey,
  12     of what the values were that informed the UBHT?
  13   A. I do not know that they were very different from the
  14     values of the Bristol & Weston Health Authority. They
  15     were to deliver good care, excellent care, within the
  16     funds made available.
  17   Q. What did the Executive Directors of the Trust see as
  18     their objectives, their goals?
  19   A. Of the Trust?
  20   Q. The Executive Directors of the Trust.
  21   A. They were there and they knew they were there to support
  22     the clinical directorate and to coach them and to look
  23     after them as proved necessary.
  24   Q. We will come back to those concepts later. Can I just
  25     go back in time? Your background is as a nurse?

   1   A. Yes.
   2   Q. And your areas of clinical expertise as a nurse included
   3     general, acute and surgery medicine?
   4   A. My areas of expertise, in the most recent years, had
   5     been psychiatry. That is where I had practised as
   6     a nurse prior to going into teaching, and I taught for
   7     about four years. So it was some years since I had had
   8     acute general nursing.
   9   Q. You had also, I think, worked for a period in oncology,
  10     neurology, and neurosurgery?
  11   A. I had. That had been some years previously, but I knew
  12     a little of those areas.
  13   Q. You first went into a managerial post I think in Devon
  14     in 1982?
  15   A. Well, I had moved into a Divisional Nursing Officer post
  16     in Wolverhampton for about 18 months prior to that. In
  17     1982, when the districts emerged, I took a post as Chief
  18     Nursing Officer in North Devon. I was there for two to
  19     three years, and I then moved to Gloucester and then
  20     general management came in.
  21   Q. If we go to UBHT 234/105, that is a letter from
  22     Mr Hucklesby, Chairman of the Bristol & Weston Health
  23     Authority, appointing you as Unit General Manager of the
  24     South Unit, one of the two units and that is the one
  25     that did not involve the BRI?

   1   A. That is right.
   2   Q. At about the same time, you assumed the role of Nurse
   3     Adviser to the Bristol & Weston Health Authority?
   4   A. I did, yes.
   5   Q. You held that post of Nurse Adviser from then until you
   6     moved to be an Executive Director of the Trust?
   7   A. That is right.
   8   Q. Later, I think at the end of the 1980s or perhaps the
   9     very beginning of some time in 1990, you swapped,
  10     I think, roles with Mr John Watson, who had been the
  11     Unit General Manager of the Central unit?
  12   A. That is right.
  13   Q. You became the Unit General Manager of that Central
  14     unit, which embraced the BRI, amongst others?
  15   A. Yes. It was not as tidy as that sounds. The swapping
  16     was to take place at almost the same moment that the
  17     purchasers and providers that the Health Authority split
  18     into, at least shadow purchasers and providers, so
  19     although we swapped, John Watson actually moved into the
  20     purchasing role and effectively, we began to be the
  21     shadow Trust, and even at that, bits and pieces of the
  22     organisation were going to be split off into other
  23     Trusts who were forming their own shadows. So it was
  24     a very tumultuous time, with people, appropriate people,
  25     doing appropriate things, as they emerged.

   1   Q. When you swapped from South to Central units, did your
   2     role as Nurse Adviser change in any way, or were your
   3     responsibilities constant?
   4   A. No, that was the same, yes.
   5   Q. Can we go, please, to UBHT 104/149? This is
   6     a performance review of the Bristol & Weston Health
   7     Authority undertaken at a time when you were the Unit
   8     General Manager of the South unit.
   9        If we just scan down to see who is involved, there
  10     are some names that are by now familiar to the Panel:
  11     Dr Roylance, Dr Baker, Mr Boardman, yourself, Mr Nix,
  12     Mrs Orchard and Dr Thomas who went on to become the
  13     Audit Committee Chairman, I think, of the Trust.
  14        If we just scan down to see who else was involved,
  15     can we go, then, to page 154?
  16        Can you just put this review in a little context
  17     for me, Mrs Maisey? What was going on at this stage in
  18     1988, do you remember?
  19   A. I cannot remember the meeting. This was 1988?
  20   Q. It is, yes.
  21   A. Was this when we were into the Mereworth debates?
  22   Q. Yes, I think we see that. If we go back to 149, and
  23     over to 150, there had been a two-day conference and it
  24     was strategic planning for the three Avon districts:
  25     Southmead, Frenchay and Bristol & Weston. And there

   1     were talks regarding Mereworth, as you have mentioned.
   2     Does this help to jog your memory?
   3   A. Yes, a bit. I was quite a junior person in these
   4     debates at this time. There were regional people there
   5     and it was their meeting.
   6   Q. If we just scan down that page, please, we see that
   7     among the subjects discussed were paediatric services
   8     and cardiology services. Is that the end of the page?
   9     Can we go back to 154, please?
  10        Paediatrics. If we move to the bottom of the
  11     page, just stopping there, those three columns set out
  12     which paediatric services were provided by which of the
  13     three health authorities, cardiology and ITU and surgery
  14     being provided by Bristol & Weston?
  15   A. Right.
  16   Q. We see there the principles for paediatric services:
  17        "The following principles guiding the service
  18     provision for children in hospital were identified
  19     (i) children should only be admitted to hospital as
  20     a last resort; (ii) the service should be child
  21     orientated with appropriate specialist care."
  22        Then "Pan-Avon objectives: (ii) to provide
  23     appropriate specialist skills for treatment of children
  24     where possible in a child orientated environment and to
  25     maintain children's services close to the associated

   1     adult service."
   2        In the case of paediatric cardiac surgery at the
   3     BRI at this time, there would be a tension, would there
   4     not, between objectives (ii) and (iii)?
   5   A. Can I just say that I probably did not even know that
   6     there was paediatric cardiac surgery going on at the BRI
   7     at this time. Even in 1988, I had been there probably
   8     almost two years. My unit did not have any children in
   9     it, except some at Weston, children born at Weston,
  10     probably, small local children, because we were doing
  11     ENT with children down at Weston, I am pretty sure, and
  12     my involvement would have been -- I do not honestly
  13     remember seeing a child in the cardiac surgery unit in
  14     all my time at Bristol.
  15   Q. I understand entirely that you were the Unit General
  16     Manager of the South Unit at this time, not the Central
  17     unit, I entirely take that point, but you were the Nurse
  18     Adviser?
  19   A. I was.
  20   Q. What I am seeking to explore is whether or not your role
  21     as Nurse Adviser -- given those objectives, the
  22     objectives being to provide appropriate specialist
  23     skills for the treatment of children, and so on -- would
  24     have brought you into contact with any debate about the
  25     appropriateness of the care in the BRI of children

   1     undergoing open heart surgery in, for example, an
   2     Intensive Care Unit that was not as well staffed with
   3     paediatrically trained nurses as a purely paediatric
   4     intensive care unit might be. Is that something that
   5     came on to your radar screen as Nurse Adviser?
   6   A. In the specific way in which you couch the question,
   7     probably not. It did emerge into my consciousness, you
   8     might say, that we had children looked after in the Eye
   9     Hospital and children in trauma and orthopedics, and
  10     subsequently it emerged, children in cardiac surgery,
  11     although they would not have been at the top of my list,
  12     and I was aware that we had a Children's Hospital up the
  13     road from all these services. Therefore, I would have
  14     been interested to see what the rationale was for having
  15     ophthalmic children down at the Eye Hospital when there
  16     was a Children's Hospital up the road; why could not the
  17     ophthalmic surgeons walk up the hill? There were
  18     answers to these questions and I accepted them.
  19   Q. When did you first become, you said earlier you might
  20     not have been aware at this time that cardiac surgery
  21     was carried out on children at the BRI. When did you
  22     first become aware that there was this split site in
  23     paediatric cardiac surgery?
  24   A. I have a feeling that it was at a medical information
  25     Working Group meeting which I know that the Panel has

   1     heard of previously. That was the sort of forerunner to
   2     audit. Dr Roylance asked that I attended the medical
   3     information group working meeting as the nurse, and
   4     I used to go and I met Mr Wisheart there and heard
   5     debates about paediatric cardiac surgery there, so
   6     I have a feeling that that is when I realised there were
   7     additional children in the BRI.
   8   Q. That was when?
   9   A. It would probably have been much the same sort of
  10     time, 1987/88. I do not know. I should not be putting
  11     a time on it because I do not really know.
  12   Q. We will come back to the split site later. Can I jump
  13     a little bit ahead? I am conscious we have not dealt
  14     with your role throughout the 1980s in any more detail.
  15     That is because you were the General Manager of the
  16     South Unit, not the Central unit.
  17        By the time you became General Manager of the
  18     Central unit, the Trust was on the horizon and it was
  19     anticipated when that swap with Mr Watson took place you
  20     would become Executive Director of the Trust and that
  21     Dr Roylance would be the Chief Executive?
  22   A. Yes.
  23   Q. Can we go, then, to the question of the Trust? The
  24     Trust was organised with a number of directorates:
  25     13, I think. Each directorate had a Clinical Director

   1     and a General Manager?
   2   A. Yes.
   3   Q. To whom was the General Manager accountable?
   4   A. To the Clinical Director.
   5   Q. To whom was the Clinical Director accountable?
   6   A. The Chief Executive.
   7   Q. To whom were you accountable?
   8   A. The Chief Executive.
   9   Q. And you were the Director of Operations?
  10   A. Yes.
  11   Q. In some other Trusts, was it the case that the General
  12     Managers were directly accountable to the Chief
  13     Executive, perhaps through the Director of Operations
  14     type role?
  15   A. I do not know the answer to that question, to be
  16     honest. I think what you have to remember is that there
  17     had never been a Director of Operations before in the
  18     Health Service, to my knowledge. There had never been
  19     a Director of Nursing before in the Health Service,
  20     unless they were -- these titles were new. General
  21     management was new -- not at the Trust time, but in
  22     1984. So these titles did not always mean what they
  23     sounded. We did not have a hang-up with titles in the
  24     UBHT; we were concerned that the things that needed to
  25     be done got done.

   1   Q. Can we just leave the question of titles, I will come
   2     back to the question of titles in the context of jobs,
   3     but you say you were not aware of another Trust
   4     elsewhere where General Managers were directly
   5     accountable to the Chief Executive.
   6        If we assume that there were to be such
   7     a structure, what would you have seen as being the
   8     advantages and disadvantages of that, compared to the
   9     system that the UBHT instituted?
  10   A. The whole philosophy behind the introduction of Clinical
  11     Directors and directorates was to involve medical people
  12     in management. Even at the introduction of general
  13     management, medical management had stayed the same as it
  14     had since 1948, so far as I can make out. It was
  15     a separate entity. It managed itself. Clinical
  16     directorates was an effort to move those people into
  17     a management role, to understand why they could not have
  18     the money that they thought they ought to have; why
  19     management had to address the issues to satisfy the
  20     Department of Health, to whom we were all accountable,
  21     which I have to say, doctors did not always believe.
  22   Q. I understand one of the key features of the directorate
  23     system was that the Clinical Directors who were
  24     clinicians were going to be responsible for managing
  25     a directorate, they were going to be "in charge of their

   1     own show" to a large extent?
   2   A. That is right.
   3   Q. But the General Managers were more often than the
   4     Clinical Directors professional Health Service
   5     managers. Would it have been better or worse to have
   6     had them accountable not to the Clinical Director but to
   7     the Chief Executive perhaps through a Director of
   8     Operations type role?
   9   A. But that is not how it was.
  10   Q. I know it is not how it was, but the question is, if it
  11     had been like that, why would that have been less
  12     advantageous?
  13   A. If all our managers had been professional administrative
  14     type managers, you mean, would it have been better for
  15     them to have left out the doctors and been accountable
  16     to the Chief Executive? I am sorry, is that what you
  17     are asking?
  18   Q. Yes.
  19   A. Then you would not have involved doctors in a management
  20     role.
  21   Q. We will come to Mrs Ferris, but can we go to WIT 89/20,
  22     paragraph 46?
  23        This is Mrs Ferris's statement that you have seen
  24     and commented on. Mrs Ferris, who was latterly the
  25     General Manager of Cardiac Services but had been

   1     involved in management in the Trust previously, I think,
   2     in surgery and orthopedics, she says:
   3        "As regards the managerial chain of command,
   4     General Managers were accountable to the Chief
   5     Executive, Dr John Roylance, through the Director of
   6     Operations, Mrs Margaret Maisey."
   7   A. She is wrong.
   8   Q. She is wrong about that?
   9   A. She is wrong, yes.
  10   Q. So the General Manager of Cardiac Services, she would
  11     appear to be saying there, she is suggesting, is she
  12     not, that you were effectively her line manager?
  13   A. She is, and she is wrong. She was never, in all the
  14     years that I knew her, she was never directly
  15     accountable to me, ever.
  16   Q. Can you account for that error by Mrs Ferris? How
  17     might she have got fundamentally the wrong end of the
  18     stick?
  19   A. If she had been accountable to me, I would have been
  20     coaching her and supporting her in a way that I was
  21     not. There were many debates about accountability.
  22     I know that in Dr Roylance's evidence, he has talked to
  23     the Panel about the "bubble", but by the time Rachel
  24     Ferris was moving into the cardiac unit, that whole
  25     issue had settled down. It was absolutely clear that

   1     the General Manager was, as it were, a Chief Executive
   2     to the Clinical Director's Chairmanship, and they are
   3     not accountable to the Trust Board.
   4   Q. Just to follow up this little example, there is only one
   5     example in one directorate: when Mrs Ferris became the
   6     General Manager of the cardiac services directorate, who
   7     was the Clinical Director of that new directorate?
   8   A. I think it was Professor Vann Jones.
   9   Q. And it was Professor Vann Jones that Dr Roylance
  10     mentioned earlier this morning?
  11   A. That is right.
  12   Q. Having previously been Clinical Director in the
  13     Directorate of Medicine?
  14   A. In which Rachel Ferris had been a junior, a middle
  15     manager.
  16   Q. Are you able to comment as to whether or not
  17     Professor Vann Jones was anxious to assume the role of
  18     Clinical Director of that cardiac services directorate?
  19   A. I do not know, but I would be very surprised if he was
  20     not.
  21   Q. He was the Clinical Director of cardiac services, but at
  22     the same time, he kept up his clinical work in again
  23     medicine and cardiology as well as teaching commitments
  24     at University?
  25   A. That is right.

   1   Q. Can we go to his statement? I think you have had
   2     a chance to see this?
   3   A. I have not seen Professor Vann Jones' statement.
   4   Q. Can I show you one or two paragraphs from it? It is
   5     WIT 115/5. Paragraphs 17 and 18. Perhaps we will just
   6     take 16 as well. Can we see the heading, please?
   7        "The Clinical Director is answerable to the
   8     Medical Director/Chief Executive in relation to
   9     management issues and to the Chairman of the Hospital
  10     Medical Committee in relation to medical issues."
  11        Do you agree with that?
  12   A. Not entirely, no, not how I would have seen it. I would
  13     have thought the Clinical Director was answerable to the
  14     Chairman of the Medical Committee and the Medical
  15     Director for medical issues and the Chief Executive for
  16     management issues.
  17   THE CHAIRMAN: Mrs Maisey, I was just intervening to say,
  18     you have not seen this and if you are not entirely
  19     comfortable about responding to it, please let us wait
  20     until you have had an opportunity, perhaps over the
  21     luncheon adjournment, to have discussed it with
  22     Mr Chambers. If, on the other hand, you are quite happy
  23     to go on, please do so, but I am always anxious that
  24     a witness should, as it were, have had an opportunity to
  25     look at things rather than be asked to comment before

   1     they have seen it, because in that way, we are helped
   2     more by your answer. That is the only guiding
   3     principle.
   4   A. Thank you very much, Chairman. I am happy, I think,
   5     to comment on those paragraphs, and I can perhaps look
   6     at the statement and comment on it separately, thank
   7     you.
   8   MR MACLEAN: Thank you, Mrs Maisey. It is the same point
   9     as Mrs Ferris makes, the same point we have already
  10     dealt with, with Mrs Ferris. Mr Wisheart was the
  11     Medical Director from 1992 and for a while was also
  12     Chairman of the HMC, as a matter of fact; is that
  13     correct?
  14   A. I am sorry, say it again?
  15   Q. It is paragraph 16, the second sentence.
  16   A. Yes, so the two were together, that is true, yes.
  17   Q. 17:
  18        "Within the directorate, a Clinical Director was
  19     assisted by a General Manager ..."
  20        That is true?
  21   A. Yes.
  22   Q. "General Managers were answerable to the Chief
  23     Executive."
  24   A. And through the Clinical Director, but, yes, they were,
  25     ultimately.

   1   Q. Professor Vann Jones would appear to be suggesting that
   2     if we pick up paragraph 18 and read paragraphs 17 and 18
   3     together, perhaps you would take a moment to do that.
   4     (Pause)
   5        What Professor Vann Jones is saying in
   6     paragraph 18 is that the Associate Clinical Directors,
   7     namely Dr Pitts-Crick and Mr Dhasmana, were answerable
   8     to him, but no-one else was directly answerable to him.
   9   A. So despite the fact he says "my General Manager" and
  10     "my" this and "my" that, he did not see them as
  11     accountable to him. Perhaps he saw them -- because he
  12     was one of the few that were very much into the "bubble"
  13     and were jointly accountable to the Chief Executive.
  14     There was room for a bit of flexibility.
  15   Q. It would appear as though Professor Vann Jones was of
  16     a similar mind to Mrs Ferris, that the General Manager
  17     was accountable to the Chief Executive. If he is of
  18     that view, your evidence must be that he is wrong in the
  19     same way Mrs Ferris is wrong?
  20   A. No, not at all. It would have been very nice if it
  21     could have been that a team of Clinical Director and
  22     a General Manager could see themselves as working
  23     together as an absolute team, the doctor with the
  24     vision, with the knowledge and contacts that he had, and
  25     where the caring was going, and the General Manager with

   1     the financial and administrative and that background
   2     knowledge to work together as a team. That is what they
   3     did, in effect. That is how they had to be.
   4        It would have been nice if they could have been
   5     equally accountable to the Chief Executive and that is
   6     how they were treated, in effect. That is how it worked
   7     in practice. But they had to work together and what
   8     Professor Vann Jones is saying is -- it is nothing to do
   9     with me. He is not seeing me as intervening between the
  10     General Manager and the Chief Executive.
  11   Q. No, you are not mentioned, absolutely.
  12   A. So what he is saying is not the same as Rachel Ferris is
  13     saying.
  14   Q. But to the extent it was your evidence that the General
  15     Manager was accountable to the Clinical Director, and if
  16     and to the extent that certainly Mrs Ferris and, at
  17     least on one reading of this, Professor Vann Jones are
  18     saying something else, they must have fallen into error?
  19   A. Certainly Rachel Ferris did, yes.
  20   Q. Can I just pick up the first sentence of 16 again? What
  21     was the management role of the Medical Director?
  22   A. He did not have a management role.
  23        I mean, I am not a Medical Director, but I know as
  24     Nurse Adviser I did not have a management role.
  25   Q. The concept of directorates with the Clinical Director

   1     being responsible for his or her own directorate, meant,
   2     did it, that it was important that the Clinical
   3     Directors should be capable of discharging their new
   4     managerial responsibilities?
   5   A. Yes, with the support of a competent General Manager,
   6     and some training. They got some training.
   7   Q. What sort of training did Clinical Directors get to help
   8     them be good Clinical Directors?
   9   A. Well, to start with, there is a sort of induction. They
  10     spent quite a bit of time as individuals with the Chief
  11     Executive. Later, there was specific training put in
  12     place for them, and they went off on training days.
  13   Q. You say "later". When?
  14   A. I do not know. I could not put a date on it, but it
  15     certainly happened.
  16        I am talking about the first tranche of Clinical
  17     Directors. It was easier for those that followed
  18     because the pattern had been set. Given that this was
  19     a new concept in this country, and it was not piloted
  20     anywhere, it was very much a "suck it and see" job.
  21        As you have heard, the Panel has heard, the way in
  22     which Clinical Directors were selected or elected or
  23     emerged was very much with the support of their peers,
  24     and with a competent General Manager, they also had some
  25     support. They were intelligent people, well committed,

   1     wanted to make it work, could see the advantages and
   2     were learning from their General Managers, as well as
   3     the rest of the Executive at Clinical Directors'
   4     meetings and so on.
   5   Q. When the Trust was implemented in 1991, what formal
   6     training had the Clinical Directors had in these new
   7     important managerial responsibilities?
   8   A. Well, there could not be any training because they did
   9     not have any Clinical Directorship knowledge anywhere in
  10     this country, I do not think, to call on. So we did not
  11     really know what was going to be required of them.
  12   Q. I think Dr Roylance said "We did not train Clinical
  13     Directors and then say 'You will start being a Clinical
  14     Director when you are trained', as happens in a stable
  15     situation. We had to, as I say, appoint them and then
  16     develop the role and define it, and even define the
  17     limits of the directorate. So this was a very
  18     interesting evolution into a new management system."
  19        Do you agree with that?
  20   A. Absolutely.
  21   Q. Can we go to WIT 89/18, please?
  22        This is Mrs Ferris's statement that you have seen
  23     and commented on, at paragraph 38.
  24        Mr Dhasmana, when he became General Manager of
  25     cardiac services in 1984, I think it was, he was the

   1     Associate Clinical Director of the Associate Clinical
   2     Directorate of Cardiac Surgery, which was a part of
   3     cardiac services. Mrs Ferris says:
   4        "I do not know for sure, but I would not be
   5     surprised to learn that Mr Dhasmana [whom she criticised
   6     earlier for lack of management skill] himself probably
   7     received no guidance or training on what was expected of
   8     him as an Associate Clinical Director."
   9        What would you say about that? Would you say
  10     Mr Dhasmana had such training, or should have had such?
  11   A. It might say something about Rachel Ferris, because she
  12     clearly does not know whether he had guidance or
  13     training. She ought to know.
  14   Q. What ought he to have had by way of guidance or
  15     training?
  16   A. I am trying to recall whether he was the first -- he was
  17     not the first associate directorate, Clinical Director.
  18     I cannot remember whether he was or he was not, because
  19     if he was the first, then what we have said earlier
  20     applies.
  21   Q. We are learning by doing?
  22   A. That is right, yes. These things were all emerging and
  23     all evolving, and if Mr Dhasmana was the second --
  24     because I thought that James Wisheart was the first. If
  25     Mr Dhasmana was the second, then he would have had the

   1     benefit of his predecessor's experiences.
   2   Q. I think Mr Wisheart was the Associate Director of
   3     cardiac surgery when cardiac surgery was part of the
   4     Directorate of Surgery.
   5   A. So my memory is right. Mr Dhasmana then came in behind
   6     him when they formed the whole thing and James Wisheart
   7     had moved on.
   8   Q. He had moved on and up, that is right.
   9   A. Then he had the benefit of that at least.
  10   Q. So Mr Dhasmana's first port of call, if he felt -- I am
  11     not saying he did -- that he needed guidance and
  12     training, being an Associate Clinical Director, should
  13     have been to his predecessors, and that would have
  14     included Mr Wisheart?
  15   A. I would have expected Mr Wisheart to have told him what
  16     he thought the post entailed at that time, yes.
  17   Q. What was the role of the Executive Directors, of which
  18     you were one, in relation to the Clinical Directors?
  19     What kind of relationship was there?
  20   A. Well, we supported them in the way we supported all
  21     staff, if they came to us. The Executive Directors,
  22     Mr Stone, Mr Nix and myself, always went to the Clinical
  23     Directors meetings, the monthly meetings, which John
  24     Roylance chaired. We would go to contractual meetings
  25     if we were asked and invited for reasons by the Clinical

   1     Directors. I was asked sometimes by Clinical Directors
   2     to go to their meetings within their directorate for one
   3     reason or another. We would give any support we were
   4     asked to give.
   5   Q. What scrutiny or oversight was there by the Executive
   6     Directors in the early days of the Trust to ensure that
   7     each directorate was developing as it ought into
   8     a properly managed "bubble", if you like?
   9   A. The monitoring mechanism, there were several of them.
  10     There was the Clinical Directors monthly meeting with
  11     John Roylance, which started off as a Clinical Directors
  12     and General Managers, so we would see them all. It was
  13     quite a big roomful, because that is 28 before you add
  14     in some others. So it then became just the Clinical
  15     Directors, and from time to time, the General Managers
  16     got invited to a meeting.
  17   Q. You would see the General Manager separately?
  18   A. I saw the General Manager, that was the second, if you
  19     like, another branch of monitoring.
  20   Q. So once the system fell out a little bit, the Clinical
  21     Directors would meet with the Chief Executive?
  22   A. Yes.
  23   Q. And the Medical Director?
  24   A. And the rest of the Board.
  25   Q. And the rest of the Board, and you separately, as

   1     Director of Operations, would meet monthly, I think,
   2     with the General Managers?
   3   A. Also with the other Board members.
   4   Q. And also with the other Board members.
   5   A. Because they would be there, and between us, we would
   6     make sure that the messages we gave to one were the same
   7     as the messages we gave to the other, but there were
   8     slightly different things to be monitored and slightly
   9     different messages sometimes to be passed to General
  10     Managers and/or Clinical Directors.
  11   THE CHAIRMAN: May I intervene very briefly? Just to
  12     clarify for the Panel's purpose, you said "and the rest
  13     of the Board" and you separately as Director of
  14     Operations would meet monthly, I think, with the General
  15     Manager, "also with the other Board members", you said,
  16     and Mr Maclean said "and also with the other Board
  17     members". That makes it look like a separate meeting,
  18     whereas I think, Mrs Maisey, you were suggesting you met
  19     them together with the Board members?
  20   A. Correct.
  21   MR MACLEAN: That is what I understood Mrs Maisey to be
  22     saying.
  23   THE CHAIRMAN: It was for my own clarity, Mr Maclean,
  24     although it may have been clear to you.
  25   A. I should have said it was the executive Board members;

   1     it did not include the non-executive.
   2   MR MACLEAN: We will come to the non-executive. Dr Roylance
   3     was asked whether each of the directors developed at
   4     their own pace depending on the personalities involved
   5     and he said "Yes"; do you agree with that?
   6   A. Absolutely, yes.
   7   Q. Was that something that the Executive Directors were
   8     comfortable with?
   9   A. Yes, some of these people had been working together for
  10     quite a long time. The directorates of radiology, for
  11     example, the senior radiographer became the General
  12     Manager, and he had been working alongside the
  13     radiologists and the radiologist who became Clinical
  14     Director, for some years -- many years.
  15   Q. So that directorate got up and running quite quickly?
  16   A. It also was clearly defined, the space in which it was,
  17     and it was quite easy to set that up, the same as the
  18     laboratory. They had their difficulties because there
  19     were radiology facilities outside of the main radiology
  20     departments, and did they belong to the Children's
  21     Hospital in which they were situated, or to the
  22     radiology department? So there were still debates, but
  23     the "bubble" was solid.
  24   Q. By and large, that was an example of a directorate that
  25     had worked well fairly quickly?

   1   A. Yes.
   2   Q. But there would be other directorates at the other end
   3     of the scale which did not get off the ground quite so
   4     easily?
   5   A. That is right, where there were -- perhaps some of their
   6     facilities were dispersed, I was thinking of psychiatry
   7     in particular, where the site for psychiatry was large
   8     and the units were separate; there was not even a big
   9     hospital building.
  10   Q. One problem with the directorates initially was what to
  11     do with the anaesthetists, was it not, whether there
  12     should be a separate directorate?
  13   A. That is right.
  14   Q. So where you had care which involved anaesthesia, there
  15     would immediately be a difficulty from Day 1 with where
  16     the anaesthetist should fit into the new system?
  17   A. Well, it did not feel like that. In the Eye Hospital,
  18     for example, that was a directorate, the directorate of
  19     ophthalmology and the anaesthetists, certain
  20     identifiable anaesthetists visited the Eye Hospital
  21     theatres and worked there. It was not a problem that
  22     I was aware of that the Eye Hospital had difficulty
  23     with, or the anaesthetist had difficulty with.
  24   Q. Which of the directorates in your view developed most
  25     slowly?

   1   A. I do not know the answer to that. They all had problems
   2     of one kind or another. In the first instance, the
   3     things that caused a problem were to do with which bit
   4     belongs to me geographically. You mentioned the
   5     anaesthetists who, almost the whole of their budget was
   6     staffing; because they did not own the theatres, they
   7     did not have any -- I think they had the equipment
   8     budget. The staff budget and the equipment budget.
   9     They had no room for flexibility of their budget,
  10     because it went in salaries; it was committed
  11     straightaway.
  12        That applied across the board to some extent,
  13     because the bulk of NHS money is committed to salaries.
  14     Whether you are talking about general surgery, general
  15     medicine, paediatrics, midwifery, whatever, each of
  16     these areas has committed its money before it starts.
  17        One of the things all the Clinical Directors did
  18     was, thought, "Great, I have my hands on #35 million",
  19     or #15 million, or #42 million, or whatever their budget
  20     was. These were big directorates; and some of these
  21     places were as big as many Trusts today.
  22   Q. The Directorate of Surgery, which initially embraced
  23     cardiac surgery, was that one of the biggest
  24     directorates?
  25   A. One of the biggest, yes.

   1   Q. And surgery always has a relationship with the
   2     appropriate medical discipline?
   3   A. Yes.
   4   Q. So in each case of surgery, there is a physician and
   5     a surgeon involved in the care of a patient somewhere
   6     along the line?
   7   A. I do not think that is the case at all. In cardiac
   8     services, that is true, but if your GP refers you to
   9     a rheumatologist, he probably has a relationship with an
  10     orthopaedic surgeon in case he has to refer you on, but
  11     you may never have anything to do with that surgeon and
  12     the bulk of his patients, I suspect, do not have surgery
  13     at all.
  14   Q. Let us take the cardiac surgery example, then. Would
  15     the position of cardiac surgery in general, and on
  16     children in particular, have been one of the most
  17     complicated areas of the new directorate structure in
  18     terms of cross-cutting between different disciplines?
  19   A. It would not be unique. It would be one that was
  20     interesting in as much as it involved physicians,
  21     anaesthetists, surgeons, paediatricians, radiologists
  22     and quite a variety of professions allied to medicine as
  23     well. So it is quite a complex one compared to some
  24     others.
  25   Q. Let us focus on your role as Director of Operations.

   1     You had this monthly meeting with the General Managers?
   2   A. Yes.
   3   Q. And the General Managers were not accountable to you?
   4   A. That is right.
   5   Q. They were accountable, according to your evidence, to
   6     the Clinical Directors?
   7   A. That is right.
   8   Q. So who set the agenda for the monthly meeting?
   9   A. They put items on if they wanted to, otherwise
  10     Graham Nix and I would usually put the agenda together.
  11     Ian Stone may well add personnel issues. John Roylance
  12     would add things, saying, "You must remember to tell the
  13     General Managers" this or that or the other.
  14   Q. What kind of items typically would you put on the agenda
  15     for the General Managers?
  16   A. The things that were worrying me at that moment, which
  17     were most likely to be how we could get in a position to
  18     respond to the multitude of demands and requirements to
  19     meet the Department of Health's constant circulars and
  20     demands for information.
  21   Q. So you, I think, were appointed Director of Operations?
  22   A. Yes.
  23   Q. Who interviewed you for that post?
  24   A. We had interviews with John Roylance and the Chairman of
  25     the time, Peter Durie, but we had been working for some

   1     years so there were no normal advertisements, and I am
   2     not sure we put in formal applications. I do not think
   3     we did.
   4   Q. So there was no competitor for any of the Executive
   5     roles?
   6   A. No, I do not think so.
   7   Q. Were you ever aware of what the selection criteria were
   8     for appointing the Director of Operations?
   9   A. As I said before, there had never been a Director of
  10     Operations in the National Health Service. This was
  11     a new phrase, a new title. It was easy to assume,
  12     although maybe not accurately, that the Finance Officer
  13     was the same person and held the same responsibilities
  14     as the Director of Finance. I suspect Graham Nix would
  15     not necessarily agree with that, because the
  16     responsibilities of the Director of Finance in the Trust
  17     were largely very different, I think -- I know -- from
  18     when it was just a Health Authority. The Director of
  19     Operations had never existed, so how could there be
  20     a job description or a criteria?
  21   Q. I was not so much focusing on the job description of the
  22     Director of Operations, I was focusing on why you, in
  23     particular, considered you were selected for that role?
  24     What was it about you that meant that Dr Roylance and
  25     Mr Durie, if that is who it was, selected you for this

   1     role?
   2   A. John Roylance in particular, but Peter Durie also, knew
   3     how I worked. They knew that I gave priority of concern
   4     to patient care, to good quality patient care, that
   5     I was also quick to respond, that I was approachable,
   6     people could find me, and I did think that I made things
   7     happen. If people had problems, I was in there solving
   8     them. I wanted everybody to be successful in what they
   9     did and I wanted what they did to be looking after the
  10     patients properly.
  11   Q. Could that fairly be summarised as saying that
  12     Dr Roylance saw you as somebody he could Trust to do
  13     a good job?
  14   A. I hope so.
  15   Q. That was the impression you had?
  16   A. I think so. I hope so. I mean, I think, firstly, that
  17     he would -- it is not how I would put it. I would
  18     think, I would hope, that he thought I was somebody that
  19     he had seen in action and he knew that what I did was
  20     what he wanted done, and he knew that my motives were
  21     the same as his.
  22   Q. Did you have a job description as Director of Operations
  23     when you took up post?
  24   A. I do not think I did. I think that over the first 12
  25     months, 18 months, we developed them, because everything

   1     was happening so quickly. Like I said, nobody knew what
   2     it was.
   3   Q. Was your role as Director of Operations, therefore,
   4     self-defining? Did you essentially draw up the
   5     boundaries of your own responsibility?
   6   A. To some degree that could be said to be true, but to
   7     a large extent, no. There were things to be done and
   8     they had to be done, and if they did not belong to
   9     Finance and they did not belong to Personnel, clearly,
  10     then either John Roylance was going to do them or I was
  11     going to do them.
  12   Q. What about Mr Boardman?
  13   A. Mr Boardman was Planning, and his role was clearly not
  14     operational. Okay, so if there were operational things
  15     to be done, if there were departmental requirements,
  16     requests for information and such like, then it was not
  17     going to go to Planning. He would be Planning, I think
  18     at that time, he was probably planning for our move from
  19     Manulife House, our headquarters, into the School of
  20     Nursing which had just moved down.
  21   Q. So Mr Boardman was responsible for moving ahead,
  22     planning things that were going to happen?
  23   A. That is right.
  24   Q. If there were numbers involved, that was probably
  25     Mr Nix's department?

   1   A. That did not stop him talking about everything. We all
   2     talked about everything.
   3   Q. If it was personnel, it was Mr Stone. If it did not
   4     fall within any other categories, you were the residual
   5     category and it would be liable to fall into your lap;
   6     is that not right?
   7   A. In discussion with Dr Roylance. It might not be
   8     appropriate for it to come to me, even then. If it was
   9     a medical matter, it could clearly go to Mr Wisheart,
  10     but ...
  11   Q. What would you say were the main areas of
  12     responsibility, the main three or four areas that
  13     defined your role as Director of Operations as it
  14     subsequently developed?
  15   A. Quite a lot of my time was spent with individual General
  16     Managers and/or Clinical Directors, discussing how they
  17     were going to develop their directorates. Sometimes
  18     that was about geographical moves, sometimes it was
  19     about financial problems, sometimes it was about
  20     staffing, all sorts of things, some of which they would
  21     have had experience with, and some of which they might
  22     not have.
  23   Q. So any managerial issue that cropped up that had not
  24     been readily dealt with before might come across your
  25     desk?

   1   A. Yes. It would not necessarily be in writing, you
   2     understand, but somebody would ring me or say, "Can you
   3     come up to the meeting? We are having a meeting on
   4     Tuesday morning. Can you come up because the Clinical
   5     Director will be there and we can just see what
   6     conclusions we can come to?", or potential actions.
   7   Q. Would it be fair to say that your role was to, as it
   8     were, "float" above the General Managers and keep them
   9     on the straight and narrow?
  10   A. If you would like to put it that way!
  11   Q. You put it however you wish.
  12   A. I saw myself as assisting Dr Roylance, trying to keep as
  13     close to his view and get inside his head to see what
  14     his view would be of this problem, or these problems, or
  15     this demand, or this request, or ... and respond in that
  16     way.
  17   Q. So your job was to understand what Dr Roylance wanted to
  18     achieve. He was responsible for the general strategic
  19     overview of the whole Trust?
  20   A. Yes.
  21   Q. Then it was important, obviously, for the success of
  22     Dr Roylance's vision, that the General Managers lower
  23     down the chain should be rowing in the same direction as
  24     Dr Roylance?
  25   A. Yes.

   1   Q. So your responsibility was to manage the General
   2     Managers to make sure that they helped to achieve the
   3     vision Dr Roylance had; is that fair?
   4   A. I had a single concern in my mind very often that,
   5     because I had been the Unit General Manager and the
   6     Manager of the South Unit, it was very easy to slip into
   7     managing the General Managers, and I was very concerned
   8     that I did not do that. So I was not managing them.
   9   Q. Mr Nix was, for example, an accountant; he was Finance
  10     Director. There was a Personnel Director. Your
  11     background was as a nurse and a Nurse Adviser, and later
  12     a District General Manager.
  13   A. Unit General Manager.
  14   Q. I am sorry, a Unit General Manager. Your role with the
  15     Trust as Director of Operations surely was essentially
  16     a managerial one, was it not?
  17   A. I may have inadvertently done this myself, a few minutes
  18     ago. We worked as a team, so even though Graham Nix was
  19     the Finance Director, he and I would still talk about
  20     management issues. Similarly with Ian Stone. We all
  21     worked very closely with John Roylance. Our offices
  22     were all cheek-by-jowl when we moved into the old School
  23     of Nursing, and we all talked together. Graham Nix had
  24     a whole raft of finance officers who worked absolutely
  25     and closely to the General Managers and were integrated

   1     into their clinical directorates. Similarly, all the
   2     clinical directorates had a personnel officer. So they
   3     all had threads into making this system work. We all
   4     were going in the same direction, and trying to make
   5     everybody deliver the care that we had contracted for.
   6   Q. I think you say in your statement that when you were
   7     Director of Operations, your role as Nurse Adviser
   8     continued and necessarily took a bit of a back seat, so
   9     you were more dependent on the Nurse Advisers in each
  10     directorate than you had been before; is that right?
  11   A. I think that is probably true, yes.
  12   Q. To the extent that you had a background in first of all
  13     nursing, and secondly unit general management, when you
  14     became Director of Operations, it was to your managerial
  15     background rather than your nursing background that was
  16     to the fore?
  17   A. I think I also say in my statement that I often did not
  18     differentiate between the two. When I would go and
  19     visit with Dr Roylance or with Graham or Ian or whoever,
  20     the Chairman sometimes, various parts of the Trust --
  21     and we are talking about the Trust; yes, we are -- then,
  22     what I would do was wear both of those hats, and
  23     sometimes one more than the other, because the nursing
  24     problems were in some directorates quite acute; they
  25     were not in radiology, where they only had five nurses,

   1     or in pathology where they only had nine, but they were
   2     in the community, where it was almost all nursing staff.
   3   Q. We will come to see the nursing role in due course, both
   4     as Director of Operations and as Director of Nursing.
   5        Can I take you to another document?
   6     HA(A) 143/48?
   7        This is a report to the District Health
   8     Authority. It is in the months leading up to the
   9     institution of the Trust. That is why it is
  10     headed "Bristol Provider Unit". That was a little team
  11     that was set up that was going to be running the Trust?
  12   A. That is right, yes, it was.
  13   Q. If we go to page 50, we see that it is October 1990 and
  14     you are already there signing yourself as Director of
  15     Operations?
  16   A. I have to say, the page you just took away also said
  17     something about Clinical Directors training, which is
  18     nice to see.
  19   Q. We will go back to that page. So you are describing
  20     yourself as Director of Operations on 5th October 1990,
  21     and that is about six months before the Trust
  22     formally --
  23   A. That was the Shadow Trust, yes.
  24   Q. Shadow Trust, yes. Can we go back as promised to
  25     page 48? Just look at those first three paragraphs.

   1        Perhaps you would just read those to yourself.
   2     (Pause)
   3        The bit I want to pick up on is the last sentence
   4     of the second paragraph:
   5        "Bristol & Weston purchasers are pursuing quality
   6     aspects of contracts with the Clinical Directors of
   7     psychiatry, maternity, cardiac surgery and
   8     ophthalmology."
   9        In what respects was quality being pursued with
  10     cardiac surgery?
  11   A. I do not know. I could not tell you at this late
  12     stage. I do not know whether I ever knew, but I could
  13     not tell you.
  14   Q. I think there was something on that page you wanted to
  15     draw my attention to?
  16   A. Only the sentence afterwards, the "study day", that is
  17     all. They have a study day.
  18   Q. How would you describe your working relationship with
  19     Rachel Ferris -- I mean from the beginning? I think you
  20     worked together in Farleigh Hospital in 1986?
  21   A. We did not work together. I had my office in Farleigh
  22     Hospital. It had been hoped and envisaged when I took
  23     up the post of Unit General Manager, South, that I would
  24     have an office in Weston, so I would actually be
  25     situated 20 odd miles down the road from the Bristol

   1     end. I actually resisted that a bit, because it just
   2     seemed too far out, and I also thought -- knew from my
   3     own experience, that hospitals for those with learning
   4     difficulties often think of themselves and get thought
   5     of by others as the "lost ones", the Cinderellas of the
   6     service, and it seemed to me very appropriate to put my
   7     office there, which was nearer the centre anyway, and
   8     halfway to Bristol & Weston.
   9        I am sorry for that diversion, really.
  10        But Rachel Ferris was employed there when
  11     I arrived as, I think, responsible for catering and
  12     portering and such like in the learning difficulties
  13     sub-unit.
  14   Q. Were you able, at that early stage in her career, to
  15     form a view of her general competence?
  16   A. Not really. I saw her when I walked through the
  17     hospital or parked the car or whatever. I just knew her
  18     as Rachel Ferris, administrative assistant, as she was.
  19   Q. When did your paths begin to cross more frequently
  20     professionally?
  21   A. I feel as though she talked to me whilst she was still
  22     there about how she hoped to move on and up, and I think
  23     she had been a national trainee and that is the path she
  24     followed.
  25   Q. She was ambitious?

   1   A. She was ambitious, and she made that clear. Fair
   2     enough. I said the opportunities would arise.
   3   Q. So when did you first begin to work more closely
   4     together?
   5   A. The next thing that is in my mind about her in
   6     particular is her applying for a job at Bristol General
   7     Hospital, in which I interviewed her. We had
   8     a discussion about her background to date and where she
   9     might go from there, because she did not get that post,
  10     and to be honest, I cannot even remember who did get the
  11     post. That is how unclear it is in my mind, but I did
  12     then -- it was later, some years later, when it became
  13     obvious that the learning difficulties hospital was not
  14     going to stay with us -- we were going to close it,
  15     anyway -- she applied for a post in the Eye Hospital,
  16     I think, and I encouraged her to do that. I may well
  17     have said to her in Farleigh -- I would have done,
  18     because it is the sort of thing I would have said to
  19     anybody who asked me -- that what was needed was wide,
  20     broad experience. You need to move up the ladder in the
  21     Health Service. In any role, you need to get wide
  22     experience. It is no good staying in one specialty.
  23   Q. In the end she applied for the job as General Manager,
  24     Cardiac Services, and you were on the interview panel?
  25   A. I believe so, yes.

   1   Q. When she got that job, as she did, if we look at her
   2     witness statement again, please, WIT 89/9, it would
   3     appear, if we take the middle of the paragraph, that she
   4     essentially is of the view that she drew up her own
   5     objectives?
   6   A. Yes.
   7   Q. Who ought to have been, if anyone, responsible for
   8     setting out her objectives?
   9   A. I felt rather sad to read the paragraph, really, because
  10     she was somebody who liked to have objectives. She
  11     liked to work within a framework and know where she
  12     stood in relation to everything, you might say, and what
  13     was expected of her, and she was thrown into a pond that
  14     had no model to follow, no template, not much in the way
  15     of job descriptions, and was constantly changing.
  16   Q. Would it be your view that, to the extent that she would
  17     have objectives as General Manager of cardiac services,
  18     those should have been set by somebody else other than
  19     her?
  20   A. If they should have been set, then it should have been
  21     by her Clinical Director, but I would have been
  22     surprised to find Clinical Directors in the business of
  23     setting objectives for their General Managers. This was
  24     early days. Maybe they do today, but I would have
  25     thought that it would not have been necessary. The

   1     objective was to get the clinical -- this cardiac
   2     clinical directorate, cardiac services, I thought you
   3     heard earlier, was pulling things from one side of the
   4     main road and another side of the main road and from up
   5     the hill and down and trying to mould together a whole
   6     lot of people who probably, nurses in particular, would
   7     not have talked to one another.
   8   Q. Did she come to you specifically for advice and guidance
   9     about what template she ought to adopt, do you recall?
  10   A. I do not recall. I recall having a fair bit to do with
  11     her over a number of things, but I do not recall her
  12     asking me for that kind of thing.
  13   Q. If she had come to you and said "Can you give me a hand
  14     in setting some objectives for myself?" what would your
  15     response have been?
  16   A. I would have said, "If you want some objectives, fine,
  17     that is not a bad notion. Write a few down for me and
  18     we will have a talk about it and perhaps refine them, or
  19     expand them. But the immediate situation is to deliver
  20     the contract" -- that was the very clear objective --
  21     "within the budget you have". I would have thought
  22     that was a bit broad, but very clear.
  23   Q. You commented on Rachel Ferris's statement. Can
  24     I remind you of something you said. It does not appear
  25     to have been scanned in, but I will check over lunchtime

   1     to see if it has been. Can I read it to you? You say
   2     you were on the interview panel that appointed Rachel to
   3     the point of General Manager to cardiac services.
   4        "I note that Rachel felt she received no guidance
   5     from me [paragraph 5] when she commenced the General
   6     Manager post. The management structure was that she was
   7     accountable to the Clinical Director who was accountable
   8     to the Chief