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Daily transcripts
Hearing summary
10th June 1999
Today the Inquiry heard from Mrs Rachel Ferris, General Manager for the Directorate of
Cardiac Services, UBHT (Nov 1994 – present) who outlined her NHS career in Bristol
which began in 1985 at Farleigh Hospital. She commented on the ethos of UBHT which she
described as being anti-bureaucratic and lacking in strategic direction. Mrs Ferris then
described the evolution of the Cardiac Services Directorate and the professional
relationships between the directorate and the executive board. She commented on the
regular meetings which took place to discuss Directorate business and described changes
which have taken place since 1994, primarily the integration of nursing services across
cardiology, cardiac surgery and cardiac intensive care. Mrs Ferris was asked about her
perception of the role and management style of the Chief Executive and the Director of
Operations/Nurse Advisor. She then commented on her discussions with purchasers about
their concerns about the waiting times for, and quality of, Bristol’s cardiac
services and went on to outline the development aims of the Directorate. Mrs Ferris was
then asked about her view of the management ability of the Associate Clinical Director for
Cardiac Surgery, Mr Dhasmana and concluded by describing the tensions within the
Directorate following the publication in the media of concerns about paediatric cardiac
surgery in 1995.
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FULL TRANSCRIPT
1 Day 27, 10th June 1999
2 (9.30 am)
3 THE CHAIRMAN: Good morning, everyone. Good morning,
4 Mr Maclean.
5 MR MACLEAN: Good morning. Can I say how grateful we are
6 for the Panel allowing us a little extra time this
7 morning. The reason for that was to allow Mrs Ferris to
8 read some comments on her evidence that have come in
9 overnight.
10 Today's witness is Mrs Ferris, General Manager of
11 the Cardiac Services Directorate at the UBHT. Can
12 I call Mrs Ferris, please.
13 MRS RACHEL CORRIE FERRIS (SWORN):
14 Examined by MR MACLEAN:
15 Q. Your full name is Rachel Corrie Ferris?
16 A. That is right, yes.
17 Q. As I have already said, you are the General Manager of
18 the cardiac services directorate of the UBHT?
19 A. Yes, I am.
20 Q. And that is a post that you have held, I think, since
21 November 1994?
22 A. Yes.
23 Q. Can we have WIT 89/1, please? Is that the first
24 page of the formal written statement that you made to
25 the Inquiry?
0001
1 A. Yes, it is.
2 Q. If we go to page 36, that is your signature, is it not?
3 A. It is, yes.
4 Q. Have you read that statement through recently?
5 A. Yes.
6 Q. Are you happy for that to stand as part of your evidence
7 to the Inquiry, or is there anything you would like to
8 alter in that statement?
9 A. No, I am happy for it to stand.
10 Q. I think you submitted, along with that statement, the
11 document that begins at WIT 89/38. That continues over
12 the page at 39. That is the document you drew up in,
13 I think, August 1995?
14 A. Yes, that is right.
15 Q. We have had some comments on your evidence. We have had
16 comments from, in no particular order -- actually the
17 order they have been scanned into the database --
18 Margaret Maisey; have you had a chance to see those?
19 A. Yes, I have.
20 Q. From Professor Vann Jones?
21 A. Yes.
22 Q. From the UBHT itself?
23 A. Yes.
24 Q. From Janet Maher?
25 A. Yes.
0002
1 Q. From Mr Ash Pawade?
2 A. Yes.
3 Q. Mr Dhasmana?
4 A. Yes.
5 Q. And Mr Wisheart?
6 A. Yes. I have just seen those two this morning.
7 Q. Can we go back to page 1, please, of that file, and just
8 look at your background? You were appointed to the NHS
9 as a graduate management trainee in September 1983?
10 A. Yes.
11 Q. What were you a graduate of?
12 A. Politics and government.
13 Q. You went straight from university into the Health
14 Service?
15 A. Yes, I did.
16 Q. If we scan down that page, we see that you worked in
17 September 1985, between then and August 1988, at
18 Farleigh Hospital?
19 A. Yes.
20 Q. Was that when you first met Mrs Maisey?
21 A. Yes, it was, yes. Mrs Maisey was based there as I think
22 at that stage she was the unit administrator for the
23 South unit and her office was based at Farleigh
24 Hospital.
25 Q. Farleigh Hospital was one of the hospitals embraced
0003
1 within the South Unit?
2 A. Yes.
3 Q. That was one of the two units of the Bristol & Weston
4 Health Authority?
5 A. That is right. The other was the Central unit.
6 Q. If we go over the page, please, to page 2, you entered
7 general management in an acting capacity at the Winford
8 Orthopaedic Hospital in August 1988?
9 A. Yes.
10 Q. And you have been in general management ever since?
11 A. Yes, that is right.
12 Q. And if we look down that page, we see that you spent
13 a time in the Eye Hospital?
14 A. Yes.
15 Q. Between 1989 and 1992?
16 A. That is right. There were two specific roles at the
17 Eye Hospital: initially as the outpatient services
18 manager and then for a period of around 11 months I was
19 General Manager of the Eye Hospital.
20 Q. That was obviously a smaller organisation than the BRI?
21 A. Yes, it was.
22 Q. Because you then moved in November 1992 to be associate
23 General Manager of certain departments within the
24 Directorate of Medicine in the BRI?
25 A. Yes, that is right.
0004
1 Q. So although you had been the General Manager of a whole
2 hospital before, was that move in November 1992 a move
3 up or down?
4 A. It was more of a sideways move. I was looking at
5 wanting to gain additional experience in the acute
6 field, particularly keen on sort of acute bed
7 management. Whilst I was looking after the non-acute
8 specialties within medicine, the role also involved
9 overall bed management for the medical directorate, and
10 I was keen to have that experience.
11 Q. You spent a relatively short period between November
12 1992 and May 1993 in the Directorate of Medicine. You
13 then moved to the Directorate of Surgery?
14 A. Yes, that is right.
15 Q. Why was that?
16 A. I think the original move to the medical directorate --
17 it was a move that I wanted, but it was particularly to
18 gain experience and I really, having had that, although
19 it was a short period of time, wanted to further the
20 experience that I had had, and felt that an opportunity
21 within surgery would allow me to do that, and it was
22 also as part of a discussion with the General Manager of
23 medicine, Janet Maher, who at that time also moved from
24 being the General Manager to Medical Manager. When she
25 moved, I took the opportunity to move out to surgery
0005
1 with her.
2 Q. In November 1994 you became the General Manager of
3 cardiac services?
4 A. Yes.
5 Q. Before we go to that, can I take you to WIT 89/40,
6 please? These are the comments of Mrs Maisey, from whom
7 we heard yesterday, on your statement.
8 A. Yes.
9 Q. Can I ask you to look at paragraphs 2, 3 and 4, please,
10 and then tell me to what extent you agree with what
11 Mrs Maisey says in those paragraphs.
12 A. I think there are some inaccuracies in Margaret's
13 recollection as she has indicated in those paragraphs.
14 The move to Winford Hospital came following the
15 interview for the post at Bristol again; she has got it
16 the other way round. She states that in section 4 of
17 her comments, but actually the move to Winford came
18 because I had been for a post at the Bristol General and
19 I was advised actually at the end of the interview that
20 I would not be appointed to the post, but that she was
21 keen to help me develop and asked me to come and see
22 her, basically, to see if another opportunity could be
23 provided.
24 Q. Mrs Maisey was keen for that?
25 A. Yes. She said she felt I had performed well at
0006
1 interview and that if I was interested, I should talk to
2 her about further experience.
3 Q. So it is right, is it, then to say as she does in
4 paragraph 4 that she took an interest in the progress of
5 your career?
6 A. I think at that stage she was very interested in the
7 career. She was interested in setting up the secondment
8 to Winford, but I think the interest in the career -- as
9 I have said in my statement, there were a number of
10 difficulties in our working relationship and I think
11 that affected her interest in my career.
12 Q. Is it right that your moves to the medical and surgical
13 directorates which we have just seen, before you went to
14 cardiac services in 1994, were part of an in-house
15 development programme for managers that the Trust was
16 implementing?
17 A. No, that is not correct. I think the expression
18 "in-house development programme" is something of
19 a euphemism. The actual move to medical directorate was
20 based on Margaret's request that I move from that
21 directorate, and I was not a willing participant in that
22 move. I was concerned that it was not in the best
23 interests of the ophthalmic unit for the newly appointed
24 General Manager to be leaving post after 10 months in
25 post.
0007
1 Q. Can we take it stage by stage? You were General Manager
2 of the Eye Hospital?
3 A. I was, yes.
4 Q. For the latter part of your period at the Eye Hospital?
5 A. Yes, that is true.
6 Q. You were originally the outpatient services manager?
7 A. Yes.
8 Q. When did you become General Manager of the Eye Hospital?
9 A. I am afraid I have forgotten the actual time period, but
10 I was there around three years. It was the last year of
11 the time that I was there that I became General Manager.
12 Q. You left in November 1992, so essentially --
13 A. Essentially before that, yes.
14 Q. So what you are telling us now about are the
15 circumstances in which you left the Eye Hospital?
16 A. Yes.
17 Q. And took up the job as associate General Manager in the
18 Directorate of Medicine?
19 A. That is right, yes.
20 Q. What was Mrs Maisey's role in that?
21 A. Mrs Maisey was keen I should move to the medical
22 directorate because she had a situation where she wanted
23 to bring a manager or a professional adviser out of
24 a professional department and give them a management
25 opportunity, and she felt that the Eye Hospital would
0008
1 provide a very good training ground for managers, and
2 that is what she hoped to achieve.
3 Basically, she asked if I would move to facilitate
4 that.
5 Q. And you agreed?
6 A. No, I did not agree at that stage, although it involved
7 a lot of difficulty in my relationship with Margaret,
8 and I did feel -- I had certainly agreed at some stage
9 that because I had become a General Manager very
10 quickly, I had still other experience to gain and I was
11 keen to gain experience in other directorates, so
12 ultimately I was keen to do something like the move to
13 medicine. I felt that the reason I disagreed was that
14 I had only been in post for a short period of time,
15 I had not had an opportunity to achieve any of the
16 objectives that I had wanted to in that particular post,
17 which also had not given me an opportunity to
18 demonstrate that I could achieve the objectives in that
19 particular post, and I felt it was disruptive for the
20 hospital and the clinicians at the Eye Hospital, who
21 were also concerned that it was very disruptive.
22 I think it fair to say that they were unhappy about the
23 proposal at that time as well.
24 Q. But it is right, is it not, that by November 1994, when
25 you became General Manager of the cardiac services
0009
1 directorate, the fact that you had immediately prior to
2 that been an associate general manager first in the
3 Directorate of Medicine and secondly in the Directorate
4 of Surgery, you were, as Mrs Maisey said, well placed
5 and had relative experience for the job you are now
6 doing?
7 A. Yes, she is correct in saying that.
8 Q. So for your long-term career, in terms of what you are
9 doing now, Mrs Maisey's suggestion was probably quite
10 a sensible one?
11 A. Yes, I think that is fair to say.
12 Q. If we go over the page, then, in Mrs Maisey's comments,
13 to page 41, she was on the interview panel when you were
14 interviewed, I think, in September 1994, for the job
15 that you now hold?
16 A. Yes, that is true.
17 Q. Who else interviewed you for that job?
18 A. I think Professor Vann Jones --
19 Q. He was the Clinical Director?
20 A. He was the Clinical Director. I am not sure whether --
21 because I had been interviewed not long prior to that,
22 I am not sure whether it was Ian Stone. There were
23 three other Panel members: definitely Professor Vann
24 Jones and Margaret. I cannot recall the third.
25 Q. Was Dr Roylance on the Panel?
0010
1 A. I am not sure, I cannot recall. It was definitely
2 Mrs Maisey and Professor Vann Jones, and it may have
3 been -- it was either John Roylance or Ian Stone.
4 I simply do not remember.
5 Q. The cardiac services directorate included adult
6 cardiology at the BRI?
7 A. Yes, it did.
8 Q. It included adult cardiac surgery?
9 A. Yes.
10 Q. And for a short period, when you became General Manager,
11 it still included open heart paediatric cardiac surgery?
12 A. Yes, it did.
13 Q. But by the time you became General Manager, moves were
14 afoot to take open heart paediatric cardiac surgery to
15 the Bristol Children's Hospital?
16 A. Yes. I started in post in November 1994 and it was
17 planned that Mr Pawade would start in April/May 1995 and
18 the service would move originally in September 1995, but
19 it actually moved in October 1995.
20 Q. And cardiac services as a directorate was established in
21 your view, when?
22 A. I believe the directorate was established in April
23 1994. I know that there has been discussion about
24 a shadow directorate prior to that, but I was under the
25 impression that the directorate was formally created in
0011
1 April 1994.
2 Q. And it was created with a Clinical Director?
3 A. Yes.
4 Q. Who was Professor Vann Jones?
5 A. That is right.
6 Q. And associate clinical directors of cardiology and
7 cardiac surgery?
8 A. Yes.
9 Q. Those were respectively?
10 A. The Associate Director for surgery was Mr Dhasmana and
11 for cardiology was Dr Pitts-Crick.
12 Q. By the time you became the General Manager of cardiac
13 services, as we have seen, you had been an associate --
14 you had been a General Manager of the Eye Hospital and
15 an associate General Manager of the directorates of
16 medicine and surgery?
17 A. Yes.
18 Q. In this same Trust, so by the time you became General
19 Manager, you would have been familiar with the ethos of
20 the UBHT?
21 A. Yes, I think that is true.
22 Q. And it had always been led by Dr Roylance; he had always
23 been the Chief Executive?
24 A. Yes, he had.
25 Q. At the time you were appointed as General Manager to
0012
1 cardiac services, what was your impression of the ethos
2 of the Trust?
3 A. I think, as I have said in my statement, I felt the
4 Trust was lacking in strategic direction; there was very
5 much a sort of culture of avoiding bureaucracy and of
6 a real abhorrence of anything that was considered to be
7 process management, anything that, you know, established
8 standards. I know that there was a lot of discussion
9 about one of the British Standards and one of the
10 departments, I think the medical physics department,
11 going for a British Standards award and that was very
12 much considered to be very process management orientated
13 and not consistent with the values of the Trust.
14 Q. Can you just give me, for a lay person so I can
15 understand it, a definition of "process management"?
16 A. I think there is a feeling by the Trust that if you
17 are spending time defining processes of an organisation
18 and of actually monitoring the performance, monitoring
19 standards as they would in industry in a very
20 mechanistic fashion, that then you would lose sight of
21 the overall business of the Trust, which was patient
22 care, and spend all your time on setting and monitoring
23 standards and monitoring processes, saying "This is the
24 process, this is how it works", and you would lose time
25 doing that and lose sight of the overall purpose of the
0013
1 organisation.
2 Q. Tell me if I have it wrong, but does that mean that
3 there was a discouragement of, for example, writing down
4 lists of indicators that certain objectives that had
5 been achieved, and you were not encouraged to go round
6 with a clipboard ticking off?
7 A. It was certainly that. The culture was very much
8 against having a paper culture. The idea was that
9 communication would be face-to-face, that everything was
10 verbal, that -- there was this fear that if you spent
11 all your time writing things down, all you would be
12 achieving would be to back up what you have said and not
13 be getting on with the work you needed to be doing; that
14 it was irrelevant and a waste of time.
15 I have to say, I subscribed to the view I did not
16 want to be involved in unnecessary administration and
17 bureaucracy, but I did feel because the culture was so
18 very much against paper and so keen to have a sort of
19 verbal culture that we did lose track of where we were
20 going and what we were doing, and people were very
21 unclear about what it was they should be doing.
22 Q. Can I take you back to your statement, to WIT 89/4,
23 paragraph 5?
24 You say when you had been appointed to previous
25 posts, you had asked your immediate manager for an
0014
1 indication of the key priorities and issues for the new
2 job.
3 What were those previous posts that you are
4 referring to?
5 A. I think the posts that you have already looked at, you
6 know, in my CV at the beginning, in outpatients, at the
7 Eye Hospital, in medicine and surgery. I had looked at
8 some of the key tasks. I mean, I had not gone to
9 previous managers and said "I am new to post, tell me
10 what to do, I do not know how to do my job", but I felt
11 it was right to update myself with the key issues in the
12 area I was working to discuss those and to look at what
13 the key priorities are and to be able to prioritise your
14 own action at the start of a post, so I had done that in
15 previous posts.
16 Q. When you were Associate General Manager in first of all
17 medicine and then surgery, who was your immediate
18 manager?
19 A. My immediate manager in both medicine and surgery was
20 Janet Maher.
21 Q. She was --
22 A. She was the General Manager.
23 Q. Of first of all medicine and then of surgery?
24 A. That's right, yes.
25 Q. When you were the General Manager of the Eye Hospital,
0015
1 who was your immediate manager?
2 A. It would be Margaret Maisey who I worked more directly
3 with. The Eye Hospital was a little different in that
4 I had been there already for a couple of years before
5 I took up post, so it was not necessary to spend a lot
6 of time talking to Margaret about what the key tasks for
7 ophthalmology were, because I had already been involved
8 with them for two years prior to that.
9 Q. When you went to the cardiac services directorate, you
10 say here you asked Mrs Maisey for advice about the
11 immediate priorities?
12 A. Yes.
13 Q. Why did you ask Mrs Maisey as opposed to anybody else?
14 A. Because she was the person I had been most involved with
15 in my career within the Trust. I actually asked
16 Mrs Maisey, I recall, at the end of the interview,
17 I started the process of talking to her about some of
18 the key tasks there.
19 Q. Who was your immediate manager as General Manager of
20 cardiac services?
21 A. Within cardiac services, I perceived that I was working
22 very closely with the Clinical Director, the
23 relationship with the Clinical Director was such that,
24 you know, we considered ourselves to be sort of a unit;
25 we worked together very closely, so I was obviously
0016
1 accountable to the Clinical Director, but it was not
2 like that in terms of our general work. I did not see
3 a line management relationship between me and the
4 Clinical Director of cardiac services, I perceived us as
5 a unit that worked closely together. Beyond that, I saw
6 myself as accountable to Margaret Maisey, and I saw the
7 Clinical Director as accountable to John Roylance.
8 Q. Have you ever heard of the expression of Clinical
9 Directors and General Managers being in a "bubble"
10 together?
11 A. I certainly read that in the transcripts this week.
12 I do not recall hearing the word "bubble". It may just
13 be that I have forgotten it over time. I think it is
14 certainly true that the General Managers and Clinical
15 Directors were a very close unit, and I think that is
16 true today. I see myself very much as part of the unit
17 with the Clinical Director. We are almost one.
18 Q. So you saw yourself as being a close colleague of the
19 Clinical Director?
20 A. Yes.
21 Q. In the same team as the Clinical Director?
22 A. Yes.
23 Q. But not in a line accountable to the Clinical Director?
24 A. No.
25 Q. Is that fair?
0017
1 A. That is fair, yes.
2 Q. Did you ever have any discussion with Professor Vann
3 Jones about the proper lines of accountability?
4 A. I do not think so. When I started we spent time
5 together talking about how we would work, when we would
6 meet and what our working arrangements would be, but
7 I do not think we ever talked about my accountability to
8 him or who I would be accountable to.
9 Q. I am sorry?
10 A. We did not really discuss who I would be accountable to
11 when I started.
12 Q. Did Professor Vann Jones ever set you any goals or
13 objectives as General Manager?
14 A. He did not set me any goals or objectives. We used to
15 meet regularly and decide at those meetings what we
16 wanted to do. I mean, sometimes we would meet and
17 I would say, "Well, I am going to go away and do this",
18 but there was never an objective-setting process in
19 a formal sense. We met weekly and had a working
20 relationship and that is how we determined what it was
21 we would be doing within the directorate.
22 Q. In your view was it valuable for General Managers such
23 as yourself to have specific objectives?
24 A. Yes, I think it was key. I mean, I do not want to give
25 the impression that General Managers walk around with
0018
1 a sheet with a load of objectives on it, and every day
2 we have it attached to our clipboard and say "Today we
3 are going to achieve this objective". I certainly do
4 not want to give that impression. What I thought was
5 important was that we, the Clinical Director and I,
6 should know what sort of direction it is we want to
7 take, where we want the directorate to go, and how we
8 want to try and achieve that. That was key. I think it
9 is very important now, and it is something that we do.
10 Q. Was not that something that in Dr Roylance's Trust, his
11 philosophy would be, that it was down to you as the
12 General Manager and Clinical Director who were in the
13 same "bubble" to get together and set your objectives
14 for the directorate? It was your job?
15 A. I think to an extent that is right, and looking at
16 Margaret Maisey's response to comments on my statement,
17 she makes that clear. She says something about not
18 wishing to usurp the responsibility of the Clinical
19 Director and General Manager, but I think that implies
20 that the setting of objectives is an entirely bottom up
21 process, that directorates are in themselves somehow
22 autonomous, they set their objectives, they achieve
23 their objectives and they somehow do it in isolation
24 from the organisation of which they are a part.
25 What I was asking Margaret Maisey for, and the
0019
1 reason I would dismiss her comments about this is that
2 I was saying, "Yes, it is right that we should set
3 objectives, but we have to do this in some sort of Trust
4 framework. We have to know what position this
5 directorate has within the Trust and what you, as
6 a Trust, are hoping to achieve", because it is important
7 that the objectives of directorates are consistent with
8 those of the Trust. We were never autonomous.
9 Therefore, what I was seeking was a framework -- I did
10 not want Margaret to do our job for us, but I did not
11 agree, and still do not agree, that this is entirely
12 a bottom up process. This is a 2-way process and the
13 objectives of directorates have to be consistent with
14 the overall objectives of the Trust and the
15 organisation, otherwise we are autonomous islands
16 existing within this loose organisation, and I do not
17 think that works.
18 Q. So to what extent would you agree with this formulation
19 of that: that each directorate could set its own
20 objectives and establish its own strategy with the
21 General Manager and Clinical Director working together,
22 but that strategy was set within the overall strategy of
23 the Trust?
24 A. Yes. I think that of course there are people that are
25 managing the directorate who have to be working on
0020
1 setting the objectives, but it cannot take place in
2 isolation from the Trust. It has to be part of an
3 overall strategic direction for the organisation. There
4 has to be a framework that that process takes place
5 within.
6 Q. If we go to paragraph 6 of your statement, just scanning
7 down the page, you say the reason for you saying in the
8 previous paragraph you had little guidance from
9 executive level in cardiac services, "the reason
10 appeared to be that under Dr Roylance the philosophy was
11 that anything seen as bureaucratic or process management
12 or administrative was undesirable"?
13 A. That is right, yes.
14 Q. Reading that paragraph, and perhaps reading it as
15 a whole, it would appear as though you are expressing an
16 element of surprise or that this was novel to you when
17 you got to cardiac services, that this was Dr Roylance's
18 philosophy?
19 A. No, I do not think that it was novel. I think
20 Dr Roylance's philosophies were well known. He was
21 a very well known individual and his values and comments
22 were well known.
23 Q. So why had you not come across the same problems, as you
24 would put it, as General Manager in cardiac services,
25 the problems you are alluding to here; why had you not
0021
1 come across those when you were General Manager of the
2 Eye Hospital, for example?
3 A. There is a difference, because cardiac services was
4 a newly created directorate. It had been created as
5 a major objective of the Trust; although I know
6 Dr Roylance did not want to state objectives, it was
7 stated as a major objective of the Trust to bring
8 together a directorate based on disease and to provide
9 a service for patients who had that particular disease.
10 Therefore, I very much felt that if that were the
11 case, we could not just stop with the creation of the
12 directorate, there had to be something more to it than
13 that. Having created a directorate that was something
14 new and something different, there had to be something
15 further that came out of that; it could not just be
16 created and exist and do nothing.
17 Q. But had not Dr Roylance and the executive directors done
18 their job to the extent that the overall strategy of the
19 Trust was to create this new directorate? They created
20 a new directorate. You were the General Manager, and
21 now it was up to you, within the bubble, to get on and
22 run the show?
23 A. No, because they created the directorate with no further
24 thought as to why they had done it and what it was
25 hoping to achieve. It was a pointless thing to have
0022
1 done, if it was not to actually achieve anything as
2 a result. The reason I wanted to, if you like, market
3 the service to the Trust was that the Trust could not
4 see any reason in a way how that particular directorate
5 fitted into the Trust, and what it was supposed to be
6 achieving. It was just created and that seemed to be
7 the end of it.
8 Of course I agree that some of the objectives and
9 future planning should occur within the directorate, but
10 as I have previously said, it seemed important that that
11 was in an overall framework for the Trust, and that just
12 was not there. Once the directorate had been created,
13 there was nothing more to be done, it seemed.
14 Q. Can we go to UBHT 34/229, please? This is a meeting of
15 the Executive Committee of the Trust and I think we
16 looked at this yesterday with Mrs Maisey very briefly.
17 It is not a meeting you were at. Can we go to 232?
18 I am sorry, if we go back, to give it some
19 context, to 231, to the foot of the page, "Matters
20 arising":
21 "Mr Wisheart record that Mrs Sarah Hoyle,
22 Mrs Mansell Griffiths, Mrs Margaret Maisey ...", and so
23 on. I see we have the same place twice. Can we go to
24 230, bottom of the page, the Chief Executive report:
25 "2 working groups had been established to advise
0023
1 Dr Roylance on the creation of new directorates", and
2 then 232, please, "which it was hoped would assist the
3 move to single client group directorates: cardiac
4 services to combine cardiac surgery and cardiac medicine
5 to allow flexibility between the 2 services."
6 So that is the initial planning of the directorate
7 being put in train?
8 A. Yes.
9 Q. That is nearly two and a half years before you were
10 appointed?
11 A. Yes.
12 Q. If we go to UBHT 81/191, this is a Directorate of
13 Surgery Management Board meeting. You were at that,
14 because you were the Associate General Manager of an
15 area of that directorate. We see your name there.
16 A. Yes.
17 Q. If we scan down that page, "Matters arising":
18 "Cardiac services has been established and
19 Professor Vann Jones has agreed to be Clinical Director
20 with the support from the current Associate Clinical
21 Directors", and those were Mr Dhasmana and
22 Dr Pitts-Crick?
23 A. Yes.
24 Q. You told us earlier that cardiac service was not
25 established in April 1994?
0024
1 A. That is right.
2 Q. This is June 1993?
3 A. That is right. My understanding from discussion at the
4 time was that that was sort of a shadow arrangement; it
5 was not until 1st April 1994 that the directorate really
6 became a directorate.
7 Q. So at this stage you yourself were not involved in
8 cardiac surgery because your responsibilities as
9 Director of Surgery were trauma, orthopedics and A & E?
10 A. That is right, yes.
11 Q. To the extent that Professor Vann Jones is a shadow
12 Clinical Director, if that is an accurate description,
13 was there a shadow General Manager?
14 A. I think that Lesley Salmon played that role. Whether
15 she was called a shadow General Manager, she still
16 remained within the Directorate of Surgery management
17 structure, and I understand that she was still
18 accountable to Janet Maher as the General Manager for
19 surgery, the Directorate of Surgery. So I do not think
20 that answers your question, does it, but -- yes, it was
21 identified as being the General Manager, but as far as
22 I understand it, she did not separate from the line
23 management relationship to the General Manager for the
24 Directorate of Surgery.
25 Q. So to the extent that there was, it was Lesley Salmon?
0025
1 A. Yes.
2 Q. Professor Vann Jones, I think, remained as Clinical
3 Director of the directorate until early 1996 when he
4 resigned?
5 A. Yes.
6 Q. Was Professor Vann Jones an enthusiast for taking up the
7 post of Clinical Director, as far as you were aware?
8 A. I think he was enthusiastic. He found the role very
9 difficult, very challenging, and I know that, you know,
10 he found it a very complex role.
11 Q. What else was he doing whilst he was Clinical Director?
12 A. He still had a very large clinical commitment as
13 a cardiologist and with his personal Chairs, Professor
14 role as well, so he had a large clinical commitment as
15 well.
16 Q. Did he have a set number of sessions per week when he
17 was devoting himself to Clinical Director duties?
18 A. I do not think he specified a specific time for dealing
19 with clinical directorate duties. I do not think he
20 took up the option of having sessions, because
21 I think -- I do not know why. You would have to ask
22 him. I do not think he took up particular Clinical
23 Director sessions, although we used to meet at regular
24 times and he used to give time in that sense.
25 Q. In your statement you set out a diagram, a table,
0026
1 WIT 89/6.
2 This is the organisational structure when you took
3 office?
4 A. Yes, although this was not published as an
5 organisational structure, this was something that I felt
6 would aid the Inquiry, so I have just done this for the
7 statement. It was not a published and circulated
8 structure at that time.
9 Q. This is your own diagram, recently produced?
10 A. Yes, just to try and give an indication of what it
11 looked like.
12 Q. We see that you are in the same box -- not a bubble,
13 a box -- as Professor Vann Jones?
14 A. Yes.
15 Q. And the two Associate Clinical Directors either side,
16 and then there are two senior nurse managers, two
17 grade H nurse managers?
18 A. Yes.
19 Q. One from the surgery side and one from the cardiology
20 side?
21 A. Yes.
22 Q. Fiona Thomas and Jenny Postow.
23 What I want to focus on briefly is the double
24 asterisk beside Clinical Director and the note at the
25 foot:
0027
1 "Anaesthetic staff were not part of the cardiac
2 services directorate but were accountable to the
3 Clinical Director for Anaesthesia, Dr Monk."
4 A. Yes.
5 Q. So anaesthesia was a completely separate director in the
6 Trust, and always had been?
7 A. Yes.
8 Q. Can we go to WIT 89/57, please? These are the comments
9 of Mr Wisheart on your statement. You have seen these,
10 I think, this morning?
11 A. Yes, I have.
12 Q. If we go to the foot of that page, Mr Wisheart comments
13 on your diagram:
14 "I do not agree with all the details of this
15 diagram, but the point to which I wish to draw attention
16 relates to the note where it says ..."
17 He sets out the note.
18 If you go over the page, 258:
19 "The statement is correct in the managerial sense,
20 in that they [the anaesthetists] were primarily part of
21 the Directorate of Anaesthesia and their salary lay
22 within the budget of that directorate. However, they
23 were full and equal members of the Cardiac Surgical
24 Board."
25 What do you understand Mr Wisheart to mean by
0028
1 saying they were "primarily part of the Directorate of
2 Anaesthesia"?
3 A. I think what he is saying is correct in the managerial
4 sense they were part Directorate of Anaesthesia, but
5 their duties involved them in working in cardiac
6 services, so therefore they were involved in the
7 business of the cardiac directorate. As he says, they
8 were members of the meetings that we had for cardiac
9 services. But, yes, they were part of the Directorate
10 of Anaesthesia. They were managed by the Clinical
11 Director and General Manager for anaesthesia. The
12 budget lay within that directorate, and they were
13 a separate directorate. They still are a separate
14 directorate.
15 Q. The Cardiac Services Directorate had a committee which
16 met. It was called what, the governing committee?
17 A. There was a small cardiac services Management Board that
18 met monthly, which had a very small representation --
19 I think myself, the Clinical Director, the Professor of
20 cardiac surgery, one anaesthetist and I think the
21 radiologist as well, so it was a small group with mainly
22 medical staff and myself.
23 Q. And then the surgeons had their own meeting and the
24 cardiologists had theirs?
25 A. The management meetings, in cardiac surgery there was an
0029
1 associate directorate meeting and the same for
2 cardiology and the cardiac surgeons also had from time
3 to time a surgeon's meeting where the surgeons got
4 together.
5 Q. So there were four separate meetings: the Cardiac
6 Services Management Board, the Associate Director of
7 Cardiac Surgery, an Associate Director of Cardiology
8 meetings, and from time to time, other surgeons'
9 meetings?
10 A. Yes.
11 Q. Which of those four, if any, is the cardiac surgical
12 board that Mr Wisheart is referring to?
13 A. I am not sure what he means by the Cardiac Surgical
14 Board; whether he means the Associate Director for
15 Cardiac Surgery or the Cardiac Surgery Management Board,
16 it is not clear from his comment.
17 Q. The top meeting, the Cardiac Services Management Board,
18 anaesthetists and radiologists would attend that, would
19 they?
20 A. Yes. There is always one anaesthetist and usually one,
21 Peter Wilde, who is now the Clinical Director for
22 cardiac services, used to go as a cardiac radiologist.
23 Q. So they would be attending the governing meeting of the
24 cardiac services directorate, although they were both
25 themselves members of another directorate?
0030
1 A. Yes.
2 Q. Did that meet any confusion, or did that work well?
3 A. The meetings themselves did not work particularly well.
4 The Cardiac Services Management Board meetings did not
5 work well because they were small and not well
6 represented. I would say that most of the decisions and
7 discussions took place at the associate directorate
8 meetings, although the Cardiac Services Management Board
9 was meant to be the most important of the meetings.
10 Q. You have drawn us another diagram, another table as
11 well. If we go to WIT 89/7, this is how it is now?
12 A. Yes.
13 Q. What I want to focus on is Fiona Thomas's role. We saw
14 her in the previous diagram. She was one of the H grade
15 nurses, she had come from the surgery side?
16 A. Yes.
17 Q. But there was another H grade nurse on the cardiology
18 side?
19 A. Yes.
20 Q. Now in your directorate there is one clinical nurse
21 manager?
22 A. Yes.
23 Q. Covering both surgery and cardiology?
24 A. Yes.
25 Q. We see that from the bottom line, do we, "cardiac
0031
1 theatres and cardiology department nursing"?
2 A. Yes.
3 Q. So there has been a change brought about there in the
4 nursing hierarchy of the directorate?
5 A. Yes.
6 Q. What was the impetus for that?
7 A. I felt that the two parts of the directorate were very
8 separate and that there were a number of areas where we
9 needed to introduce more flexibility in how the nursing
10 staff actually worked. For example, within the catheter
11 laboratories I wanted to reduce some of the demarcations
12 and problems there, but also, because we were short of
13 staff in other areas, I wanted to be able to rotate
14 staff through from cardiology, through to theatre,
15 through to intensive care, and I felt that there would
16 be a clearer focus if we had one nurse manager that was
17 responsible for doing that. We could then manage the
18 nursing staff as a group of nursing staff and make much
19 better use of the staff that we had.
20 Q. When did this change come about?
21 A. I cannot remember the exact date, I am afraid, but
22 probably two years ago, or may be more? A couple of
23 years ago, I think.
24 Q. Did the Director of Nursing of the Trust have any role
25 in that type of change?
0032
1 A. I remember that Margaret Maisey was not particularly
2 keen on I grade posts within the Trusts. Over a period
3 of time the I grade nurses reduced very much, so there
4 were probably only a couple of I grade nurses left, but
5 Margaret and I did not particularly work very closely on
6 that, so there was no particular comment from Margaret
7 on that.
8 Q. What was the role of the Director of Nursing so far as
9 you were concerned?
10 A. It was a very limited role. Margaret Maisey's role was
11 much more the Director of Operations.
12 Q. Let us take it in stages. When Margaret Maisey was
13 Director of Operations, she was also the Nurse Adviser
14 to the Trust?
15 A. Yes.
16 Q. In that role of Nurse Adviser, what were her
17 responsibilities, as far as you perceived them?
18 A. I think to advise the Trust and to be involved in sort
19 of nursing standards and practice and looking at nurse
20 competence and those sorts of issues, although there was
21 no, as there is now, very clear nursing strategy and
22 a clear way of developing nursing staff, but she would
23 advise and the other Nurse Adviser that I worked with
24 would advise on training issues and competence and
25 standards of practice.
0033
1 Q. How did that role, Nurse Adviser, differ from the role
2 of Director of Nursing Mrs Maisey later took?
3 A. I think the Director of Nursing role was much more
4 important, was a more clearly defined role, certainly
5 with clearer objectives. The way the role has developed
6 now has been to really look at having a very detailed
7 strategy for nursing and to look at nursing across the
8 whole Trust to bring some Trust focus to nursing,
9 because obviously at the time the clinical directorate
10 structure left everything very much to directorate
11 level. So the new Director of Nursing is much more
12 proactive and has been much more of a way of enhancing
13 the nursing profession within the Trust.
14 Q. The situation that obtained when you were first General
15 Manager in the cardiac services in terms of waiting
16 lists and demand for services was what?
17 A. When I joined the directorate -- I am sorry, could you
18 say that again?
19 Q. I did not put it very well. I was trying to ask you,
20 what was the waiting list position in November 1994?
21 That is a much more simple way of putting it.
22 A. I cannot remember how many patients were waiting above
23 a particular time, but the position when I took over the
24 directorate was that there were very long waits both for
25 cardiac surgery and for cardiology. And that, you know,
0034
1 patients were waiting from the start of the time they
2 first became ill, it could be up to two or three years,
3 if they required surgery, before they actually received
4 surgery. There was a very long chain of events from
5 actually the patient first experiencing chest pains to
6 seeing a GP to then having a length of wait for an
7 outpatient appointment, followed by maybe a length of
8 wait for a diagnostic test, a length of wait for another
9 outpatient appointment to see a surgeon, and then
10 surgery, if that was the course of action that was
11 decided. So there were very long waits.
12 Q. To what extent did you focus upon the position of
13 children who might undergo open heart surgery at the BRI
14 in the year when you were General Manager before the
15 split site was ended?
16 A. Not really at all. My focus in-post was very much the
17 adult work and the adult service and the decision had
18 been made to move the children and for Ash Pawade to
19 start in the May and for the service to move, so I had
20 a very limited role in terms of managing the children's
21 service, the children's aspect within the directorate,
22 and looking at issues there.
23 Q. Was there someone perhaps in a shadow capacity at the
24 Children's Hospital who was taking on responsibility for
25 the children operated on at the BRI in the months
0035
1 leading up to Mr Pawade taking up his post?
2 A. There may have been, but I think that -- I do not know.
3 You would have to ask the Manager of the Children's
4 Hospital, but --
5 Q. You were the General Manager of cardiac services at the
6 BRI. What discussions did you have about the management
7 of surgery on children between November 1994 and October
8 1995, and with whom?
9 A. I think there were discussions about the transfer of the
10 service, but if you are talking about contracting and
11 sort of financial arrangements for children's
12 operations, then, yes, they came up in a limited fashion
13 at contract monitoring meetings, but there was no
14 detailed discussion. I did not have a detailed
15 discussion with purchasers or other users of the service
16 about paediatric waiting times and price and those sorts
17 of issues.
18 Q. That deals with purchasers, outside of the Trust. What
19 about discussions between you and, say, a General
20 Manager at the Children's Hospital?
21 A. There were discussions. I recall that I attended
22 meetings up at the Children's Hospital about the actual
23 transfer of the service. That was very much to look at
24 issues like transfer of equipment, staffing issues,
25 transfer of staffing, training nurses and things. That
0036
1 was specifically related to the transfer.
2 Q. If we go to paragraph 75 of your statement at
3 WIT 89/28 -- we will come back to this paragraph again
4 later, but this paragraph deals with an incident in
5 March 1995 involving a child.
6 A. Yes.
7 Q. I assume a child who was due to undergo open heart
8 surgery at the BRI?
9 A. Yes.
10 Q. We will come back to this later. You refer to
11 discussions with, I think, Mr Wisheart and Dr Hayes,
12 a paediatric cardiologist, and with Dr Roylance and with
13 Mr Pawade. But there was no mention of any discussion
14 with any other -- not General Manager -- or no
15 discussion with the management of the Children's
16 Hospital?
17 A. No.
18 Q. Why not?
19 A. Because the child was on Mr Wisheart's list and was due
20 to be operated on at that stage at the BRI, so I did
21 perceive that to be an issue I should be dealing with.
22 Q. So it was:
23 A. It was within my remit, yes.
24 Q. So children operated on by cardiac surgeons at the BRI
25 in 1995 were within your remit in the same way as
0037
1 adults?
2 A. Yes.
3 Q. The long waiting list for cardiology and cardiac
4 surgery: is that a problem that had persisted for some
5 time when you took office?
6 A. I think that there had been concerns before I took up
7 office about the length of wait for both cardiology and
8 cardiac surgery, yes.
9 Q. What is the position now?
10 A. There are still concerns about the length of wait for
11 both cardiology and cardiac surgery, although we have
12 been able to reduce the length of time for both
13 cardiology and cardiac surgery. We are having
14 a difficulty at the moment with surgery with waiting
15 lists rising again, but there has been a period where
16 waiting lists have reduced.
17 Q. Shortly after you took office as General Manager, the
18 paediatric work moved to the Children's Hospital, and
19 that allowed more adult work to be carried out at the
20 BRI?
21 A. Yes, that is right.
22 Q. So that allowed a reduction in waiting lists, did it?
23 A. Yes. It allowed us to expand the service, and we have
24 continued to try and do that service.
25 Q. You presumably know that there had been a series of
0038
1 expansions of the service at the BRI from the mid-1980s
2 until the mid-1990s?
3 A. Yes.
4 Q. And that would now be characterised as fairly
5 significant, would it, from 275 cases a year to -- what
6 is it, 1,400 or thereabouts?
7 A. It is about 1,300 at the moment. Yes, it is
8 a significant increase over the years.
9 Q. Can we go to your statement at 89/9, please?
10 You mention costs. Over the page to page 10,
11 paragraph 15, the foot of the page, the last sentence:
12 "I was aware of the fact that the cardiac services
13 being provided in Bristol were more expensive than in
14 other areas and that we were losing work to the centres
15 in London because they were able to provide the services
16 more cheaply."
17 A. Yes.
18 Q. Why was Bristol more expensive than other centres?
19 A. It is a good question. I think that other centres were
20 maybe actually pricing their services differently.
21 I know some of the prices offered by the London
22 providers were related to not actually the cost of the
23 service; they were to a certain extent subsidised.
24 I think the Oxford price, which was the other area that
25 we compared ourselves with, actually priced differently
0039
1 so that they priced a core price but with a supplement
2 for the intensive care stay. So we were actually
3 comparing different things. Purchasers were comparing
4 different things.
5 Q. Was the length of stay of patients in hospital in
6 Bristol longer than elsewhere?
7 A. I think that there were other areas that were
8 discharging patients earlier and that was something we
9 looked at when we introduced the discharge co-ordinator
10 role for the directorate, which was a specific post to
11 look at trying to achieve earlier discharge for
12 patients.
13 It was, again, difficult to get comparative data,
14 because some people provided, for example, Walsgrave
15 explained that they were discharging a number on the
16 third day following cardiac surgery but they were not
17 giving you average length of stay. We certainly felt
18 that we did have longer lengths of stay, but it was hard
19 to get absolutely hard information about that.
20 Q. Let us look at paragraph 17 in that same page. You
21 say -- this is a paragraph that Mr Langstaff discussed
22 with Dr Roylance; you may have seen that on the
23 transcript:
24 "Cardiac disease is one of the major causes of
25 death ... I felt the Trust was not committed to
0040
1 developing the service."
2 As we have just discussed, the Trust, and earlier
3 the Health Authority, had carried through an expansion
4 of cardiac services from 275 operations a year to
5 I think at this stage, what was it, about 800 or 900
6 operations a year in a 10 year period?
7 A. Yes, I think that is true, but I think what had happened
8 is that with the creation of the directorate, the plans
9 for further expansion were quite limited and we were not
10 keeping pace with the demand, the local demands and the
11 demand from purchasers across the region.
12 Because there was no Trust framework in which to
13 decide how the service was going to progress, it really
14 was a feeling certainly that we had within the
15 directorate that the Trust was not committed to further
16 development of the service and I notice there are
17 comments that it was not a matter for the Trust to be
18 committed to developing the service, and that was
19 a matter for purchasers to increase their investment in
20 the service. I think that we disputed that within the
21 directorate and were aware that there were a number of
22 other resources available for developing the service
23 that were not entirely reliant on increased income from
24 purchasers. For example, we knew that the facilities
25 were limited and the capacity was limited and that
0041
1 capital resources were available within the Trust, and
2 indeed, we were able to obtain extra capital to develop
3 part of the service in 1996, but we were aware that
4 capital was available and we were also aware that
5 resources were available for service developments.
6 I felt that it was very important that cardiac,
7 although it had developed tremendously, was still very
8 much behind the sort of type of service that was
9 required to keep pace with the demands being expressed
10 from purchasers across the region.
11 Q. Let us just break that down a little. Despite the fact
12 that there had been this significant increase in the
13 number of operations over ten years, it is right, is it
14 not, that the number of operations and cardiological
15 investigations had never kept pace with the demand;
16 there had always been a pent-up demand for cardiac
17 services?
18 A. Yes. There always will be, and it is very hard for
19 the service to keep pace with demand, because demand
20 will always be outstripping supply.
21 Q. So there is nothing particularly strange about the fact
22 that the Trust had not taken steps to keep pace with
23 demand?
24 A. No, it is not unusual for tension to be there between
25 demand and supply, but I think we felt that the gap was
0042
1 so great and that the potential was there, it was not us
2 in the directorate saying "We want to develop this
3 service". The opportunities and requests were coming
4 from the purchasers across the region with whom we were
5 dealing, and that was the frustration within the
6 directorate.
7 We realised that demand would outstrip supply, but
8 although there had been a large expansion, it was
9 looking very limited in terms of the future expansion we
10 were able to achieve to at least try and keep pace with
11 some of the requests coming in from purchasers.
12 Q. You say in the last sentence in paragraph 17 you felt
13 that the Trust was not committed to developing the
14 service.
15 A. Yes.
16 Q. What did you mean there?
17 A. We were not looking for the Trust to build a new cardiac
18 unit, but we were looking for help in terms of improving
19 the facilities that we had for cardiothoracic services.
20 Q. You mean the Board were not committed to developing the
21 service?
22 A. Yes.
23 Q. The directors?
24 A. Yes. We felt that the Trust, the Board, the Chief
25 Executive, was not committed to developing the service
0043
1 and that we were having to, as all directorates do, all
2 directorates will fight hard to try and develop the
3 services they are working in, but we felt that there was
4 a complete disinterest from the service.
5 Q. But this Board had fairly recently taken the decision to
6 move paediatric cardiac open heart surgery to the
7 Children's Hospital in order to allow yet another
8 expansion of adult work at the BRI. Surely that was
9 demonstrating a commitment to the further expansion of
10 the service?
11 A. That was limited and there was no further commitment to
12 develop a service after that. That is why we felt
13 within the directorate it had to be a clear objective of
14 the directorates to push the development of the service
15 even further. We knew that the creation of the
16 additional capacity with the children's service was
17 going to be very limited.
18 Q. Can we go to paragraph 24, page 13? You have mentioned
19 this already, Mrs Ferris. There is no point in reading
20 that paragraph out, but the last sentence:
21 "In April 1996, the Trust Board agreed that the
22 directorate should be reorganised."
23 A. Yes, that is right.
24 Q. Along the lines that you had been suggesting. This was
25 very largely the same Trust Board as had been in place
0044
1 when you became General Manager of cardiac services?
2 A. Although in April 1996 there was a new Chief Executive,
3 but, yes.
4 Q. Apart from that, it was, I think, substantially perhaps,
5 off the top of my head, entirely the same.
6 To what extent did you think that the fact that
7 there was a new Chief Executive was decisive in the, as
8 you perceived it, change of attitude of the Trust Board?
9 A. I think the appointment of the new Chief Executive was
10 very important, because -- you referred to the paper
11 that we worked on, the "brainstorming" paper in August
12 1995. Following that, we started a very clear process
13 of developing the strategy of the directorate and we
14 were assisted in that process by the new Chief Executive
15 and as a result of that, we were asked to put together
16 a very clear paper for the development of the service,
17 that, you know, made very clear the requirements of the
18 service, which we did.
19 That paper was completed in January 1996, and then
20 was approved by the Board in April 1996. That involved
21 a significant capital cost of just under 3 million,
22 which was identified, although, as I have noted in one
23 of the comments on my statement, it was the Trust's
24 comments that the money was not actually made available,
25 but it was accepted that this is what needed to happen
0045
1 and that that would then be part of the Trust's
2 longer-term strategy and the Trust's estate strategy.
3 Q. Mrs Maisey in her comments on your statement, we need
4 not go to this document, but paragraph 8 of her comments
5 on your statement, WIT 89/42, she says:
6 "The Trust Board [and she means under Dr Roylance,
7 I think, in context], were very proud of the cardiac
8 services and Dr Roylance always referred to them as the
9 'jewel in the crown' of UBHT."
10 Did you ever hear Dr Roylance, or hear tell
11 Dr Roylance referring to cardiac services in that way?
12 A. Not at all. The "jewel in the crown" phrase was
13 actually something that the directorate used when we
14 made a presentation to, I think it was called the
15 Marketing and Development Committee, in, it must have
16 been 1995. We decided that we really wanted to give the
17 directorate a high profile and we wanted to go in with
18 some sort of phrase that would be remembered by that
19 committee and would help us in terms of developing the
20 directorate.
21 So that phrase, the "jewel in the crown", was
22 something that came up from the directorate and at the
23 meeting that we made that presentation, I think
24 Dr Roylance had already left the organisation by then.
25 Q. Do I understand your evidence to be that the decision
0046
1 that the Trust Board took in April 1996, which you refer
2 to in paragraph 24 -- it is on the screen -- would not
3 have been taken, in your opinion, if Dr Roylance had
4 still been the Chief Executive?
5 A. I do not think so, because the comments I have already
6 made about understanding the future strategy of the
7 directorate within the sort of Trust framework went
8 against the development of the directorate, and I think
9 when Hugh Ross started he was very keen to develop the
10 strategies of the directorates within that Trust
11 framework, and I think he recognised very quickly that
12 the directorate did need to develop in a way that we
13 said it should develop. He was actually very helpful to
14 us and came to one of our strategy meetings in December
15 1995 to help us, to achieve the writing of a long-term
16 strategy plan that we wanted to. It was his suggestion
17 that we would then put to the Board a paper that made
18 very clear what we needed in terms of the facilities for
19 the service, so that the Board could consider that. So
20 it was very much his initiative that we should write the
21 paper we wrote in January 1996, talking about the
22 relocation of the service on to one site.
23 Q. I just want to deal with a couple more points, and then
24 perhaps it is time for a break --
25 THE CHAIRMAN: May I just clarify the answer given? When
0047
1 you say "I do not think so", I am not putting words into
2 your mouth, but do you mean, "I do not think it would
3 have"?
4 A. Yes.
5 THE CHAIRMAN: It is important for me to understand the
6 answer.
7 MR MACLEAN: You are agreeing with the hypothesis in the
8 question?
9 A. Yes.
10 Q. You said that the phrase the "jewel in the crown" was
11 one that you had used within the directorate, or the
12 cardiac services directorate itself used. How would it
13 be that that directorate could be thought of, even by
14 itself, as being the jewel in the crown, if the Trust
15 Board were not committed to it and showed such a lack of
16 interest in it?
17 A. The purpose of that presentation, and it was a little
18 tongue-in-cheek, that title, but the purpose of that
19 presentation was for us, for the directorate, we wanted
20 to persuade the Trust that we could fit into and could
21 be a major strength of the Trust and that we could
22 achieve that. So, you know, you have mentioned that
23 term, but it was very much a sort of tongue-in-cheek,
24 you know, way of trying to bring attention to the
25 directorate's plans.
0048
1 Q. When we were discussing the Trust Board's decisions in
2 April 1996, it is right, is it not, that by that time
3 there had been a good deal of discussion in the public
4 arena about cardiac services at Bristol generally, and
5 paediatric cardiac services and surgery in particular?
6 A. Yes.
7 Q. So it would be right, would it not, to take into account
8 the fact that the Trust, in 1996, was faced with
9 a rather different scenario in terms of the public than
10 that which had faced Dr Roylance's Board earlier?
11 A. Yes.
12 Q. So to what extent would you agree with the suggestion
13 that it was perhaps rather less surprising that the
14 Trust Board, given all that had happened by April 1996,
15 should be prepared to invest in cardiac services in
16 order to reassure the public as to the quality of the
17 service?
18 A. I think by that stage the profile of cardiac services
19 was very high, but perhaps not for the right reasons,
20 and I think it is understandable that the Trust Board
21 should be keen to improve the facilities and develop the
22 service, yes. I am agreeing with you.
23 Q. So might it not be that it was those events that had
24 taken place, rather than the fact that Dr Roylance
25 happened to be replaced by Mr Ross, that in fact was the
0049
1 true reason for the April 1996 decision?
2 A. I think that is part of it, although I do believe
3 strongly that the new Chief Executive did put more
4 emphasis on the development of strategy for the Trust,
5 and you will see that actually at that time an awful lot
6 of work went on within the Trust to look at the whole
7 Trust's long-term strategy, and as part of that, there
8 were very clear messages about the development of both
9 children's services and oncology services at the same
10 time, so cardiac became in a way part of those three
11 regional specialties.
12 So, yes, I would agree there was a major interest
13 in developing the service because of the past history of
14 the service. That has to be taken into account; but
15 also, there was the development of strategy that had
16 targeted the development of the three regional
17 specialties. I think that was very much as a result of
18 the new Chief Executive's approach to the development of
19 strategy.
20 Q. So, from your perspective, you perceived a greater or
21 an increased strategic thinking concerning cardiac
22 services?
23 A. Yes.
24 MR MACLEAN: Sir, I wonder, is that an appropriate moment
25 for a short break?
0050
1 THE CHAIRMAN: Yes, shall we take 15 minutes and then
2 reconvene at 11 o'clock?
3 (10.48 am)
4 (A short break)
5 (11.05 am)
6 MR MACLEAN: Can we go to the document that you supplied
7 along with your statement, Mrs Ferris? It is
8 WIT 89/38.
9 First of all, if we look at the page as a whole,
10 there are some annotations on this, some handwriting.
11 Whose is it, do you know?
12 A. I think that is mine. It is mine.
13 Q. Can we look at the top part of the document? You were
14 the sole author of this document?
15 A. Yes.
16 Q. "The creation of the cardiac services directorate
17 represented the achievement of a major UBHT Trust
18 objective to develop a patient focused/disease based
19 directorate and this is our major strength."
20 A. Yes.
21 Q. So that achievement was an achievement of the Trust
22 Board?
23 A. Yes.
24 Q. Then you go on to set out a number of weaknesses as you
25 perceived them, which threatened the future existence of
0051
1 this fledgling directorate, and you summarise them.
2 I do not want to go through them all, but can I look at
3 just some of them, please?
4 If you go to 1.2, you say:
5 "Purchasers perceived cardiac services in Bristol
6 as an expensive service with long waiting times and poor
7 quality results (e.g. cardiac surgery)."
8 A. Yes.
9 Q. That is an example of poor quality results, as you saw
10 it. Were there any other areas of poor quality results?
11 A. I think that particular perception had come about -- all
12 of these 17 points here came about after discussion with
13 various purchasers and GP fundholders and other people.
14 One of the things that was coming up very frequently was
15 questions about the quality of results for cardiac
16 surgery, and there were questions about -- obviously in
17 paediatric surgery, things had already happened there,
18 but purchasers were concerned and worried that they
19 might well find poor quality results across the board
20 and they were asking questions about adult cardiac
21 surgery as well.
22 Q. Can I just slow you down a little bit? Those concerns
23 that purchasers were voicing were voiced in the wake of
24 publicity about paediatric cardiac surgery?
25 A. Well, yes, because --
0052
1 Q. Is that right?
2 A. Yes. I commenced in 1994 and from that time up until
3 this time, in August 1995, I conducted discussions and
4 meetings with various purchasers and events about
5 paediatric cardiac surgery were becoming known then, so
6 there were more and more questions from purchasers about
7 results and quality of service.
8 So, yes, that is true.
9 Q. Was it right, strictly speaking, to say that purchasers
10 perceived there were poor quality results, or was it
11 rather that purchasers were querying whether there might
12 be poor quality results, which is a different thing?
13 A. I think the perception was that there were poor quality
14 results, but purchasers had no evidence to support that
15 view. What they were asking me for was some way of
16 finding the evidence to suggest whether that was true or
17 otherwise. What they were saying was that there was
18 a perception that results were poor, but they did not
19 really know that that was true and they were asking for
20 information to try and support, or not, that assumption.
21 Q. If we look at 1.2 and 1.3 as well, which is about
22 communication, which was perceived to be poor, who held
23 the perception at 1.3?
24 A. That comment came up after discussion at a number of
25 levels with purchasers, and that would be with contract
0053
1 monitoring teams and Health Authority teams. It also
2 came up after discussion with individual GPs and GP
3 fundholders, so it came from a variety of sources and
4 there were a variety of examples as well. There were
5 complaints about basic communication like qualities of
6 discharge letters or letters received by GPs following
7 clinic appointments. There were also comments and phone
8 calls that I received about the difficulty people had
9 actually finding somebody within the directorate to talk
10 to if they had a problem they wished to discuss.
11 So that came from a variety of different sources
12 and was really about communication at a variety of
13 different levels.
14 Q. So part of it was communication, as it were, with
15 yourselves?
16 A. Yes.
17 Q. And part of it was communication to the outside world?
18 A. Yes, and part of it was communication about management
19 issues and part of it was communication about clinical
20 issues and about what had happened to a patient in
21 hospital. That was where the concerns about discharge
22 summaries and clinic letters came from, so it was
23 communication at a variety of levels.
24 Q. 1.4: "No proactive audit programme/strategy."
25 A. Yes.
0054
1 Q. I think you are prepared to deal in more detail with
2 audit subsequently in writing. I do not want to go into
3 it in any great detail today, but in general terms, was
4 that your perception? That was your own judgment, was
5 it?
6 A. No, none of these things -- obviously all of these
7 things have come from me as well, but that has been on
8 the basis of discussion with people that use the
9 service; and I felt that there was no proactive audit
10 programme, that had also come through from discussions
11 with purchasers and is linked to point 1 and point 2
12 where they were saying "You are not being proactive.
13 We have a perception that things may not be right but
14 you are not telling us whether that is true or not", so
15 it was coming both from myself internally but also from
16 the users of the service.
17 Q. So your (if I can use the word) "customers" were telling
18 you that this was the position, and it accorded with
19 your own opinion?
20 A. Yes.
21 Q. If you look at 1.9, which is over the page:
22 "Leadership in some areas is weak."
23 A. Yes.
24 Q. You were the General Manager and Professor Vann Jones
25 was the Clinical Director. Were you not the leadership
0055
1 of the directorate?
2 A. I think in that particular point I was referring in
3 particular to the Associate Clinical Director for
4 Cardiac Surgery.
5 Q. Mr Dhasmana?
6 A. Yes, that is right.
7 Q. So this had not come from purchasers; this was your
8 view?
9 A. Yes.
10 Q. So some of these statements are your opinion and some
11 are based on what purchasers have said, and some are
12 a mixture of the two?
13 A. Yes. If I could just say this paper was produced to
14 stimulate discussion and therefore it was an
15 amalgamation of perceptions from elsewhere, comments
16 that had been made to me from users of the service and
17 my own perceptions having been in post for several
18 months by this stage. So it was a variety of different
19 sources and a variety of different perceptions, and it
20 was deliberately written to be presented to the
21 clinicians to give them something to think about in
22 terms of how we developed the future strategy for the
23 directorate.
24 Q. So it was designed to stimulate debate and discussion
25 which was liable to look at the fundamentals of the
0056
1 organisation?
2 A. Yes.
3 Q. Can we look at 1.15? This is August 1995. From where
4 did that comment come about IT?
5 A. Was I was particularly concerned about information
6 technology. That has come from me. I was concerned
7 about it, both for contracting purposes, the Trust
8 hospital systems I felt were inadequate, but also the
9 audit systems for clinical audit, so it really came from
10 me. They obviously discussed things like that with
11 other people within the directorate, but that was very
12 much my impression of the directorate.
13 Q. If we go to UBHT 229/13, this is a letter to you, a memo
14 to you, from Mr Wisheart. I take it that when he refers
15 to 1.1 to 1.17, he is replying to your paper, because it
16 had 17 points to it.
17 A. Yes, that is right.
18 Q. He also seems to be referring to a point, 2.0, which
19 I do not think we have attached to your statement, do
20 we?
21 A. No. I do not know what the reference to 2.0 is.
22 Q. But it does appear as if the references in the memo to
23 1.1 to 1.17 do tally with the paper we have just looked
24 at.
25 A. Yes.
0057
1 Q. If we look at the third paragraph there, Mr Wisheart
2 says to you:
3 "I do not wish to copy (sic) on every point from
4 1.1 to 1.17."
5 I think it might mean "comment", but it does not
6 matter.
7 "Regarding point 2.0, the perception of a poor
8 quality service with long waiting times should be
9 countered by making our results known and Alan", that is
10 Mr Bryan is it?
11 A. Yes.
12 Q. "already has a draft audit report for 1994/95 which
13 could be used in this area."
14 A. Yes.
15 Q. What became of that suggestion from Mr Wisheart?
16 A. We did publish that report. We published it quite
17 widely. Alan produced a report which initially
18 I thought was in a very clinical format and I wanted it
19 to be amended slightly so it could be more easily read
20 by a wider audience. We did that and then produced
21 a report for 1994/95 which we circulated quite widely.
22 I need to stress at this point that Alan Bryan had
23 also, prior to this, been working for some time on
24 looking at outcomes in audit for the academic
25 department, so that information had been available
0058
1 specifically for the Professor of Cardiac Surgery and
2 the senior lecturer, but now what we were doing with the
3 1994/95 report was to look at the whole unit's results
4 and to want to circulate them widely to do as James has
5 suggested there, to try and counter poor perceptions by
6 presenting some factual information.
7 Q. So there was some information which was available at
8 that time in draft, which Mr Wisheart was saying, "Let
9 us make this known" and you took up that suggestion?
10 A. I do not know if at that date the report was in draft
11 and was later amended, but it was initially written in
12 draft and amended and sent out, and I worked on that
13 with Alan Bryan. You are implying from that we then
14 redrafted the report and sent it out. I do not know
15 that that is absolutely accurate, but, yes, the report
16 was amended at some stage to make it appropriate for
17 a wider audience and then circulated.
18 Q. About this time I think you were engaged in producing an
19 information pack about the directorate; is that right?
20 A. Yes.
21 Q. If we go to UBHT 84/33, this is the cardiac surgery
22 associate directorate meeting, so this is one half of
23 the cardiac services directorate?
24 A. Yes.
25 Q. And Mr Dhasmana was still the Associate Clinical
0059
1 Director, although I think he had made clear that he was
2 standing down by this stage; is that right?
3 A. Yes.
4 Q. And he is not actually at this meeting.
5 The surgeons who are at this meeting -- perhaps
6 you could identify those surgeons to us?
7 A. Mr Pawade, Mr Hutter, Mr Bryan, and Professor Angelini,
8 the surgeons.
9 Q. We see that Mr Dhasmana and Mr Wisheart, neither of them
10 were present?
11 A. No.
12 Q. If we go to 35, and scan down the page, at paragraph 8:
13 "The information package previously circulated was
14 discussed."
15 Had you drawn up that information package?
16 A. Yes.
17 Q. "The following points were noted". Those were your
18 initials in the right-hand column, so these are points
19 for you?
20 A. Yes.
21 Q. At point (iii):
22 "Contract monitoring information by individual
23 consultant is not useful."
24 What had the information pack contained about
25 individual consultant monitoring information?
0060
1 A. It would have contained information about the numbers of
2 procedures that had been carried out in a particular
3 period, usually a month. It was a monthly information
4 report. I think from this, that what we must have done
5 at that stage was to actually try and break down the
6 contract performance against individual consultants.
7 When we developed this package, we started off doing it
8 with suggestions from people as to what might be in it,
9 and then wanted to bring it back to decide what was and
10 was not useful. I can only assume, I cannot remember,
11 that we must have monitored by individual consultant and
12 then it was decided it was not useful and it was decided
13 not to do it.
14 Q. So it was monitoring numbers of operations carried out?
15 A. Yes.
16 Q. For each surgeon to each purchaser?
17 A. Yes.
18 Q. It was not concerned with outcome?
19 A. No. It was nothing to do with outcomes; it was simply
20 numbers of operations done. I think perhaps the reason
21 we looked at individual consultant numbers was because
22 we were aware that particular consultants would be more
23 likely to operate on patients from particular areas and
24 we wanted to see how that filtered through to their
25 attendance at outpatient clinics in other hospitals, so
0061
1 that somehow we could make a decision about balancing
2 the workload more equally across the different
3 consultants. But from my memory of this meeting, we
4 decided that that really was not a very helpful thing to
5 do, so we did not do it.
6 Q. So the fact that one surgeon might have carried out
7 a small number of operations for a particular purchaser
8 was not necessary or even at all a reflection on that
9 surgeon?
10 A. No.
11 Q. So it was right, was it not, that to publish that
12 information broken down by individual result would not
13 have been of any use?
14 A. No, that is right.
15 Q. If we go back to your witness statement at 89/12,
16 paragraph 9, this is again you pointing out that
17 purchasers and GPs, who were also purchasers, of course,
18 were saying that the service was poor.
19 Did you have any hard evidence that Health
20 Authorities or GPs were voting with their feet and
21 taking their work elsewhere?
22 A. The really hard evidence, I suppose, was that the
23 Somerset contract we had was very much under threat when
24 I started and that in the monitoring meetings they were
25 talking about taking their work away. Whether or not
0062
1 that was bluff or reality, I do not know, but
2 I certainly took it seriously. They were looking at
3 perhaps referring patients to the new unit in Plymouth
4 when that opened. That was a fairly large chunk of the
5 work, the patients that we would operate on that came
6 from Somerset. So that in itself was very significant.
7 Q. At this time, when you took office, cardiology, I think
8 in particular, was consistently overspent?
9 A. Yes.
10 Q. If we look at UBHT 299/25, this is a memo from you to
11 Dr Roylance. If we go over the page to 26, at the
12 bottom, we see that it was copied to Mrs Maisey?
13 A. Yes.
14 Q. If we go back then to the beginning, you are setting out
15 there the steps that are going to be taken in order to
16 try to redress the financial problem?
17 A. Yes.
18 Q. If we scan down so we see the whole page, you deal with
19 the two branches of the directorate in turn, cardiology
20 and cardiac services?
21 A. Yes.
22 Q. Over the page:
23 "The current overspending in cardiac services is
24 related entirely to our contract position."
25 What was happening was that too much work had been
0063
1 done on a block contract; is that right?
2 A. Yes.
3 Q. And you do not get any prizes for doing too much work?
4 A. No, you do not get paid for doing more work than the
5 contract's target allows.
6 Q. You do get paid for doing more work in a variable
7 contract?
8 A. Yes, you do.
9 Q. The block contract was with the Bristol & District
10 Health Authority?
11 A. Yes.
12 Q. You were anxious to make sure that non-emergency work
13 from Bristol & District should be essentially put on the
14 backburner whilst more work was done from purchasers
15 with variable contracts?
16 A. Yes. I think it is an important point that we were not
17 threatening emergency or urgent work, but, yes, in terms
18 of routine work, we did restrict that to try and improve
19 the financial position.
20 Q. Why send this memo to Dr Roylance? How common was it
21 for you to send memos of this nature to the Chief
22 Executive?
23 A. He asked that General Managers should do that. It was
24 asked. It was a specific request from the Chief
25 Executive that we should do that.
0064
1 Q. Do it when? Every so many months or what?
2 A. I think initially it was to be every month. I am sure
3 it was meant to be a monthly thing. As soon as our
4 financial position became known at the end of the month,
5 we would then explain to the Chief Executive what the
6 reason for the overspend was and what action we would
7 take to restore the situation.
8 Q. So these memos were regular?
9 A. They started off being regularly requested, and then it
10 did not continue. I do not remember writing more than
11 two of these.
12 Q. And they were concerned with finance?
13 A. Yes.
14 Q. Why copy it to Mrs Maisey and not, for example, to
15 Graham Nix?
16 A. I am sorry, I do not know. I recall being asked to do
17 that. The letter was to Dr Roylance and Mrs Maisey
18 wished to have a copy.
19 Q. Did that strike you as odd?
20 A. It does now, yes.
21 Q. As you recall, Dr Roylance said "Send this to me and
22 copy it to Mrs Maisey"?
23 A. Yes, and the request had come from Dr Roylance, but
24 whether it came directly to General Managers from him,
25 I do not know. I believe that this request came up at
0065
1 the monthly meeting that Mrs Maisey had with the General
2 Managers. We were asked to do that. That was one of
3 the actions from the monthly meeting we had with
4 Mrs Maisey but we were asked that it should go to
5 Dr Roylance and that it had been requested by him.
6 Q. WIT 89/17, paragraph 35. You have touched on this
7 briefly. This is a paragraph that is concerned with
8 Mr Dhasmana, essentially, who was the Associate Clinical
9 Director of Cardiac Surgery.
10 A. Yes.
11 Q. You say that your impression was that he found it
12 difficult to provide leadership in meetings and so on.
13 A. Yes.
14 Q. Was it your impression that these failings, as you saw
15 them, in Mr Dhasmana's managerial capabilities, or
16 leadership qualities, could have been addressed and
17 remedied?
18 A. No. I do not think so. My impression of Mr Dhasmana
19 was that he was a very straightforward and human
20 individual who was very good at -- he was basically
21 a very nice person who was really, I suppose in a way
22 quite simple in his approach to things. That was fine
23 and I think that helped our working relationship
24 initially, but in terms of dealing with some of the
25 difficult things, in terms of pulling clinicians
0066
1 together or helping to unite them, in terms of dealing
2 with difficult conflict situations, chairing meetings,
3 the things I have put there, in dealing with hostility,
4 he was very out of his depth so far as that was
5 concerned, and although I did want to support him as the
6 General Manager, I wanted to help him, I did not believe
7 that he had the skills to do the things that I have
8 identified there that he was not able to do.
9 Q. Mr Dhasmana has given some comments on your statement.
10 If we go to WIT 89/52, please, that is the first page of
11 his comments. You have seen this document?
12 A. Yes, I saw that this morning.
13 Q. If we go to page 54, at the foot of the page,
14 Mr Dhasmana actually is specifically commenting on
15 paragraph 38 of your statement, which we will come back
16 to in a minute.
17 He says he did attend a course, "Management skills
18 for the newly appointed consultant", but there were no
19 job description or written guidelines handed to him when
20 he became Associate Clinical Director in January 1993.
21 Would you find it surprising that he should not
22 have been handed a job description or written
23 guidelines?
24 A. I find it surprising he was not given any guidance in
25 how he should be effective in the Associate Clinical
0067
1 Director role. The course he attended would not have
2 given him anything like that, although I am aware that
3 the role of the Associate Clinical Directors, and indeed
4 the Clinical Directors, was still very much evolving and
5 developing and in fact, the Clinical Director roles did
6 differ from directorate to directorate, depending on the
7 style of the directorate, the style of the clinicians
8 within it. But, yes, I am surprised -- I am not
9 surprised because of the nature of the Trust, but
10 I would be concerned that he had not received any
11 guidance.
12 Q. So in this Trust at that time, it is not surprising, but
13 you think it would have been wise; is that a fair
14 summary?
15 A. Yes, thank you.
16 Q. Mr Dhasmana says that he did talk to, I think, four
17 different people. He spoke to Mr Baird, the Clinical
18 Director of Surgery; Mr Eltringham, who was the Chairman
19 of the Division of Surgery. Where did that role fit
20 into the hierarchy?
21 A. The Division of Surgery meetings were very much clinical
22 meetings, they were not managerial meetings. There is
23 still a debate about where the Division of Surgery fits
24 into the management machinery of the Trust, but they are
25 very much to deal with clinical and professional
0068
1 matters, whereas the directorate and associate
2 directorate roles are very much to do with the
3 management of the service.
4 Q. What was Mr Eltringham's managerial role in the surgery
5 directorate, so far as you recall?
6 A. Other than him being Chairman of the Division of
7 Surgery, I cannot recall that he had a managerial role
8 within the Division of Surgery. That may be because
9 I do not know exactly what he was doing, but ...
10 Q. So, so far as you recall, he had no managerial role?
11 A. Yes, as I recall it.
12 Q. Mr Wisheart was, in January 1993 -- I will be corrected
13 if I am wrong -- the Medical Director, I think?
14 A. Yes.
15 Q. Lesley Salmon had been the Associate General Manager.
16 As we discussed earlier, to the extent that there was
17 a shadow General Manager of cardiac services
18 subsequently, it was her?
19 A. Yes.
20 Q. And Mr Wisheart, as we see there, was at that time the
21 Associate Clinical Director of cardiac surgery.
22 Perhaps with the exception of Mr Eltringham, would
23 it or would it not be sensible for Mr Dhasmana to have
24 approached those people for some guidance as to how to
25 carry out his duties as Clinical Director?
0069
1 A. Yes, I am sure that was sensible; I am sure it was the
2 right thing to do.
3 Q. Was there anywhere else he could have turned, in your
4 view?
5 A. I would have thought that perhaps the Director of
6 Personnel maybe would have had a role, but I think
7 otherwise -- he has talked to the Medical Director and
8 to colleagues; he has talked to the General Manager.
9 I think that would be a reasonable group of people to
10 try and obtain guidance from.
11 Q. At the bottom of the page he says:
12 "My main responsibility would lie with the
13 contractual and financial obligations of the associate
14 directorate."
15 Do you agree with that?
16 A. Yes.
17 Q. "But the overall responsibility would lie with the
18 Clinical Director."
19 Do you agree with that?
20 A. Yes.
21 Q. "I was expected to be a channel of communication between
22 him and the members of the Associate Directorate of
23 Cardiac Surgery."
24 Do you agree with that?
25 A. Yes.
0070
1 Q. "I was told very clearly that I was not responsible for
2 my consultant colleagues and vice versa."
3 A. Yes. I mean, that is a matter of interpretation. As
4 I say, the roles of the Associate Clinical Directors
5 were developing. If you look at the previous page and
6 look at his obligation to the contractual and financial
7 performance of the associate directorate, he could not
8 do that without at least some, maybe not managerial
9 responsibility for his consultant colleagues, but he had
10 to be able to be working closely with his consultant
11 colleagues and actually suggesting and proposing
12 decisions that would affect the practice of his
13 colleagues, to be able to undertake or achieve that
14 objective for the financial and contractual management
15 of the associate directorate.
16 So what I am saying is that if there were changes
17 or if there were action that needed to be implemented --
18 for example, we talked about the restriction on
19 cardiology work: if we were restricting cardiac surgery
20 work for financial or contractual reasons, then
21 Mr Dhasmana would need to be working with his consultant
22 colleagues to determine how that happened.
23 So it is difficult to separate the responsibility
24 for the consultant colleagues from that objective of
25 achieving financial and contractual objectives.
0071
1 Q. If I miss out a couple of lines, tell me if you think
2 they are important, in which case I will come back to
3 them. If we go two or three lines down, do you see the
4 sentence:
5 "I believed that I did not have any controlling
6 influence as an Associate Director and relied on my
7 colleagues' co-operation and support in performance of
8 my function."
9 To what extent was it your view that an Associate
10 Director did have a controlling influence?
11 A. I do not think you can ever have a controlling influence
12 over cardiac surgeons, and I think consultants are
13 a very difficult group to have a controlling influence
14 over. I think what I perceived was that he would have
15 a more proactive role to play in terms of asking and
16 attempting to get agreement over different activities of
17 the directorate, which obviously would be affected by
18 the performance and behaviour of the consultants within
19 it.
20 So on the one hand I agree that he could not
21 manage or be in control of the consultants, but that he
22 had a very proactive role to play in terms of working
23 with them to control or change or direct what they were
24 doing within the directorate.
25 Q. To what extent is it fair to say that it was your
0072
1 perception, as I think Mr Dhasmana may well be saying,
2 that his approach was to take decisions and move things
3 forward on a consensual basis?
4 A. I think there is always going to be a difference in
5 style, but the way in which the Clinical Director and
6 Associate Clinical Director roles developed had been
7 discussed greatly within the Trust and I have been
8 involved with that in a number of other directorates.
9 The way that the philosophy with the Trust has been
10 described was that the Clinical Director's role was to
11 give some of the vision and leadership to the
12 directorate. Therefore, although it was a developing
13 role, I felt that the concept I had was one that had
14 actually been developed within the Trust. Janardan and
15 I discussed that. We discussed his role. We discussed
16 how he and I would work when I first started within the
17 directorate. We talked about these things when
18 I started.
19 Q. To what extent would it be fair to say that
20 Mr Dhasmana's approach to managerial meetings was to
21 move forward on a consensual basis?
22 A. It was not a separate forward split between consensus
23 versus, you know, a more proactive, perhaps more
24 autocratic, he is suggesting, way. He was not moving
25 forward in any way. There was no consensual style
0073
1 because he had no credibility as a Clinical Director.
2 So actually nothing was happening. It was not a simple
3 case of his approach was different to mine and I was
4 trying to ram down his throat an approach I thought
5 worked and he had a different approach. I do not
6 believe there was any approach. That was the main
7 problem.
8 Q. Mr Dhasmana says in his comments at page 53,
9 paragraph 3, first of all that meetings had become
10 fractious: and by 1995 that was the case, was it not?
11 A. Yes.
12 Q. He tried hard to get them together, to draw people
13 together?
14 A. I think he tried to do that, yes.
15 Q. Then he says he acknowledged that you intervened on
16 a few occasions, but "these were mainly on behalf of the
17 vocally strong faction. In my eyes, she was taking
18 sides instead of providing me any support as a General
19 Manager in conducting the meeting."
20 A. That was obviously the view that he had, but I recall
21 that what I was trying to do was actually to allow both
22 factions, however many factions there were, to a voice,
23 and not to allow meetings to disintegrate into slanging
24 matches between different groups of surgeons.
25 Q. So the factions were surgical factions?
0074
1 A. Well, there were differences amongst surgeons. There
2 were also differences between anaesthetists and
3 surgeons. So there were different groups.
4 Q. How did Mr Dhasmana interact with Mr Wisheart at
5 meetings of this nature?
6 A. My recollection is that Mr Dhasmana deferred on a number
7 of occasions to Mr Wisheart. Mr Wisheart was very
8 experienced at managing meetings; he was very good at
9 managing meetings. He often allowed Mr Wisheart to do
10 that, because he found it difficult.
11 Q. Was that deference that you perceived something that was
12 more apparent with Mr Wisheart than with others?
13 A. Yes.
14 Q. Why?
15 A. I mean, I do not know. I think Mr Dhasmana and
16 Mr Wisheart worked closely together. Mr Dhasmana
17 obviously had a lot of respect for Mr Wisheart and
18 Mr Wisheart, I think, possibly -- maybe this is an
19 incorrect assumption, but I think Mr Dhasmana saw
20 Mr Wisheart as more experienced in some of the things
21 I have mentioned, particularly dealing with
22 confrontations and dealing with meetings. But I think
23 to an extent that is speculation.
24 Q. Can I go to page 18, paragraph 37, please? This is back
25 to your statement.
0075
1 "I expected to be able to discuss with my Clinical
2 Director the strategy and planning issues and the
3 decisions that needed to be made before meetings took
4 place .... It was not possible to do this with
5 Mr Dhasmana."
6 But Mr Dhasmana was of course never the Clinical
7 Director?
8 A. No, that is incorrect. What I mean is that I expected
9 to be able to discuss with the Clinical Director and the
10 Associate Clinical Directors depending on -- you know.
11 I expected to be able to discuss those issues with all
12 of them.
13 Q. You say you felt that he, Mr Dhasmana, found it
14 difficult to understand some of the concepts with which
15 you had to work?
16 A. Yes.
17 Q. Which?
18 A. I think he found the way in which the system of
19 contracting worked quite difficult to understand.
20 I remember none of the surgeons liked the system of the
21 internal market, but were actually quite good at
22 understanding how it could benefit the directorate, and
23 Mr Dhasmana found it hard to understand that and hard to
24 understand about things, you know, the difference
25 between a block contract and a variable contract and how
0076
1 to maybe profile work, how to understand the effects of
2 demand, what the effect of, you know, increasing demand
3 from a particular area would have on the way we provided
4 the service, those sorts of issues, really.
5 Q. So as we have discussed, if you were doing more and more
6 work for a block contract purchaser, you did not get any
7 financial thanks for it.
8 A. Yes.
9 Q. That would mean you had to take decisions or try to
10 reach a view that you would stop doing non-emergency
11 block purchaser work and start doing variable work?
12 A. Yes.
13 Q. That essentially involved getting the surgeons to agree
14 or telling the surgeons which patients they could or
15 could not treat?
16 A. Yes, of course, because obviously if you are switching
17 the work you are doing and operating on people from
18 another area, the surgeons are doing those operations,
19 so yes, it does require them to co-operate with that.
20 Q. I will move away from Mr Dhasmana, unless there is
21 anything else you want to add to this area of
22 discussion?
23 A. No.
24 Q. Mr Dhasmana in due course resigned, I think, as
25 Associate Clinical Director?
0077
1 A. Yes.
2 Q. And he was replaced by Mr Hutter?
3 A. Yes.
4 Q. Can I turn to Mrs Maisey, whom we discussed briefly
5 earlier?
6 If we go to page 20, please, if we go to the foot
7 of the page, paragraph 47, we have discussed the fact
8 that you knew Mrs Maisey in 1985. You say you felt
9 bound to challenge a number of Mrs Maisey's comments and
10 decisions.
11 What period are we discussing there? Was this
12 when you were at cardiac services, or previously, or
13 both?
14 A. No, this was during the whole period of time that
15 I worked within the organisation, so from 1985 up to the
16 time Mrs Maisey retired.
17 Q. You use the word "challenged" her comments and
18 decisions. That is a strong word to choose. What was
19 the nature of the "challenge"?
20 A. There were a number of issues. Do you want specific
21 examples? There were issues, for example, when
22 I managed the service at Winford and we were
23 implementing the clinical nurse grading structure, we
24 disagreed with the way in which that was implemented.
25 So there were some fairly significant challenges.
0078
1 Q. It is one thing to challenge somebody's decisions. Did
2 that lead to bad blood between you?
3 A. I think to a certain extent Mrs Maisey welcomed
4 challenge. That was one of the things she liked about
5 the people around her. So it did and it did not. On
6 the one hand she felt pleased to have people that did
7 challenge her, but on another level, I think she was
8 irritated by that, and I wanted to implement things and
9 I felt there were obstacles to doing it.
10 Q. Did you perceive any change in Mrs Maisey's attitude or
11 approach when she ceased to become Unit General Manager
12 at the Central unit, as it was then, and became Director
13 of Operations at the Trust?
14 A. No. Her style was the same.
15 THE CHAIRMAN: May I just clarify for my own mind, are you
16 using the word "challenge" as an alternative to
17 "disagree", or are you using it in as the rather more
18 forceful idea of confrontation?
19 A. It could be both, depending on the circumstances.
20 I think more "disagree". Sometimes it could be
21 confrontation, yes.
22 MR MACLEAN: But that type of disagreement is something that
23 Mrs Maisey, as you have told us, welcomed. Was it
24 something that you saw as not unhealthy in the
25 relationship between managers?
0079
1 A. I think disagreement between managers can be very
2 healthy. The difference here, I feel, is that there
3 were -- the examples are very arbitrary decisions,
4 decisions made without judgment or knowledge and
5 therefore, you know, when you are disagreeing with
6 somebody on the basis of those sorts of decisions, that
7 is not quite so healthy because you then do not have any
8 opportunity to take that further or to work that out and
9 to do something about it.
10 So, yes, I think it is healthy, and I enjoy
11 working in a situation where you are able to challenge
12 and feel comfortable to challenge the decisions of those
13 around you, but it was not quite like that in terms of
14 my relationship with Mrs Maisey.
15 Q. Can we go to page 25, paragraph 63? Now we are talking
16 about cardiac services.
17 A. Yes, we are.
18 Q. You say you "did not feel able to be open or to confide
19 in my immediate colleagues and managers."
20 By "managers" there, we are talking about ...
21 A. I am talking about the other General Managers within the
22 Trust, so my counterparts in other areas.
23 Q. It seemed to me that managers would watch to see who was
24 in favour, and those who were not were avoided. You
25 felt there was a culture of fear and blame?
0080
1 A. Yes.
2 Q. Who was in fear of whom and who was doing the blaming?
3 A. The General Managers were in fear of the action that
4 would be taken by Mrs Maisey if they did not fit into
5 the perceptions or requirements that she had of them,
6 which I think is different to being worried and
7 performing well in their post, in that they are worried
8 about what would happen. There was a real fear of the
9 arbitrary way in which some managers were in favour and
10 some managers were out of favour, and I was very
11 interested to read the statement of Steve Boardman, who
12 also talks very much about the "club" and who was in and
13 who was out, and who would be "put back in their box" if
14 they were not doing what they were told.
15 In Margaret's comments about what I said about the
16 management development group, I think she was thinking
17 that I was saying there was a culture of fear and blame
18 at the management development group.
19 Q. Can we look at that? It is wit 89/44, paragraph 13. Is
20 that the passage?
21 A. Yes.
22 Q. What is your comment on that?
23 A. The management development group itself was an
24 opportunity for the managers to go every week to express
25 their delight that they did not happen to be in Margaret
0081
1 Maisey's spotlight in that particular week, so that
2 group was actually quite a supportive group for the
3 General Managers working within the Trust, because we
4 would come along every week with some sort of relief
5 that it was not our turn in that particular week to be
6 in Margaret's spotlight.
7 Q. When it was your turn to be in the spotlight, what was
8 the spotlight spotlighting?
9 A. It would involve all sorts of shouting and belittling
10 and undermining of people in public arenas, so that the
11 person themselves were left in no doubt as to what
12 spotlight they were in. It would also involve that --
13 I am not necessarily talking about myself, I am talking
14 about many other people within the Trust. It also
15 involved them being discussed with other managers in
16 other meetings but without them being present, so that
17 everybody knew who was "unpopular" at that particular
18 time.
19 Q. So if you were, for example, were to be spotlighted in
20 one of these meetings, you would be spotlighted in front
21 of other General Managers?
22 A. Yes, you would.
23 Q. So to what extent is it fair to say that when Mrs Maisey
24 here is referring to it being difficult to see how the
25 management development group sessions could be seen to
0082
1 be used to display a culture of fear and blame --
2 A. Yes, I think she is right. The management development
3 group was not an opportunity to perceive the culture of
4 fear and blame.
5 Q. So she is right about the particular instance?
6 A. Yes. I think she misunderstood what I was saying.
7 I was saying that the philosophies of the Chief
8 Executive were made particularly known through the
9 management development group and then I went on to say
10 there was a culture of fear and blame. It did not
11 follow on. Perhaps there should have been a new
12 paragraph there. It did not follow on from the comments
13 about the management development group.
14 Q. You say in your statement, still about Mrs Maisey,
15 page 32, at the foot of the page you refer to
16 Dr Roylance and as you saw it pushing back
17 responsibility to directors. Then you say, at the end
18 of the paragraph:
19 "I saw Mrs Maisey's role as controlling the
20 General Managers in order that Dr Roylance could get on
21 with other things."
22 A. Yes. I think that Margaret Maisey played a very
23 particular role for the Chief Executive. I think that
24 was her role. She herself, I think, on many occasions,
25 described herself as the Rottweiler of the Trust, so
0083
1 I think her own view was consistent with that.
2 Q. You may have seen in yesterday's transcript, if you
3 looked at it --
4 A. I am sorry, I have not had an opportunity to look at
5 Mrs Maisey's transcript from yesterday.
6 Q. Mrs Maisey was shown some articles from Private Eye.
7 I do not want to show them to you, but one of those
8 articles referred to Mrs Maisey as being Dr Roylance's
9 "sidekick".
10 A. Yes. Well I would agree with that, yes.
11 Q. Can we go back to Mrs Maisey's comments on your
12 statement at page 47?
13 She deals there with systems of appraisal. Let us
14 look at this paragraph:
15 "There were systems of appraisal in place in my
16 time as Unit General Manager [before the Trust]. There
17 was a system of annual objectives drawn up and agreed
18 with the next in line to each manager and approved and
19 countersigned by the superior."
20 She then says, essentially, that the pay for the
21 next year was performance related.
22 Then she says:
23 "There was a system of assessment of performance,
24 for example, used whilst we were preparing for the Trust
25 status and for clinical directorates", and the nurses
0084
1 had their own system.
2 To what extent, as an Associate General Manager
3 and later as a fully fledged General Manager in the
4 Trust, did you have such a system of appraisal in
5 respect of your performance?
6 A. I stated in my statement that there was no system of
7 appraisal in place within the Trust. That is obviously
8 incorrect. I apologise for that.
9 What I was getting to was, there was a system of
10 performance related pay and as at the time that I was
11 General Manager for the Eye Hospital, I benefitted from
12 that system. I think as an Associate General Manager,
13 I received an appraisal by the General Manager.
14 However, I think when the system of performance related
15 pay was withdrawn, there was no system for staff
16 performance and development review for General
17 Managers. I have not had a performance review since
18 I was an Associate General Manager working in the
19 Directorate of Surgery. So she is right to say there
20 were systems, but I do not believe there were systems
21 for General Managers and decisions made about General
22 Managers were not based on the results of information
23 that had come out of individual performance reviews.
24 Q. So that remains the case now?
25 A. Yes, although the Trust is influencing a system of
0085
1 individual development of the performance review at the
2 moment.
3 Q. Can I go back to page 46 --
4 A. I am sorry, just to qualify that, that was for General
5 Managers. There have been for a long time systems of
6 performance review for other staff within the Trust.
7 They have been in place for some time.
8 Q. Thank you. 46, the first new bullet point. This is
9 still Mrs Maisey's comments on your statement:
10 "There was every opportunity for staff to raise
11 any matter of concern of interest or of a personal
12 nature. Other than the complaints process, a procedural
13 system was not seen to be the way to handle the issues
14 described by Rachel ... My relationships with staff
15 were such that a number of staff not only brought to me
16 for discussion and advice their professional needs ...
17 but also their personal issues ..."
18 I think it follows from your evidence that you did
19 not perceive Mrs Maisey to be approachable from your
20 point of view in that way?
21 A. I need to clarify this. Mrs Maisey was not approachable
22 in terms of most areas. She was, and I know from other
23 staff, happy to talk to them about the sort of things
24 that she has mentioned there, some of the personal
25 issues, marriage, pregnancy, divorce and separation,
0086
1 that sort of thing, but I think because of the culture,
2 the way she worked and her personal style, if you had
3 a complaint or a problem that she thought was valid,
4 maybe she would think about it, but the opportunities
5 were not there. They certainly were not there if there
6 was a problem as there was with paediatric cardiac
7 surgery. There was no opportunity to talk to her about
8 that, because her philosophy was that she was not
9 interested or did not deal with things she did not agree
10 with, and therefore there was no way of actually taking
11 that further or discussing it.
12 Q. To the extent that you perceived a culture of fear and
13 blame, as you have put it, how did that manifest
14 itself? What effect did that have, for example on
15 staff?
16 A. The staff were frightened to raise their concerns.
17 Staff were watching to see -- were worried about the
18 ramifications for themselves, particularly amongst
19 General Managers; if they were not in favour, then they
20 were hardly likely to go and raise their matters of
21 concern with Mrs Maisey. They did not feel that they
22 would be heard.
23 I say this, I am not just necessarily talking for
24 myself, because as both Mrs Maisey and I have said, she
25 enjoyed challenge and she and I could discuss things on
0087
1 occasion, but there were occasions where, if you were
2 not in favour, then other staff certainly experienced
3 this, the possibility was not there to raise matters of
4 concern.
5 Q. When you say "other staff" you mean staff other than
6 people at your level of general management? Did this
7 culture of fear and blame, as you saw it, cascade
8 further down?
9 A. Yes, I think it did. I think it pervaded every aspect
10 of the organisation. I think the nursing staff were
11 terrified of her. The issue I have raised about dealing
12 with drug errors is a very key point. If you talk to
13 the nursing staff, they will tell you they were
14 terrified of Mrs Maisey finding out or being involved,
15 and that drug errors was one area where they came into
16 contact with Mrs Maisey.
17 Q. Did this culture, as you saw it, have an effect on staff
18 turnover? Did people leave?
19 A. No. I cannot recall the turnover figures for the Trust
20 and whether or not they compare very unfavourably with
21 other Trusts, but I think people tended to be committed
22 to the area that they were working within and their
23 loyalties lay to that area.
24 I mean, I do not really think I can answer that.
25 I do not know what the turnover figures were. I do not
0088
1 perceive that large groups of staff were leaving because
2 they were unhappy with the way Mrs Maisey had handled
3 them. I think what it did, though, was to create an
4 organisation where people were frightened to report
5 things, particularly with drug errors, and my
6 conversations with nurses support that. They were
7 frightened to report drug errors because they felt they
8 would be disciplined, and it did not give an opportunity
9 to review the systems that