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Daily transcripts
Hearing summary
22nd June 1999
Today the Inquiry heard from Mrs Fiona Thomas, Clinical Nurse Manager, United Bristol
Health Care NHS Trust (UBHT) who began by describing the layout of the Cardiac Surgery
Department during the late 1980s and early 1990s. She discussed the responsibilities of
her role set out in various job descriptions during the period of the Inquiry’s
investigation and commented on the implications for nurses of the change to Trust status.
She commented on discussions surrounding the under-spending of the cardiac surgical budget
and how that under-spend was used within the Directorate of Surgery. She contrasted the
role of the Nurse Advisor, Mrs Margaret Maisey, and the role of the new Director of
Nursing. Mrs Thomas then explained the change in the way drug errors are investigated
within the Directorate since 1994. She went on to outline the nurse staffing requirements
and the difficulties experienced recruiting trained paediatric nurses and theatre nurses.
She described the structure of Directorate meetings and commented on the issues discussed
and the role of Mr Dhasmana (Associate Clinical Director) and Mr James Wisheart (Medical
Director) at the meetings. She then confirmed that occupancy of beds by children in the
ITU was a problem for the consultants with adult patients, as the children needed a longer
stay in ITU post-operatively. She then went on to describe support for nursing staff and
the involvement of the Bristol Heart Circle in providing support for families of children
undergoing open-heart surgery. She concluded by discussing the communication styles of the
consultants on the ward.
This afternoon Sister Sheena Disley, Ward Sister, Ward 5B (Intensive Care and High
Dependency Unit) UBHT, gave evidence to the Inquiry. She commented on her job description,
her lines of accountability and her perception of the role of the Nurse Advisor, Margaret
Maisey. She described how issues of concern could be raised with clinical colleagues and
managers, and then went on to describe the professional relationships between surgeons,
intensivists and nursing staff. Sister Disley then described the counselling available to
staff on the ward and the pressures of breaking bad news to families and dealing with
stressful situations. She concluded by commenting on the split-site and the implications
for nursing care.
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FULL TRANSCRIPT
1 Day 32, 22nd June 1999
2 (9.30 am)
3 THE CHAIRMAN: Good morning everyone. Good morning,
4 Mr Maclean.
5 MR MACLEAN: Good morning, sir. Today's first witness is
6 Fiona Thomas. Perhaps she would make her way to the
7 witness's chair, please.
8 Before you get too comfortable, the first thing we
9 ask the witnesses to do is to stand to take the oath,
10 please.
11 MRS FIONA THOMAS (SWORN):
12 Examined by MR MACLEAN:
13 Q. Your full name is Fiona Vicki Thomas?
14 A. Yes.
15 Q. Can I ask you to look at the screen, please, at
16 WIT 114/1. That is the first page of the formal written
17 statement that you have made to the Inquiry?
18 A. Yes, it is.
19 Q. If we go to page 32, that is the last page?
20 A. Yes.
21 Q. And that is your signature towards the bottom?
22 A. Yes.
23 Q. You have also, I think, submitted as an annex to the
24 statement, if we go to page 33, and then over the page,
25 there is a document headed "Job profile" for the
0001
1 Clinical Nurse Manager in the Directorate of Surgery?
2 A. Yes, it is.
3 Q. Then, if we go over the page, this is the personal
4 specification for Clinical Nurse Manager in Cardiac
5 Services?
6 A. Yes.
7 Q. I think there are some other job descriptions between
8 pages 37 and 39, and then, if we go to 41 and 42, you
9 supplied two pages, 41 is the first one, and 42 the next
10 one, showing a layout of the cardiac unit at the BRI?
11 A. Yes.
12 Q. Those are the documents that you have supplied with your
13 statement?
14 A. Yes.
15 Q. Have you read your statement through recently?
16 A. Yes. Yesterday.
17 Q. Is there anything in it that you want to change or add
18 to, or subtract from?
19 A. No.
20 Q. I think you are now aware that there have been some
21 formal comments on your statement from some others?
22 A. Yes.
23 Q. I just mention who they are briefly and we may come
24 back to them in due course. At WIT 114/45, there are
25 some comments from Pat Fields. You have seen those?
0002
1 A. Yes.
2 Q. 46: some comments from Professor Angelini?
3 A. Yes.
4 Q. And I think this morning you have seen some comments
5 from Mr Dhasmana?
6 A. Yes.
7 Q. And from Mr Wisheart?
8 A. Yes. I have just read them through.
9 Q. We will come back to those. If we go back then to the
10 beginning, back to page 1 --
11 THE CHAIRMAN: Mr Maclean, I do not think we have seen
12 Mr Dhasmana's.
13 MR MACLEAN: We will not come to them until everybody
14 has seen them.
15 Back to WIT 114/1. You began your career at the
16 BRI in May 1986 as a Senior Staff Nurse?
17 A. Yes.
18 Q. You hold the Diploma in Nursing which you obtained,
19 I think, in 1990?
20 A. Yes.
21 Q. And your first promotion was after about two years,
22 was it not, when you became a G grade Sister?
23 A. Yes. I started working in the Bristol Royal Infirmary
24 in the May of 1986 and as a senior staff nurse and then
25 I undertook the G grade role when the unit expanded and
0003
1 that was in May 1988.
2 Q. That was about the time when there was an expansion of
3 the Intensive Care Unit?
4 A. Yes, it was.
5 Q. And there was some work done and new catheterisation
6 labs in the cardiological side at about the same time?
7 A. I do not know about the cardiological side. I was not
8 involved in that side at that time.
9 Q. Help us with the nomenclature of the G grade system.
10 That grading system was introduced when?
11 A. In the April of that year, just before I undertook this
12 post.
13 Q. And that led to all nurses everywhere having to be
14 enrolled into one of the new grades?
15 A. Yes. I was a staff nurse as the grading came in and
16 there was a lot of discussion about the grading issues
17 then, but I do remember I did start the Sister's job as
18 a G grade, as far as I can recall.
19 Q. You stayed in that job for about four and a half years?
20 A. Yes.
21 Q. And then became an acting Clinical Nurse Manager at
22 H grade?
23 A. Yes.
24 Q. Then eventually you took on that job full-time?
25 A. Yes. I took over for the first year while the previous
0004
1 nurse manager took maternity leave.
2 Q. You are now I think the Clinical Nurse Manager of the
3 whole Cardiac Services Directorate?
4 A. Yes.
5 Q. Embracing ward, theatre, surgery and cardiology?
6 A. Consisting of about eight areas.
7 Q. That is what you set out on page 2, if you go to page 2,
8 paragraph 6.
9 A. Yes, that is right. It is the theatres, Ward 5A, the
10 ward, 5B, which is the high dependency and the intensive
11 care, the cardiothoracic ward which joined the
12 Directorate last June, which is Ward 6. That is the
13 surgical side. Then I have the management of the
14 cardiological side which is Ward 20, coronary care unit,
15 and the nursing staff and the cardiology labs. There
16 also is another side section, of course, which is the
17 rehabilitation staff as well. I have two Sisters who
18 work the rehabilitation which covers both surgery and
19 the surgical side and the cardiological side.
20 Q. If we go to 41, please, it is not a terribly good
21 copy, but can you just help us with what time we are
22 now looking at, when this represented the layout of
23 level 6 at the BRI?
24 A. This was from when it was expanded initially in 1988.
25 Yes.
0005
1 Q. If we just run down what we have here, on the extreme
2 left-hand side we have first of all the cardiac
3 intensive care unit, have we not?
4 A. Yes.
5 Q. Next to that is the high dependency unit?
6 A. Yes.
7 Q. Then what has been titled "old nursery"?
8 A. Yes.
9 Q. That is where the children where cared for once they
10 were out of the intensive care unit?
11 A. Yes, they were. They were cared pre-surgery in there,
12 as well as post-surgery.
13 Q. And there are four spaces in there. We see the
14 numbers.
15 A. Yes.
16 Q. And there were -- is it 7 spaces in intensive care?
17 A. It is actually 7 in there with one side ward which makes
18 it 8.
19 Q. The side ward is at the very end?
20 A. The far end of the left-hand side, yes.
21 Q. Then there are various offices across the corridor?
22 A. Yes.
23 Q. I think if we run down those, from the left-hand side,
24 there is Mr Dhasmana's office, then the relatives' room;
25 is that right?
0006
1 A. At the very far left-hand side there is the stairs and
2 then the SHO's room, the Senior House Officer's room,
3 a rubbish room and Mr Dhasmana's room, the relatives'
4 room.
5 Q. The next one I cannot read.
6 A. That was a gas room. That was where blood results were
7 read, in that room.
8 Q. Then there is a staff room?
9 A. Yes.
10 Q. The secretary's office and then Mr Wisheart's office
11 which is next to the play room, a dining-room and
12 a relatives' kitchen area?
13 A. Yes. Well, the dining-room was quite a big dining-room
14 and at the very end we had -- the Heart Circle paid to
15 have that made into a kitchenette area so the children's
16 relatives could make drinks and actually make some food
17 there if they required it.
18 Q. This whole area covers both Wards 5A and 5B, we see from
19 the foot of the page?
20 A. I do not think 5A is all on this map. 5A goes up into
21 the right-hand corner.
22 Q. And that is the ward?
23 A. That is the ward, yes.
24 Q. And 5B would be the intensive care high dependency unit?
25 A. Yes.
0007
1 Q. And the writing at the top, round the corner, I think,
2 on the same floor, there were two rooms knows as Blaise
3 and Wiltshire?
4 A. Yes.
5 Q. Those were rooms where relatives could stay overnight?
6 A. Yes.
7 Q. While their friends or relatives were being treated?
8 A. It was used for the children's parents, so it was the
9 children's parents. We never used it for adult
10 relatives, we just used it for children's.
11 Q. I think the writing is a little difficult to read, but
12 there was also a property nearby, was there not, which
13 had five bedrooms in it?
14 A. That was 66 Horfield Road. I think that was jointly run
15 with the Children's Hospital and the Heart Circle and we
16 had five rooms or six rooms -- five bedrooms in there
17 where the parents were able to stay as well, which was
18 just literally up behind the back of the BRI.
19 Q. If we go over the page to 42, this shows the position
20 between 1992 and 1995.
21 A. Yes.
22 Q. If we look at the text on the right-hand side at the
23 top, Blaise and Wiltshire rooms continued as bedrooms
24 until the paediatric service transferred in October
25 1995?
0008
1 A. Yes.
2 Q. Then in October 1995 it was converted into offices?
3 A. Yes. I have put it in as "about 1992". 1992 is as far
4 as I can recall. Some of the rooms were moved,
5 changed.
6 Q. What is the important change? Is it that the nursery
7 is moved?
8 A. Yes, I think that is the important move: that the
9 nursery was moved to further up the ward, so it was in
10 the middle of the ward near the clinical rooms and near
11 the desk area and the telephones, probably. That was
12 another reason.
13 Q. So the nursery which was beside high dependency -- it
14 is not very easy to see.
15 A. No. It has moved up to where on the bottom right-hand
16 side -- that is it, that area there.
17 Q. The clinical room you referred to is just above that?
18 A. It is just opposite, yes, that is right, yes.
19 Q. And is there anything else of particular significance
20 that we should note and compare?
21 A. No, I think that was the main change while the children
22 were there. I think once the children left, then many
23 of the offices along the top were changed. I can go
24 through those if you wish me to go through those.
25 Q. In the first diagram, the first table we looked at in
0009
1 41, there was a room known as the relatives' room next
2 to Mr Dhasmana's office, as it happened?
3 A. Yes.
4 Q. Is that the room where, if there was any bad news to be
5 broken, it would tend to be broken?
6 A. Yes, it did, because it was just near the intensive
7 care unit.
8 Q. In the second map, the one we are looking at now, 42,
9 you have not actually given that room a title. Did it
10 maintain its previous use?
11 A. Yes, it is still in its present use even now today, as
12 a relatives' room.
13 Q. That is a room that is 8 square metres, the room fourth
14 from the left on the left-hand side?
15 A. Yes, that one, yes.
16 Q. Those are slightly difficult to read, but I think it
17 gives the Panel a helpful indication of what was where.
18 Is there anything else that I should be drawing out of
19 those two pages?
20 A. I suppose the only thing else was that the children's
21 nursery always had children's size bathroom facilities
22 with it. When we moved the nursery further up the ward,
23 we had to reallocate the children's bathroom and toilet
24 facilities so they were not actually en suite, but they
25 were near.
0010
1 Q. They were close by?
2 A. Yes.
3 Q. You have been a Clinical Nurse Manager since I think
4 November 1993, first of all of cardiac surgery alone and
5 then more recently the whole ambit of cardiac services?
6 A. Yes.
7 Q. If we go to 114/35, this specification for Clinical
8 Nurse Manager, cardiac services, H grade: is this the
9 one that would have applied to you once cardiac services
10 became a directorate in its own right?
11 A. Yes, it did. It continued.
12 Q. If we go to 37, this one is Clinical Nurse Manager,
13 cardiac surgery, so this one is the predecessor of the
14 one we have just looked at; is that right, because this
15 one only applies to cardiac surgery?
16 A. Can I just look in my statement? It might make it
17 a bit clearer, the order.
18 Q. If we go to 114/1 paragraph 5, the foot of the page,
19 you say, in paragraph 5:
20 "From November 1993 until December 1996, I was
21 Clinical Nurse Manager of cardiac surgery. There is
22 annexed to my statement a copy of the job description."
23 A. Yes.
24 Q. "From 1996 my responsibilities grew to include
25 cardiology".
0011
1 A. Yes, that is right.
2 Q. So I take it that the job description at 37 is the
3 one that applied up until 1996, because that is entitled
4 "Cardiac surgery", and then the one at 35 embraces
5 cardiology as well?
6 A. Yes. If you go back to the two job descriptions, I now
7 know which was the earlier one. That one I think was
8 the first one that I dealt with. Yes, I would agree,
9 yes.
10 Q. So the Inquiry is concerned primarily with events up
11 until 1995.
12 A. Yes.
13 Q. We appreciate your job has changed since then. It is
14 this one, therefore, that covers the period at the
15 latter end of the period that the Inquiry is concerned
16 with?
17 A. Yes.
18 Q. So can we just look at this one, then, a little bit?
19 You are responsible to the Inpatient Services
20 Manager, responsible for the cardiac surgery unit.
21 Actually this job description, if we look at page 39, is
22 dated at the very foot of the page there 1988.
23 A. Yes.
24 Q. So this job description --
25 A. This is why I am just slightly at a dilemma here,
0012
1 because I cannot quite remember whether there was the
2 one that I took over and the other one was the one that
3 was written at a slightly later stage. I mean, it was
4 all before 1995.
5 Q. This one is dated 1988.
6 A. Yes.
7 Q. That is obviously before Trusts?
8 A. Yes, it was before Trusts, yes.
9 Q. Before directorates?
10 A. Yes.
11 Q. To what extent did the bringing about of the directorate
12 system under the Trust alter the day-to-day life of
13 someone who was a Clinical Nurse Manager of cardiac
14 surgery?
15 A. I suppose initially probably just -- I mean I had always
16 had a budget so it did not affect the fact -- the budget
17 was still there. I suppose it affected the way the
18 contracts came into the unit and the fact that suddenly
19 we had to think of purchasers and contracts, but before
20 that -- we still cared for the patients. That probably
21 made no difference there.
22 Q. Obviously the patients were still coming in and you
23 still had the same procedures and so on, but was there
24 more or less administration when the Trust system came
25 in?
0013
1 A. I do not think it necessarily made any difference, I do
2 not think, initially. It is not as if on 1st April
3 suddenly I had a load more paperwork to do. That did
4 not happen. I think just with evolution it gradually
5 changed, for the role to be slightly different, to the
6 fact that one was having to look a lot more at where
7 contracts were coming from, and I think I also felt that
8 there was a great need for the nurses to know and
9 understand how systems had changed, from that angle, and
10 I think there may have been a lot more push on
11 finances -- I think there was.
12 Q. Because it was important to cost the service?
13 A. Yes.
14 Q. Was there more paperwork rather than less when the Trust
15 system came in, from a nurse's point of view?
16 A. I do not think there probably was. I do not think so.
17 Not initially, no.
18 Q. There was not much difference initially?
19 A. I do not think so.
20 Q. What about subsequently?
21 A. I think probably because I had to be a lot more careful
22 with the money, the budgets, I mean, in one way it was
23 slightly easier, because with purchasers you knew
24 exactly how many contracts you were going to have that
25 year, so in a way one could say it was easier to plan,
0014
1 I suppose from my angle, a nursing angle, because
2 depending on how many contracts came in we knew how many
3 beds we were going to need, so I could then work out
4 with the General Manager how many nurses we need to
5 manage that unit, so in one way it was slightly easier.
6 Q. Because it was more particular?
7 A. Yes.
8 Q. If we go in your statement, please, to WIT 114/3,
9 paragraph 14, and just look at the screen, this
10 paragraph deals with financial conflict, as you put it,
11 between cardiac surgery and other types of surgery in
12 the time before cardiac services were a separate
13 directorate?
14 A. Yes.
15 Q. Was it the impression that cardiac surgery was used
16 effectively to bail out other parts of the surgical
17 directorate?
18 A. That was my perception, yes.
19 Q. If we go to page 46, this is Professor Angelini's
20 comment on your statement. We will come to that in just
21 a moment, because he is actually dealing with the next
22 paragraph.
23 Before we go to that, can we just go to
24 Mr Wisheart's comment at WIT 114/47? It is the first
25 paragraph. Mr Wisheart says:
0015
1 "The subdirectorate of cardiac surgery became part
2 of the new Directorate of Cardiac Services in April
3 1994. It is true that while in the Directorate of
4 Surgery the underspend of cardiac surgery was sometimes
5 used to help with the overspend of other subdirectorates
6 within the Directorate of Surgery."
7 That is what you have just said?
8 A. Yes.
9 Q. "The irony is that when cardiac surgery moved to the
10 Directorate of Cardiac Services, certainly in the early
11 years, the cardiac surgery underspend was used to help
12 with the cardiology overspend."
13 Then he refers to Mrs Ferris's evidence, "So it
14 was not quite as simple as saying that cardiac surgery
15 had total control of its own resources."
16 Is that fair comment, in your opinion?
17 A. I agree with the beginning of it. I think whether the
18 directorate joined as a whole and we became
19 a directorate, I still feel that we were more in control
20 of the whole cardiac side, so at that stage I felt that
21 we were able then to use the money to benefit cardiac
22 surgery because I think with cardiology coming on line,
23 ultimately, that is the whole circle of care, the
24 patient coming in with cardiology could end up in
25 cardiac surgery. So I think what Mr Wisheart has
0016
1 written is true, but I think it seemed easier from where
2 I was to actually use money for what was to benefit the
3 patients, i.e. equipment at that time.
4 Q. So is it fair to say that to take money from cardiac
5 surgery to as it were bail out cardiology was something
6 that you did not mind so much because cardiac surgery
7 was going to get the benefit from an improved
8 cardiological surgery, albeit bailing out some of part
9 of the Directorate of Surgery would mean no benefit
10 would derive to your department? Is that what it comes
11 to?
12 A. Yes, I think that is how I probably felt about it, yes.
13 Q. It comes across I think from your statement that the
14 nurses in cardiac surgery, first of all, would see the
15 boundaries of their loyalty -- they saw themselves as
16 being part of which team? Did they owe their loyalty
17 principally to the Trust or the hospital, or their
18 unit? What was the --
19 A. To their unit, to the ward, and I still think they
20 probably do now to a degree. Their loyalty is to the
21 ward and to the team that they are working with.
22 I think that when we were part of surgery and we had
23 become a directorate, I do not think they probably
24 thought -- they knew they were part of surgery, but
25 probably their main emphasis was on the ward and getting
0017
1 things achieved in the area itself. I think people are
2 much more aware now that we are a directorate. When we
3 became a cardiac services directorate, people very much
4 then started to think a little more holistically from
5 a cardiac angle, and then it also developed a little bit
6 more when I became the nurse manager of the whole
7 directorate. I still think it was slightly split when
8 there were two nurse managers, one for cardiology and
9 one for surgery, so it was still fairly split. That is
10 why, when you talk about the cardiology side and the
11 underspend, I was not as clear of that as I am now, of
12 course.
13 Q. So can that be summarised by saying that the nurses on
14 the ward saw themselves more rationally as part of the
15 cardiac services team, once that directorate was
16 established, than they had previously done when they
17 were part of the Directorate of Surgery?
18 A. Yes, but I still think they very much are part of the
19 unit on Ward 5, wherever they are working.
20 Q. The system previously was, was it not, that nurses would
21 tend to spend a good deal of time in a single part of
22 the unit; is that right?
23 A. I am not quite sure what you mean.
24 Q. Is there more rotation now of nurses throughout the
25 cardiac services directorate than there was before?
0018
1 A. There is to a degree, yes. There is. I do try and
2 encourage nurses to move around and get experience in
3 other areas if they wish to, and a lot of nurses will
4 come and speak to a sister and say, "I would like a bit
5 of coronary care experience", and then we would look at
6 rotating them to another area, but often it would mean
7 that we have a sort of cross-fertilisation, really. We
8 need to have somebody from that area to come and swap
9 round because I do not have extra staff in all the
10 clinical areas, I just have to move them round, so I do
11 have to look at it quite carefully. So, yes, people do
12 rotate around as much as we can help.
13 If there are certain areas short on certain days,
14 then of course the Sisters will try and see if nurses
15 are free in certain areas and could rotate to that
16 ward.
17 So, yes, that is the case. But when you say
18 "rotate", I think the thing with nurses is that they
19 like to work in one area and to feel they belong to that
20 area and have the team atmospheres, that they become an
21 expert in that area. I am not keen on nurses moving
22 willy-nilly from area to area and actually having no
23 base.
24 Q. Your job now is to float a little above the different
25 sides of the directorate and take a view of the bigger
0019
1 picture?
2 A. Yes, definitely, yes.
3 Q. And is that a system that works well?
4 A. Yes. Yes, I think it does.
5 Q. So to have the single Clinical Nurse Manager who happens
6 to be you?
7 A. Yes.
8 Q. Was it an improvement?
9 A. When I was the Nurse Manager of surgery, and then there
10 was another Nurse Manager for cardiology, I found it
11 quite difficult because she would actually be asking me
12 for advice about her side and of course it was quite
13 difficult for me to get involved because I did not
14 really know the area.
15 When she left it was decided by the General
16 Manager and the Clinical Director that it would be
17 easier or it might be beneficial that I took over the
18 whole directorate. I think initially it was quite
19 daunting, the thought of having another 3 clinical
20 areas, but actually I think it was easier because I just
21 continued the same standards that I had already set or
22 which were set up in cardiac surgery over into
23 cardiology. So it was quite a serious challenge, but
24 I would say now, here two or three years later, we are
25 getting equal consistency throughout all my areas now.
0020
1 Q. Can we go to page 5, please, paragraph 21? You say:
2 "Since achieving Trust status, there have been
3 a much clearer chains of command and even more so since
4 we became a directorate in our own right after April
5 1994."
6 You worked in the BRI before Trusts. We have
7 dealt with that. You were a staff nurse and then
8 a sister?
9 A. Yes. Only in cardiac -- only in Ward 5.
10 Q. So are you able to compare like with like in the
11 pre Trust versus post Trust days?
12 A. I would find it quite difficult because I was
13 a staff ... I think as a sister, I cannot really recall
14 it being that much different, I do not think. I think
15 it is difficult to remember.
16 Q. You say there were clearer chains of command. As
17 a nurse manager, you would report in terms of managing
18 the unit to the Associate General Manager or the General
19 Manager of the directorate?
20 A. Yes.
21 Q. If we go to page 6, paragraph 23, you say:
22 "As a sister, I was involved in the clinical
23 aspects of care and had little to do with management.
24 I remember there being very little communication from
25 the Director of Nursing."
0021
1 You do not recall Julia Thomas, who was a Nurse
2 Manager, telling you that she was having any meetings
3 with the Trust's Chief Nursing Adviser.
4 The Trust's Chief Nursing Adviser was Mrs Maisey,
5 was it not?
6 A. Yes, I think it was, yes.
7 Q. What was her role, as far as you were concerned, after
8 the Trust was established when she was Director of
9 Operations and Nurse Adviser?
10 A. In the statement, in paragraph 24, I have put there that
11 I was aware of the Trust Nursing Advisory Committee
12 meetings, so I was aware that they went on. But
13 I actually did not attend those. Sue Harris, the Nurse
14 Manager of the other part of the directorate, she
15 attended those.
16 As far as I was concerned, my line of command, my
17 responsibility was to the Associate General Manager and
18 then to the General Manager, and to the associate
19 Clinical Directors or the Clinical Director. And we
20 were very much kept in that sort of remit. We did not
21 really need to go elsewhere, apart from certain bits and
22 pieces, so there was very little time I needed to
23 actually think that I needed to have a Director of
24 Nursing at that time, because it was not there when
25 I took over as Nurse Manager. It was not something that
0022
1 I thought about. There were no meetings that
2 I attended. As I said, the other Nurse Manager attended
3 those.
4 Q. There is a Nurse Manager now, a Director of Nursing now,
5 Mrs Maisey took on that title latterly, and now there is
6 a Director of Nursing?
7 A. Yes.
8 Q. In paragraph 23, do I detect an element of regret or
9 disappointment, that what you are saying is that there
10 could have been more communication from the Director of
11 Nursing?
12 A. There could have been, but I think at that time
13 Mrs Maisey's job was not actually pure Director of
14 Nursing, it was a very different role than the Director
15 of Nursing we have now.
16 Q. That is what I am trying to explore. I am not attacking
17 Mrs Maisey, I am trying to find out whether there was
18 something that she or somebody else could have been
19 doing which was not being done which you felt ought to
20 have been done.
21 A. I did feel at times that I did not know, from a nursing
22 angle, where nursing was going, sometimes, and I did not
23 know where, for instance -- I mean, I have to look at an
24 example, unlike today, for instance, at the moment, with
25 looking at nurse documentation, I am looking at nurse
0023
1 documentation now generally in the unit and having to
2 think about what we should be doing and where we should
3 be going, so I was able to talk to the present Director
4 of Nursing for advice, whereas I think previously it may
5 have been difficult to know who you talk to people for
6 advice. I mean, if I needed advice I could have gone
7 and seen the Director of Nursing, Mrs Maisey.
8 Q. You said there you have to look at an example, like,
9 today, for instance.
10 A. Yes. Clear pathways, we are looking at that, for
11 instance. And I have been to see the present Director
12 of Nursing about that. I suppose if there was a big
13 topic like that several years ago, if I would have
14 needed to, then I could have gone and seen Mrs Maisey
15 and talked to her about it.
16 Q. So there has been more strategic direction feeding down
17 through the nursing system in the Trust? Is that what
18 you are saying?
19 A. Yes, there could have been, but at that time I cannot
20 recall what there was around, compared to today.
21 Q. In your statement at paragraph 57, page 13, you say that
22 Margaret Maisey had a strict disciplinary approach to
23 drug errors. You recall some drug errors in 1992 and
24 1993 concerned with syringe pumps getting air into
25 them. You went to Pat Fields, a nursing adviser for
0024
1 surgery, and she considered the drug errors fairly
2 serious. And they were very serious, were they not?
3 A. Yes.
4 Q. It is very serious to get air into syringe pumps?
5 A. Yes.
6 Q. So there is no criticism there of Pat Fields,
7 considering the drug errors to be serious?
8 A. No, not at all, no.
9 Q. There was then formal disciplinary procedures instituted
10 and I get the impression that the nurses rather got the
11 blame initially?
12 A. I think there was a culture that nurses did tend to take
13 the blame for drug errors.
14 Q. Take the blame, or be given the blame?
15 A. Probably both. The nurses themselves took the blame
16 because they have pride in their position and their job,
17 and I think they do tend to take the blame, but I think
18 they were also probably given the blame.
19 I think may be, okay, this may not have been
20 worded quite as well as I probably could do it now, on
21 reflection, but I think what I was trying to look at, or
22 trying to get over was that Margaret Maisey had quite
23 a disciplinary approach towards some procedures.
24 Q. She was seen as being authoritarian on drug errors?
25 A. Yes. I am not saying there was a disciplinary approach
0025
1 to all drug errors, I am not saying that, I am just
2 saying there was a very formal approach to drug errors
3 and as I recall, at the same time as I took over as
4 manager there were some drug errors. This is a long
5 time ago and I am having to rethink to remember some of
6 them. I do remember this specific issue about syringe
7 pumps because it was a big issue with syringe pumps and
8 there was also the financial aspect of it as well, so
9 there were two things, really.
10 With this particular incident, what I had to do
11 was to ask Pat Fields for advice, because she was my
12 Nurse Adviser, and I would have discussed it with the
13 Associate General Manager as well. Asked Pat Fields for
14 advice, who would have said "You need to do an
15 investigation". As soon as you start doing
16 investigations it becomes a fairly formal process, and
17 I think that is what I used to consider, and the nurses
18 used to consider, that the formal process was like
19 a disciplinary process and that is how we looked upon it
20 at that stage. That is my perception and that is what
21 I would say the nurses' perception was. We would then
22 go on to investigate it formally from, you know, written
23 statements. We would then go back to Pat Fields and
24 discuss with Pat Fields the issue, and then it was up to
25 Pat Fields to decide what happened then, basically.
0026
1 Q. I think you have had a chance to see Mrs Ferris's
2 evidence to the Inquiry?
3 A. Yes.
4 Q. She says in her evidence that you spoke to her about
5 drug errors and you and Mrs Ferris between you decided
6 not to handle drug errors through the formal process in
7 the way that they had been before?
8 A. What was happening when these -- because the consequence
9 of this syringe pump and air getting into it was
10 actually nothing to do with the nurses at the end of the
11 day, it was to do with the syringe pumps malfunctioning
12 so of course we had gone through a lot of problems and
13 a lot of bad feeling, bad morale caused by all these
14 investigations going on. It was finance and it was the
15 syringe pumps -- I am sorry, I have forgotten what you
16 asked me then.
17 Q. Let us take it in stages. Mrs Ferris said that you and
18 she decided when she became General Manager not to deal
19 with drug errors in the same formal way as they had been
20 before. That is right, is it?
21 A. I remember discussing them with Mrs Ferris when one
22 occurred and I think she would probably say, "Well, what
23 in your opinion should we be doing?" You have to
24 consider then I had been a Nurse Manager for a year or
25 so and I had had quite a lot of experience with dealing
0027
1 with quite a few drug errors. So I still used to talk
2 to Pat Fields, I still remember talking to Pat Fields
3 about it, but not necessarily writing down a great
4 lengthy description to her, but I do remember discussing
5 with her still, and then Rachel and I would just take
6 a slightly different approach with myself and one of the
7 Sisters from a clinical area, whichever area it was,
8 discussing with the nurses what had actually happened.
9 Q. So it was less formal?
10 A. It was less formal, but it was still treated very
11 seriously and the nurses were interviewed by myself and
12 one of the Sisters regarding what had actually
13 happened. My main emphasis at the time then, because
14 the nurses who had been involved in the drug error
15 potentially causing harm to a patient, was that I felt
16 it was important to be seen to be actually looking and
17 maybe looking at, was there a problem, because if a drug
18 error happens, there is usually a problem somewhere.
19 Either the nurse is training or there is a systems
20 failure. It is either one or the other.
21 Q. Or the syringe pumps did not work?
22 A. Yes, or the equipment does not work.
23 Q. Do we then take it that the approach to drug errors that
24 you were referring to in the paragraph meant that
25 Mrs Maisey presented a forbidding and perhaps slightly
0028
1 hostile exterior to nurses who found themselves involved
2 in a drug error episode. Would that be fair?
3 A. I think nurses were very frightened of the fact that if
4 they were involved with a drug error, that they could be
5 disciplined, yes.
6 Q. Mrs Ferris said, at I think page 87 of her evidence in
7 the transcript, that the nursing staff were "terrified"
8 of Mrs Maisey.
9 A. I think Mrs Maisey's reputation probably terrified
10 them. I do not think many of them had ever met
11 Mrs Maisey, but I think it was the reputation that went
12 before her.
13 Q. How did that reputation filter to the nurses if they had
14 never actually met her in the flesh?
15 A. I do not know.
16 Q. Just on the grapevine?
17 A. I think it just goes on the grapevine.
18 Q. So would it follow from that, to the extent that
19 Mrs Maisey was the senior nurse in the Trust who was one
20 of the ears who would potentially be available to listen
21 to nurses with professional concerns or complaints, that
22 it would be unlikely that these nurses, frightened as
23 they were of her reputation, would go knocking on her
24 door and bring to her their concerns?
25 A. Yes. I think it would be very difficult for a nurse to
0029
1 go and talk to her.
2 Q. I do not want to go into particular drug errors in great
3 detail, but do you remember whose syringes they were,
4 who they came from?
5 A. The syringe pumps came from cardiac surgery.
6 Q. Who manufactured the faulty pumps?
7 A. No, I cannot recall at this particular moment.
8 I probably will be able to in a little while.
9 Q. If we go over the page to page 14, you say it later
10 transpired that the errors were due to syringe pumps
11 which were old and had failed. How did that come
12 about? Was that not something that could have been
13 picked up earlier?
14 A. It probably could have been picked up earlier. I mean,
15 equipment in the early time, a lot of equipment, when
16 I remember taking over, when I was a sister and an early
17 Nurse Manager, equipment was bought and donated by the
18 Heart Circle, which was very generous of them. They
19 used to buy a lot of equipment, but there was not
20 necessarily any consistency in the equipment that was
21 bought. It just tended to be what was on offer at the
22 best time, at that time. You know, reps could come in
23 and say "I have a syringe pump at this price", and that
24 is how we had it.
25 So we had quite a mixture, but, I mean, there was
0030
1 only a couple of companies that made them. I do not
2 think there was any particular programme on how old
3 certain equipment was, whereas nowadays one would say
4 most medical equipment, you should not be using it after
5 it has been used for ten years. So nowadays, I am
6 keeping an eye on how old some of our equipment is. But
7 I think in those days, I do not think we probably were
8 looking at it from that sort of angle. I mean, I think
9 just as technology has advanced and how we are using
10 more equipment today. We are having to look at that
11 continuously.
12 Q. If we go to page 45, please, and then we will leave the
13 syringe pumps. This is Pat Fields' comments. She does
14 not recall the particular incidents as being subject to
15 disciplinary process in the formal sense, which she
16 would appear to define as being involvement with the
17 union rep and personnel.
18 It is right they would not be involved?
19 A. I do recall one drug incident actually going, and it was
20 very formal and it was held in the faculty room with one
21 of the Sisters from one of the clinical areas. I do
22 recall her having her union rep. I cannot remember
23 whether that was to do with syringe pumps or not;
24 I cannot remember. But I do remember one occasion we
25 did get to that stage.
0031
1 I mean, I just perceived it as slightly different
2 than Pat Fields perceived it differently, but that is
3 just the perception I had and the nurses had in the
4 clinical area.
5 Q. Pat Fields says she does not agree -- the middle of the
6 second paragraph: "... that the nurses were disciplined
7 in any formal sense although information was gathered in
8 a proper way by way of formal statements to ascertain
9 what had happened."
10 A. Yes.
11 Q. Is it that the nurses perceived the very gathering of
12 those statements as being a formal disciplinary process,
13 even if it did not lead in the end to a letter saying
14 "You have been given a warning"?
15 A. That is right. For nurses to start writing things down,
16 nurses are not used to having to write a lot of things
17 down, apart from patient care. When they start having
18 to do this, it is formal statements, then I think that
19 is when they considered it was starting a disciplinary
20 procedure, even though Pat Fields says it is not. That
21 is fine, that is her perception of it. In the clinical
22 area, it is a different perception.
23 Q. So that is a reconciliation between what she says which
24 is accurate and what you have said is accurate but from
25 a different perspective?
0032
1 A. Absolutely, yes.
2 Q. Is it your view that there has been a bolstering now of
3 the professional accountability line for nurses in the
4 Trust? It was something that Mr Baird said in his
5 evidence, page 107. Is that your perception?
6 A. Would you just repeat that again, sorry?
7 Q. Mr Baird said there had been a bolstering of the
8 professional accountability line for nurses at the
9 Trust, a specified Director of Nursing on the Board,
10 and so on.
11 A. I would agree. I think there is a very clear line.
12 I mean, I have almost like two lines of command now.
13 I sort of have Rachel Ferris and Peter Wilde, the
14 Director and General Manager, and then I also have the
15 other line up to Lindsay Scott.
16 Q. Who is the --
17 A. Who is the Director of Nursing; and there is also an
18 Associate Director of Nursing as well, an Assistant
19 Director of Nursing, if Lindsay Scott is not around.
20 So I think it is well sorted at the moment.
21 Q. If we go to page 8 of your statement, please,
22 paragraph 34 -- let us go to 33, first of all. You are
23 referring to monthly meetings after the Trust was
24 formed, attended by surgeons, anaesthetists and
25 professions allied to medicine. The Associate Clinical
0033
1 Director in the first instance was Mr Wisheart and
2 Lesley Salmon was the Associate General Manager. We
3 heard from her yesterday.
4 A. Yes.
5 Q. You said you found the meetings difficult and you felt
6 unable to raise issues. There was conflict between the
7 surgeons and the anaesthetists.
8 What was that conflict about?
9 A. The meetings were quite difficult. They were held at
10 5.30, at the end of the day, so everybody worked all day
11 and then you went to this meeting at the end of the
12 day. It was chaired by the Associate Clinical Director,
13 John Wisheart, and there was Lesley Salmon, the
14 Associate General Manager, and at some stages there was
15 the General Manager as well, who was Janet Maher. She
16 was there on other occasions as well. I found the
17 meetings difficult. I was quite junior and it was quite
18 daunting being in a room with 20 consultants. So it was
19 quite daunting. I do remember -- I mean, I have seen
20 some of the minutes of the meetings and I did raise some
21 issues if I felt able to. There was conflict at the
22 meetings. It is quite a while ago.
23 One thing that I do recall was to do with the
24 intensivist role. There was quite a lot of discussion
25 about the intensivist role. There was also a lot of
0034
1 discussion about theatres finishing late and theatre
2 staffing levels. There was a lot of discussion about
3 theatres, a lot of times.
4 Q. Was the conflict about theatres finishing late
5 because -- obviously people wanted to get home and did
6 not want to be at work all the time. Was it about that
7 or was it about concerns being raised that the patients
8 were suffering because operations were going on too
9 long?
10 A. I think both. Both. We had trouble recruiting staff to
11 theatres, even in those days. We still have problems
12 now. A lot of it was because people did not finish at
13 5 o'clock or 6 o'clock, they ended up staying late so if
14 you had social arrangements in the evening you could not
15 go. That restricted people from coming to join the
16 department, as well as, I think maybe operations did
17 take longer than we had expected, basically.
18 Q. That happened frequently, did it?
19 A. I would not say it happened frequently. It happened.
20 Q. Regularly?
21 A. Well, it happened every week.
22 Q. Every week?
23 A. Yes.
24 Q. You have told us about the theatre finishing time, and
25 you mentioned the conflict over the intensivist's role.
0035
1 Was that a struggle, essentially, for who would be in
2 charge of the patient post-operatively? Is that what
3 that was about?
4 A. Yes, it was, because at that time there were surgeons
5 who would care for their patients predominantly in the
6 intensive care unit and then the anaesthetist would come
7 in as well and give their input as well, give their
8 clinical knowledge, and there were various different
9 anaesthetists and of course just one surgeon, and
10 I think there was a view that the management of the
11 patients in intensive care could be managed better if
12 there was one person in that day managing the care of
13 any patient. I think this is why the intensivist role
14 was suggested and other units in the country had
15 different management of patients and in the intensive
16 care unit and I think there were some consultants,
17 probably anaesthetists who had come from other areas
18 were bringing in ideas to look at maybe to have one
19 person in charge, yes.
20 Q. And the anaesthetists thought that the person in overall
21 charge should be an intensivist?
22 A. Yes. I do not know whether they were looking at taking
23 over completely; I think they were looking at working
24 with the surgeon.
25 Q. Being given a greater role than previously because they
0036
1 had been seen as subservient to the surgeons?
2 A. No, I do not think they were seen as subservient to the
3 surgeons, no. I think it was just to try and look at
4 a standardised approach of care for that patient, say
5 for that day, whereas if you had different doctors
6 coming in and changing things as the day went on, it
7 would not be as beneficial to the patient as if you had
8 one person coming in and looking after the patient for
9 that whole day.
10 Q. Did this conflict between surgeons and anaesthetists
11 ever focus on the treatment of children as opposed to
12 patients in general? Was that an area of conflict?
13 A. I think like doctors do, they can disagree with
14 a pathway of care, and I think there were times when
15 anaesthetists and surgeons disagreed with care and
16 management of children, whether it was a drug therapy or
17 what it was.
18 Q. What were the areas of debate and concern with children?
19 A. I do remember them being there, having great debates
20 over changing drugs, changing drug therapies, because
21 a tiny change of a drug therapy to a child is an
22 absolute major change and it could have a major affect
23 on the child, but often they did that together for
24 support and to get the best care for that child in
25 a way, so there were two angles really to that. One was
0037
1 to get the best care for the child and at other times
2 they may disagree with each other.
3 Q. If we look at paragraph 34, which I mentioned a moment
4 ago, do I take from that that the conflict in your view
5 was more marked than it might have been because of the
6 way in which the meetings were chaired, that it was not
7 nipped in the bud as well as it might have been?
8 A. It might have been, but I do not know because in
9 a way -- those meetings were the only times when I think
10 a group of people got together to discuss and debate
11 a situation and it was probably the only time that
12 everybody could air their view at that time. I think
13 Mr Dhasmana just probably found it quite difficult to
14 stop discussion -- you know, when was it debate, when
15 was it the right time to stop the debate.
16 Q. Mr Dhasmana, you say, was not quite sure when to stop
17 people from talking and how to stop arguments, so
18 Mr Wisheart stepped into the breach, usually, was how
19 you put it. Why was it Mr Wisheart as opposed to anyone
20 else who should have ended up chairing the meetings?
21 A. Because he had been the previous Associate Clinical
22 Director, and I think he also had those skills and
23 I think Mr Dhasmana had worked with him for a long time
24 and often looked to him for support.
25 Q. If we look at WIT 114/48, paragraph 4, these are
0038
1 Mr Wisheart's comments on your statement. He says:
2 "I cannot recall any occasion when I took over
3 a meeting chaired by Mr Dhasmana. I may have tried to
4 resolve some disagreements."
5 So Mr Wisheart is suggesting that it was his role,
6 he would take on the role, of trying to reach
7 a consensus.
8 Was that your impression?
9 A. Yes, I think it was.
10 Q. I think Mr Dhasmana has used the expression -- we will
11 see this -- that Mr Wisheart did not take over as
12 Chairman but tried to play an "elder statesman's" role
13 in order to resolve differing views after a prolonged
14 discussion." Is that fair comment?
15 A. Yes.
16 Q. That Mr Wisheart was seen, certainly by Mr Dhasmana, as
17 the "elder statesman", the wise counsel of these
18 meetings?
19 A. Yes. He had done the job before and had the
20 experience.
21 Q. Moving to something else, the nursing ratio in intensive
22 care at the end of the period when children were there,
23 let us take that period, was what, in intensive care?
24 A. In intensive care, it was one nurse per patient.
25 Q. And the way that it works is that in order to work out
0039
1 how many staff you need to staff the unit as a whole, we
2 have this concept of whole-time equivalents?
3 A. Yes, that is right.
4 Q. Because obviously it cannot be the same nurse all the
5 time?
6 A. Yes.
7 Q. What was the whole-time equivalent ratio?
8 A. One is about 5.4 full-time equivalents per intensive
9 care bed, is actually what Ward 5 -- that is what
10 I inherited when I took over, so roundabout 5 and
11 a half.
12 Q. When you took over in 1993?
13 A. 1993, yes. I do a slightly different formula now, it is
14 slightly different, but that is what --
15 MRS HOWARD: Mr Maclean, can I just interrupt for a moment
16 and ask, is that whole-time equivalent for adults, or
17 was that inclusive of the total in the intensive care
18 unit?
19 A. For the intensive care unit.
20 MR MACLEAN: I hope this reference is right. Let us go to
21 page 17, first, of your statement. You say there, at
22 the foot of the page, new professional organisations
23 have been set up, namely the British Association of
24 Critical Care Nursing and the British Cardiac Society.
25 Are you familiar with the national standards for
0040
1 nursing ratios that have been published by some of these
2 national bodies?
3 A. The Intensive Care Society, yes.
4 Q. If we go to WIT 60/11, please, this is the Paediatric
5 Intensive Care Society standards for paediatric
6 intensive care.
7 If we go to page 15, if we scan down, I hope
8 there is a heading which says "Paediatric intensive
9 care."
10 "Apart from infants who undergo treatment in
11 a neonatal intensive care unit children who become
12 critically ill at any time between birth and adolescence
13 require the facilities of a paediatric intensive care
14 unit."
15 This is in the 1990s, this document.
16 If we go to page 18 and at the foot of the page --
17 I will get you the exact date of this, but as I recall,
18 it is 1992 or 1993. I think it is 1993.
19 "It is essential that there is a senior nurse with
20 several years experience of paediatric intensive care in
21 charge of the unit ... a minimum of one trained nurse to
22 one patient is usually required throughout the entire
23 24 hour period. Flexibility of resources and staff is
24 required in order to provide optimum care of the
25 patients according to their needs. To establish the
0041
1 appropriate nurse/patient ratio, clinical classification
2 scores 'dependency categories' can be used."
3 If we go over the page to 19 and go to the foot of
4 the page, "Additional factors influencing nurse
5 establishment":
6 "When calculating nursing establishment, it is
7 also necessary to make allowances for staff handover
8 time, holidays, sickness and study leave ..."
9 The conclusion, to cut a long story short, is that
10 the bedside establishment is recommended as being 6.4
11 whole time equivalents to 1, to cover any 24 hour
12 period.
13 The next paragraph qualifies that and says it
14 might have to be higher in certain circumstances?
15 A. Yes.
16 Q. I think Dr Ratcliffe, who gave evidence on March 25th,
17 as long ago as that, said at page 152 of her evidence
18 that that ratio, 6.4 to 1, has been endorsed by the
19 Paediatric Intensive Care Society and I think holds good
20 today.
21 So that is the ratio that was never achieved?
22 A. No, but this is for paediatrics. You have to remember
23 that the unit was a mixed unit. That is why when
24 I answered the question it was 5.4 for the whole
25 intensive care unit, because of course there were
0042
1 8 beds, not necessarily 8 beds would have been
2 a patient, at this stage when we are talking, who would
3 be ventilated and may be considered an intensive care
4 patient.
5 Q. I appreciate of course it was a mixed unit and
6 I appreciate the standards are paediatric standards. Is
7 it therefore the case, is it your evidence, that for the
8 children who were in intensive care in the mixed unit,
9 they did receive that correct ratio of nurses?
10 A. They always received one nurse per patient every single
11 shift. If the patient was more dependent, which
12 sometimes they were and they needed two nurses per
13 shift, then another nurse would have worked with that
14 nurse.
15 Q. There were four, were there, paediatric intensive care
16 cases in the intensive care unit?
17 A. Well, actually, there were 8 beds. Any of those beds
18 could have been used for children, depending on their
19 need.
20 Q. If we go to page 22 of your statement, paragraph 92, at
21 the foot of the paragraph -- I am conscious of what goes
22 above it and I will come back to that:
23 "There were only two paediatric nurses permanently
24 on our staff."
25 Does that mean two paediatrically trained nurses
0043
1 per shift, or only two in total?
2 A. There were two who had RSCN in the total staff.
3 Q. So they may or may not have been on any particular
4 shift?
5 A. Yes, that is right, but there was one who was the
6 F grade who worked in both the intensive care unit and
7 the ward area, and the other RSCN worked in the
8 nursery. She was based in the nursery, but there were
9 intensive care nurses who had undertaken paediatric
10 courses but they were not necessarily an RSCN.
11 I remember recalling one nurse going to Great Ormond
12 Street for a short course of, I do not know, four weeks
13 or something over a period of time, and there was
14 another nurse who went to Southampton and did another
15 course, so there were other nurses who had done extra
16 paediatric adaptations to their training.
17 Q. And there were some people that came in from elsewhere,
18 as you referred to earlier in the paragraph?
19 A. There were, but predominantly we were looking at nurses
20 who were intensive care trained, I mean in adults.
21 Q. If the intensive care unit had been a dedicated
22 paediatric intensive care unit, only for children, how
23 many of the nurses in the 6.4 whole-time equivalent
24 ratio that was recommended would have been registered
25 sick children's nurses, would you have expected?
0044
1 A. If it was a pure paediatric unit?
2 Q. Yes.
3 A. But if it was a pure paediatric unit, it would have been
4 at a Children's Hospital.
5 Q. I know.
6 A. I probably cannot answer that because I do not know.
7 I do not think I would know, because I do not know what
8 the staffing situation would have been like for
9 a paediatric hospital paediatric intensive care unit.
10 Q. If you were put in charge for the day of a paediatric
11 intensive care unit, and somebody said to you, "What is
12 the whole-time equivalent ratio for nurse staffing?" you
13 would know that the answer was 6.4, that is the
14 recommendation; yes?
15 A. Yes.
16 Q. If somebody said to you, I appreciate you have not been
17 the Nurse Manager of a dedicated paediatric intensive
18 care unit before, but "How many of the 6.4 whole time
19 equivalents would you expect to be registered sick
20 children's nurses, in an ideal world?" what would your
21 answer be?
22 A. All of them.
23 Q. 6.4?
24 A. In an ideal world, yes.
25 Q. Now there is a dedicated paediatric intensive care unit
0045
1 in the Children's Hospital, are you able to help us with
2 what percentage of the total nursing staff there are
3 registered children's nurses?
4 A. I would assume they all were, but I would not be able to
5 tell you exactly. I would just assume it.
6 MR MACLEAN: Thank you. Sir, is it a convenient moment for
7 a short break?
8 THE CHAIRMAN: Yes. Thank you, Mr Maclean. Shall we break
9 now and return at 11 o'clock?
10 (10.47 am)
11 (A short break)
12 (11.00 am)
13 MR MACLEAN: We were dealing with the nursing ratios
14 and so on just before the break. Was there ever any
15 concerted effort made before the paediatric open heart
16 surgery went to the Children's Hospital to increase the
17 number of registered sick children's nurses working in
18 the BRI intensive care unit?
19 A. We tried several times to attract children's trained
20 nurses to the BRI by many adverts, advertising
21 nationally, but what it came down to basically was that
22 the children's nurses did not want to work in a unit
23 where there were adults. If there were times when there
24 were no children in the intensive care unit they may
25 have had to have looked after an adult and of course
0046
1 their philosophy is very different. They do not want to
2 work with adults, they want to work with children.
3 So we tried really hard to attract them. The
4 F grade that actually I would have considered our first
5 RSCN, we actually seconded her to go and do a paediatric
6 course and then she returned to Ward 5. The second one,
7 it was just an absolute added bonus, hence we did try
8 and encourage nurses to go off to other units to do
9 training, shortened courses.
10 So we tried everything I think we possibly could
11 have tried at that time.
12 Q. Was there a national surplus or deficit of registered
13 sick children's nurses?
14 A. I think there was a deficit. From what I remember from
15 talking to people at the Children's Hospital, they also
16 found it difficult to attract RSCNs with intensive care
17 experience into their intensive care unit. So with the
18 cardiac intensive care unit, what we were trying to look
19 at was trying to have lots of nurses who had done an
20 intensive care course and had intensive care
21 experience. That is the standard that we were trying to
22 achieve there. If we had an RSCN, that was just an
23 added bonus, which was excellent.
24 Q. You told us just before the break about the 8 beds in
25 intensive care and if I understood you correctly, some,
0047
1 none or all of those beds might be occupied at any one
2 time by adults or by children?
3 A. It was rare. I do not think I have ever seen it full
4 with 8 children in there. I think probably the most
5 I probably recall may be 5.
6 Q. Children would typically spend longer in intensive care
7 than would adults, post-operatively?
8 A. Yes, they did.
9 Q. So it could be the case, could it not, that there would
10 be adults ready, willing and able to have their
11 operations, but no available space in intensive care to
12 house them after the operation?
13 A. Yes. It is the same situation as there is today, yes:
14 lack of beds, basically, in the intensive care unit.
15 Patients are not well enough to move through as we would
16 have necessarily planned, yes.
17 Q. So there is always a demand for particularly adults to
18 have surgery, and one of the bottlenecks is to be found
19 in intensive care?
20 A. Yes.
21 Q. But that bottleneck would be more marked, more profound
22 in the days when there were children in the intensive
23 care because they would be there for longer?
24 A. Yes, and you could have three or four beds blocked for
25 a longer period of time because they were not moving
0048
1 through, yes.
2 Q. So that led to some tension, did it?
3 A. Yes, it did, yes.
4 Q. Do not take it from me, let us take it from your
5 statement. If we go to 114/29, paragraph 121, you see
6 in the third line you say:
7 "Some surgeons complained at times if there was
8 a shortage of beds for adult cases as children were
9 staying in ITU and blocking beds."
10 Which surgeons would voice that kind of concern?
11 A. The surgeons that needed the adult patients and the
12 other thing is that all surgeons have certain operating
13 slots; they only have a few operating slots per week,
14 I do not know, 5 sessions maybe or something a week, so
15 if some surgeons operated the day after they operated on
16 children, then they may find they did not have any
17 beds. It is not actually that much different than
18 today, where come Thursday and Friday and we have
19 operated all week you may be short of beds.
20 Q. But you would get through more patients now without
21 children than you would have done with the children,
22 because the adults spend less time?
23 A. You would expect so, but with patients, some adults are
24 very sick as well and you need a longer length of time
25 in intensive care as well.
0049
1 Q. Let us just go back to that paragraph in the third
2 line. The surgeons who would be complaining, we come
3 back to it in the last sentence, "The conflict between
4 the adults surgeons and the paediatric surgeons."
5 The paediatric surgeons I assume were Mr Dhasmana
6 and Mr Wisheart and the adults' surgeons were
7 Mr Hutter --
8 A. Mr Hutter and Mr Bryan and Professor Angelini. I mean,
9 I cannot recall whether Mr Bryan was there when the
10 children were there or not, I am not sure about the
11 dates, but, yes. And also Mr Keen at some stage,
12 because he was there. But then that is conflict that
13 happened then, and it stills happens to some degree now,
14 with beds.
15 Q. Was there ever any pressure that you could detect to
16 do fewer operations on children in order to increase the
17 number of adults who were provided with surgery?
18 A. No. I think we would then go to look at an expansion
19 programme. I think if there was an expansion in
20 contracts, then we would say "We need to look at
21 expansion within the department". So, no, there was
22 not, unless it was a planned expansion.
23 Q. The expansion that took place in the early 1990s was an
24 expansion of adult operations -- I think we saw this
25 with Mr Nix: there were 150 paediatric operations and
0050
1 after the expansion it was still planned to be 150
2 paediatric operations, but there had been an increase in
3 adult operations?
4 A. Yes.
5 Q. So would it be right to say that the focus of expansion
6 of the cardiac unit was on adult work rather than
7 paediatric work?
8 A. If Mr Nix said that the contracts were increased,
9 I would have to agree with that. I would not
10 necessarily know, to be honest, from my angle, because,
11 I mean, I was looking at just making sure that the
12 intensive care was staffed and managed.
13 Q. Do not agree with Mr Nix just because I badly report
14 what he may or may not have said. Is your evidence that
15 it is not really within your compass?
16 A. It is not in my remit, really. I do not know. In 1990
17 I was not really involved in the expansion plans.
18 Q. When you became the Nurse Manager in November 1993,
19 although you had been acting Nurse Manager from November
20 1992, the designation of the BRI as a supra-regional
21 centre for neonatal and infant cardiac surgery was
22 coming to an end. Did you have any contact with the
23 Supra Regional Services Advisory Group?
24 A. No, never.
25 Q. Or any involvement with reporting to the group through
0051
1 the Region of the numbers of paediatric operations?
2 A. No. No, I was never involved.
3 Q. Did you ever see any people from the Department of
4 Health or the Supra Regional Services Advisory Group
5 coming around the unit to carry out an inspection?
6 A. I do not recall them, no.
7 Q. Were you ever aware of any specific encouragement
8 coming from outside of the Trust to increase the number
9 of neonatal and infant open heart operations performed
10 at the BRI?
11 A. No.
12 Q. You were never aware of there being a push on to bump
13 up the numbers?
14 A. No, I do not think so, no. Not at all.
15 Q. If we go to page 14 of your statement, please, the
16 bottom of the page: support groups for nurses were set
17 up in 1988 or 1989. That is the old Health Authority
18 days before purchaser/providers, before Trusts?
19 A. Yes.
20 Q. Initially run by a social worker. If we go over the
21 page, please, "The social work department changed and we
22 were unable to receive this support."
23 Do I detect an element of regret there?
24 A. Yes. The social work department linked quite strongly
25 with the ward dealing with patients' convalescence and
0052
1 parents and financial issues and things like that, so
2 there was a social worker around quite a lot of the
3 time. It was a man; I do not remember his name or
4 anything, but he was actually quite supportive to staff
5 and he, I think, was asked, or he offered -- he may have
6 been asked, I do not know, I cannot remember -- whether
7 he would be interested in running some support groups.
8 He undertook that role and we actually went to the
9 social work department purely because it was actually
10 off the ward area, the clinical area. He did run some
11 support groups -- I cannot remember how many. I do
12 remember attending one myself, but I cannot remember how
13 many. Then it just seemed that that sort of service,
14 once we had set that up, whether it was then because it
15 was Trust status, I do not know why, actually, it
16 stopped. I do not remember really why it stopped.
17 Q. Do you remember when it stopped?
18 A. I do not, but I do remember looking in some of the
19 information that has come that I had asked Freda Gardner
20 and also Helen Stratton -- I do not remember if there
21 was a linkage there with two of them -- I know there is
22 a letter somewhere saying I had asked one or two of them
23 if they would take over running one of these support
24 sessions for the nurses.
25 Q. Let us look at UBHT 135/118 ... 23rd August 1993. This
0053
1 is to Jean Pratton of the Heart Circle:
2 "I am writing to inform you that after meeting
3 with Fiona Thomas and Lesley Salmon I have taken over
4 the co-ordination of the paediatric care on Wards 5A and
5 5B [that would include the intensive care unit]. This
6 of course will involve the co-ordination of the work of
7 the Heart Circle staff, Helen Stratton and Helen
8 Passfield and I hope you will be in agreement with
9 this."
10 Then we see what is said.
11 If we scan down, it is copied to various people
12 including you and there is a tick besides that. Is that
13 your writing?
14 A. Yes.
15 Q. "There is going to be a meeting to discuss issues
16 involved in the management of paediatric patients. We
17 will then have a regular weekly meeting to discuss the
18 ongoing management of all patients on the cardiac unit."
19 You say you are apprehensive about this?
20 A. "I am apprehensive about this", star. It has a star.
21 "I feel your advice and guidelines" -- I am not quite
22 sure. This is just notes that I must have made on this
23 memo.
24 Can you scroll back so I can see what the date is
25 of this? It might just give me some idea, then, of --
0054
1 1993. I think 1993 was to do with the set-ups in
2 paediatric interest groups. I think this is probably
3 what followed this meeting. There were paediatric
4 interest groups, which you do have copies of all those
5 minutes, and I think this was to do with this. This was
6 looking at the management -- there were two, there were
7 several. This one, we were looking at how this group of
8 staff worked together in the management and care of the
9 patients, psychological sort of care as well, and then
10 there was the other one with the paediatric interest
11 group on which we got senior nurses from the ward areas
12 and also we got intensivists involved as well. That was
13 to do with maybe more patient management. I think this
14 was to do with how we were looking at linking the Heart
15 Circle with staff involved with care.
16 Q. What Dr Gardner is concerned about here is her providing
17 services to the patients or to the relatives of the
18 patients rather than to the staff?
19 A. Yes.
20 Q. If we go to UBHT 135/97, this is December 1993, this
21 is the group, is it not?
22 A. Yes, it is. That has Steve Pryn, the intensivist, yes.
23 I think that is what it is.
24 Q. If we scan down --
25 A. I know what this was, this was looking at
0055
1 a multidisciplinary group to look at the care of the
2 children within the unit to see if we could make
3 improvements with the care of the children, basically,
4 because the Heart Circle employed more staff. The Heart
5 Circle were very good at funding several nurses because
6 they funded Helen Stratton and they funded at some stage
7 Helen Passfield as well, and also I think they may have
8 given Freda Gardner some money as well. I am not sure
9 what. They funded something to do with some of her
10 post. I cannot quite recall.
11 Q. The Inquiry has heard a bit about Helen Stratton,
12 Helen Vegoda previously. Dr Gardner has two roles: as
13 a support of the staff and support for the patients and
14 families. Let us look at the latter of those two first.
15 What was the role of Helen Stratton and the other
16 people who did that type of job?
17 A. Initially it was Helen Vegoda who was actually -- she
18 was employed as a sort of counsellor, I think we used to
19 call her, a heart counsellor, and she was employed and
20 based at the Children's Hospital, if I remember.
21 She was not a nurse. I think her background was
22 a social work background, but she was based at the
23 Children's Hospital and I think she used to work for
24 us. I remember I was a Sister, so it was in the late
25 1980s, that she used to work and care for and support
0056
1 the parents, so basically, I remember her role was to
2 support parents of children who were undergoing open
3 heart surgery, and she would meet the parents often at
4 the Children's Hospital or at the outpatient department,
5 because of course she was based there, and she would at
6 times come down and support parents through intensive
7 care.
8 She did not necessarily always come down with
9 all of them, but she used to get quite friendly with
10 some parents, not necessarily all parents.
11 Q. Can I just help you? If we go to WIT 85/32, these are
12 your comments on Sheena Disley's statement. We are
13 going to hear from her later. It is paragraph 37.
14 "Helen Vegoda was employed by the Bristol Heart
15 Circle".
16 A. Yes, that is right.
17 Q. "Her role was mainly to be based at the BCH but she ...
18 did not visit ITU on a regular basis".
19 You draw a distinction between her role on the one
20 hand and Helen Stratton on the other?
21 A. There was quite a difference.
22 Q. Helen Stratton was a nurse, Helen Vegoda was not.
23 Helen Vegoda was based at the BCH and Helen Stratton was
24 the reverse, based at the BRI, and spent some time up
25 there, as opposed to the other way round. Are those the
0057
1 key differences?
2 A. Yes, and also Helen Vegoda, because she was basically
3 employed at the Bristol Children's Hospital, she did not
4 necessarily want to come down to the BRI. Also it was
5 very difficult to get hold of her at certain times. She
6 did not drive and it was difficult to get her when
7 parents who had had support from her and also required
8 it at certain times she was not able to come. So
9 I think what we did then was we talked to the Heart
10 Circle and they said they would fund another person for
11 a short-term contract. That is, I think, how Helen
12 Stratton was employed on a contract, whether it was two
13 years or three years -- I think it may have been
14 three -- I cannot quite recall. That is what happened.
15 Helen Stratton was employed to work for Ward 5
16 specifically. She had an office in Ward 5 and she was
17 a nurse, she had intensive care background, she had
18 worked in the cardiac surgery unit in Ward 5, but
19 I cannot remember what else she had done, but she was an
20 intensive care nurse, not a paediatric nurse; she was
21 intensive care.
22 Q. So she was a cardiac liaison nurse?
23 A. Her title was cardiac liaison work, which was slightly
24 different. Her role was to support the family before
25 and after surgery in whatever remit you would say the
0058
1 support was. She probably did have a role in supporting
2 some staff at a later stage.
3 Q. Let us focus on the parents for a moment. If there
4 was bad news if things were going badly in theatre, if
5 it became clear to the nurses or to the doctors that the
6 child was not going to make it, would Helen Stratton
7 have a role in breaking that news to parents, or would
8 that be done by a clinician?
9 A. It would usually be done by a clinician, but there
10 were times where sometimes the Sisters would also speak
11 to the family as well, and there may have been times
12 when Helen Stratton may have spoken to the family, but
13 normally it was done by the clinician and Helen Stratton
14 and the Sister was there as a support. It was usually
15 done as a group. But most of the time the nurses would
16 tell the family how sick the child was because sometimes
17 the Sisters just did not necessarily know until the
18 surgeon had arrived to talk to the parents anyway.
19 Q. Can we go to UBHT 135/92? We are into 1994 now.
20 At this stage there was a vacancy and Helen
21 Stratton it would appear was not around at this point?
22 A. That is right. I think Helen Stratton had an initial
23 contract and then that was extended for another year,
24 I remember, because I think I was involved then with
25 that extension of her contract. That was through the
0059
1 Heart Circle, again, I think, and then there was going
2 to be a gap for the next year, probably, but I think the
3 children's move was probably planned for early 1995
4 because a new surgeon was coming in the early part of
5 the year, but in fact it did not actually happen until
6 October 1995. I think that is probably why the Heart
7 Circle were not keen on funding another position, and
8 also, I do not think we had any funds in Ward 5 to do
9 that, so I think we had to look at another support
10 mechanism, really, for the staff.
11 Q. So this is now turning to the staff?
12 A. Yes, this is for the staff, because Helen also used to
13 have a role of running some support groups for staff as
14 well, which actually I do not think I mentioned.
15 Q. That is clear from this memo, is it not: that there were
16 support meetings for the staff, it must be in context,
17 and Helen Stratton was to facilitate that. That was her
18 role?
19 A. Yes.
20 Q. And she was not around, so you wanted Dr Gardner to fill
21 that role, and she did?
22 A. Yes, she did.
23 Q. And that is what you referred to, if we go back to your
24 own statement, WIT 114/15, paragraphs 64 and 65.
25 A. Yes.
0060
1 Q. Just to tidy this up, UBHT 213/14, it is my incompetence
2 this is out of order, a Heart Circle meeting of
3 1st March 1993.
4 A. Yes.
5 Q. You see it is attended by Lesley Salmon, then I think
6 the Associate General Manager?
7 A. Yes, that is right.
8 Q. And you. Who was Odette Ashendon?
9 A. I am looking now, I do not know. I do not know.
10 Q. If we look down a little bit, we see the heading
11 "Helen Stratton's position: Helen has taken on more
12 responsibility for the Heart Circle and her job is
13 developing well."
14 Then there is a reference to the contract you
15 mentioned?
16 A. Yes.
17 Q. So the contract was running out in October 1993?
18 A. That is right, and then Jean was the President of the
19 Heart Circle and she suggested a 50-50 split, and then
20 Lesley and I were going to go and discuss the options.
21 Q. Can we go down a little more? Helen Passfield, and then
22 there is a reference, do you see:
23 "All three members of staff working primarily with
24 the children needed some help in setting objectives and
25 working together."
0061
1 A. Yes.
2 Q. Who were those three and what were they doing?
3 A. That was particularly Kathy Warren, the F grade
4 paediatric RSCN, and then Helen Passfield. So Kathy
5 Warren was the F grade paediatric nurse for both areas,
6 and then there was Helen Passfield who was the...
7 I think she was employed as a play leader, because she
8 had gone off. She was a nursery nurse and then had gone
9 off and done some further training to become a play
10 leader, so that we had a qualified play leader actually
11 in Ward 5 to look at play with the children.
12 Q. So this is looking not at the relatives, the parents,
13 not at the staff, but at the actual paediatric patients
14 themselves?
15 A. That is what Helen Passfield's role was, but with
16 Helen Passfield and Kathy we needed to make sure they
17 had clear objectives set so that they were all working
18 towards the same goal at the end of the day, and
19 I undertook with Freda, looking at Helen Passfield's
20 role. And I undertook Kathy Warren's role looking at
21 her objectives very clearly and setting out objectives
22 for Kathy Warren in developing the paediatric management
23 and we set up many things for her to look at practice
24 and look at improving practice in certain areas
25 following her course once she had become an RSCN.
0062
1 Q. So again the Heart Circle was involved in funding of
2 those roles?
3 A. They were not involved with Kathy Warren. She was
4 employed as an F grade on the ward, but with Helen
5 Passfield -- I cannot actually remember, to be honest,
6 with Helen Passfield. It was likely.
7 Q. Now can we go to something else? Your statement at
8 page 114/17, paragraphs 71 and 72. Paragraph 71 deals
9 with the change of nurse education in 1990. You refer
10 to your taking the Diploma in Nursing. I do not know if
11 you have seen Mr Baird's evidence, but he referred to
12 the change of arrangements for training nurses which
13 meant that they were now trained, I think, at University
14 much more than they had previously been. They used to
15 be trained on the ward. He said that he had been
16 brought up on a system which survived on student nurses
17 but that then the training arrangements changed and, as
18 he put it, "suddenly they were all very clever and they
19 have degrees".
20 What difference did that make, practically, to the
21 arrangements of nursing on the ward, the fact that this
22 change had taken place in the method of training?
23 A. It was quite drastic on some wards, because some wards
24 did require those extra staff, extra nurses, and
25 third-year student nurses particularly were used as
0063
1 a good pair of hands for patient care. Student nurses
2 up until the change were used as staff caring for
3 patients.
4 Q. So when they were not around?
5 A. When they were not around, there was a deficit of
6 nurses, of carers, then, one could say, and then the BRI
7 had introduced quite a big training programme for HCAs
8 to try and get more HCAs to try and fill up the gap that
9 was going to be present when there were no student
10 nurses.
11 Q. An HCA being ...
12 A. A health care assistant. So the Trust was being quite
13 proactive in looking at that. That was quite a good
14 angle.
15 Q. So the replacement, as it were, was to train up the HCAs
16 a bit so that the qualified nurses could be freed up to
17 do what they had to be qualified for?
18 A. Actually, auxiliaries were trained, the training for
19 auxiliaries changed to become health care assistants so
20 an auxiliary could do extra training to NVQ level 2 so
21 they were able to be more knowledgeable about certain
22 aspects of nursing care, so they were able to do some of
23 the nursing care roles.
24 Q. So this change affected the whole of the National
25 Health Service?
0064
1 A. Yes, everywhere.
2 Q. Across the country?
3 A. Absolutely everywhere. The student nurses then went
4 into University and then trained to diploma level, which
5 is still currently happening. That is Project 2000, as
6 you said. There was still another training, the degree,
7 so they have been running parallel.
8 Q. Those are the degrees Mr Baird was referring to?
9 A. Yes, I think so.
10 Q. Paragraph 72, you refer to yourself and Mrs Ferris
11 visiting Coventry in 1995. You say that you do however
12 remember two theatre nurses going to Birmingham in late
13 1993 around the same time as Mr Dhasmana?
14 A. Yes.
15 Q. You say they came back with some ideas of how areas of
16 the theatres could be changed, which were then
17 implemented. Do you remember what those were?
18 A. I think it was fairly simple things like positioning in
19 theatres and standing on one side of the operating table
20 compared to the other side, things like that, which
21 Birmingham were working with and they thought it was
22 quite good, "We think we might do it", and Birmingham
23 seemed to be working very well on that system. They
24 were quite simple things, but I think they had quite big
25 implications in the working environment initially.
0065
1 I cannot remember any other changes at that time.
2 Q. In your witness statement at paragraph 36, page 8,
3 you say:
4 "When Mr Keen and Mr Wisheart were the consultants
5 [you] remember ward rounds being very old-fashioned.
6 The Sister would follow the surgeons around the ward,
7 together with an entourage of junior doctors. As
8 a Sister", so this is pre-1992 when you became an acting
9 nursing manager, you played what you could only describe
10 as "a subservient role following the surgeons with
11 trolleys of notes and x-rays, holding up the x-rays for
12 the surgeons to view."
13 Mr Wisheart has commented on that paragraph at
14 WIT 114/48, paragraph 5. You see what he says there.
15 Was it your impression that you were the only
16 Sister who had this feeling of subservience, or was
17 there a feeling that was shared by other Sisters?
18 A. I think the ward rounds, they were on a certain day of
19 the week, on a Friday I think, and when I say
20 "subservient", I mean the Sister would take the trolley
21 and put the x-rays up. That is the subservience.
22 I think the Sisters were able to say and comment on the
23 care if they felt there was need to, so --
24 Q. Was it a case of having something to say which you felt
25 disabled from saying?
0066
1 A. No, I do not think so. I think if you felt you had
2 something to say on that patient's care, you could say
3 it. Whether it was listened to, was a different
4 matter.
5 Q. It would not be listened to if you said something? That
6 was the fear, was it?
7 A. Probably. But then I do not think it was probably any
8 different at that stage than probably in many other ward
9 rounds in any other hospital, probably, or any other
10 ward in the BRI.
11 Q. You refer to the ward rounds as being very
12 "old-fashioned" for those two particular consultants?
13 A. I suppose I am comparing "old-fashioned" from then to
14 now.
15 Q. You make another comparison, do you not, at
16 paragraph 37, 114/9. You compare the two consultants
17 you have just mentioned with Mr Dhasmana. So this is
18 not a comparison with then and now, this is a comparison
19 with then and then. You say:
20 "Mr Dhasmana's rounds were different, more
21 relaxed. He encouraged all members of the team to
22 provide input into the management of all the patients."
23 You then go on to say he had poor communication
24 skills with some nurses. Is there not a bit of
25 a tension between paragraphs 37 and 38 of your
0067
1 statement?
2 A. No, it is two different issues, really. The rounds,
3 I was comparing the other two surgeons to Mr Dhasmana's
4 rounds, the Thursday and Friday morning rounds. He did
5 have a different approach; he had a little bit more of
6 a relaxed approach to actually going around looking at
7 his patients. It was slightly different. Simple
8 things; he would pick up the x-ray himself, he did not
9 expect the Sister to pick it up. Which meant it was
10 a bit more of a relaxed way.
11 When I go on to 38, that is a different issue.
12 These issues I am talking about are really sort of 1994
13 onwards, probably, I would have said. I know I wrote
14 a letter to him at one stage, which I am sure you will
15 show.
16 Q. Yes. Let us not get ahead. The Panel are bemused
17 because they have not seen the letter.
18 A. With that -- this was really after 1994. He did have
19 a bit of a conflict with one nurse, senior, on other
20 wards and she did question him with patient care and he
21 did find sometimes conflict like that, questioning his
22 management with one patient, quite difficult at times.
23 So this was a nurse who was -- this was later on, this
24 is in 1994/95, and she was actually questioning him
25 about the care of a patient.
0068
1 Q. And that was not questioning that was welcomed?
2 A. It was not welcomed.
3 Q. So to that extent, when we were discussing a moment
4 ago with the other two consultants that you mentioned
5 that if the Sister spoke up, the fear was that what was
6 said would not be listened to, there was actually not
7 very much difference between them on the one hand and
8 Mr Dhasmana on the other?
9 A. The trouble is, because this is quite a long timespan,
10 Mr Keen had left -- I do not know when he retired. You
11 are asking me in this statement for information from
12 1988 right through to 1994, so 38 relating to the later
13 stages, 1994/95; I think the early bits I am talking
14 about with the rounds probably are earlier.
15 Q. You refer to a particular incident in paragraph 38.
16 There is only one incident there.
17 A. Yes, I did refer to a specific incident.
18 Q. You have dated it. Was that an isolated incident with
19 Mr Dhasmana, or was it repeated on other occasions?
20 A. It was repeated on other occasions, I think, not
21 necessarily probably to this degree, but he did have
22 conflict with myself if I was working clinically, or
23 with the Sisters about bed management and care in
24 intensive care, but I do not think he was necessarily
25 different from any of the other surgeons.
0069
1 Q. No, so it actually was not --
2 A. I do not think he was different. I do not think there
3 was anything different from the other surgeons.
4 Q. So apart from the more relaxed atmosphere in terms of
5 who would hold up the x-ray, on matters of substance
6 there was not much difference? Is that a fair way of
7 putting it?
8 A. Yes, probably.
9 Q. Can we go to UBHT 228/1, please? Is this the letter?
10 A. Yes.
11 Q. 26th October 1995, so this is before the incident that
12 you referred to at paragraph 38, because you date that
13 specifically to 2nd November.
14 A. What do I ...
15 Q. At paragraph 38, can we see that again, 114/9, the
16 particular incident you refer to you date very
17 specifically to 2nd November 1995.
18 A. I do, yes. I think I was referring to the letter that
19 you have just shown. I am not quite sure why I put
20 2nd November.
21 Q. Shall we see the letter again, please, then,
22 UBHT 228/1: 20th October 1995:
23 "Dear Janardan, I am very concerned that you were
24 verbally aggressive on the telephone to a health care
25 assistant ... on Ward 5A this afternoon. She came to me
0070
1 to complain of your attitude towards her".
2 I will not read it all out. We see what is said
3 in the following sentences.
4 "I have discussed this issue with the senior staff
5 nurse on Ward 5A."
6 Who would that have been?
7 A. The senior staff nurse on Ward 5A would have been
8 Rebecca Lanyon, I think, at that stage. She may have
9 been a Sister.
10 Q. "Who informed me that 9 out of 10 nurses will not do
11 a ward round with you as they are frightened at what you
12 will say to them. The theatre staff are also standing
13 up for themselves and some are refusing to scrub for you
14 in theatre.
15 "I am sure this may be a shock to you to hear that
16 the nurses have a negative attitude towards you. Your
17 attitudes towards the staff must improve to produce
18 a happy, good working atmosphere amongst the cardiac
19 team."
20 The author of that letter, which was you, would
21 seem to be reporting a different view from the one set
22 out at paragraph 37 of your statement about his rounds
23 being different, more relaxed and encouraging all the
24 members of the team to provide input?
25 A. I think it is to do with the time-scale. You have to
0071
1 look at the date here. This is October 1995. So we
2 would have had a year of paediatric media attention,
3 which I think had changed Mr Dhasmana's -- I think it
4 had changed him, drastically. I think that is the main
5 thing you have to look at. I think what I was talking
6 about was previous to this. I think in this latter
7 year, that last year, I would say like mid-1994 to here,
8 when there was all the media attention, I think things
9 changed -- seriously changed.
10 Q. So it would not be fair to take from this letter the
11 impression that 9 out of 10 nurses had always had this
12 view of Mr Dhasmana?
13 A. No, not all the time. I think during this later -- in
14 the period of time, I think life was very, very
15 difficult. Very difficult. I think that is really what
16 I want to get over to you was very different then than
17 probably the year before or two years before then, and
18 I think he was under immense stress and his stress was
19 coming out towards the nurses. He would not take it out
20 on anybody else, but he probably took it out on the
21 nurses at that time.
22 Q. I understand that. I am sure the Panel have the point
23 about reading that letter in its proper context.
24 A. I do not think I had ever written to a consultant before
25 then. It was a very difficult time.
0072
1 Q. I was going to ask you how common an occurrence this
2 was, for a Nurse Manager to write to a consultant?
3 A. That was the first time I had ever done it. The first
4 time I had ever done it. I mean now I do not worry
5 about it, I write to them all the time. But that is on
6 lots of other bits and pieces. But then, I think that
7 was probably the very first time I did it.
8 Q. You mentioned the media attention, I think you said from
9 mid-1994 onwards.
10 A. I think that was round about right at the time.
11 Q. Is that when you would date the change in Mr Dhasmana's
12 attitude, from mid-1994? I do not want to trap you into
13 naming specific dates. I know it is a long time ago.
14 A. I would have definitely said 1995. Whether I am being
15 too wide in going back to 1994, but I would have said
16 definitely 1995 when there was lots of stress going on.
17 I would probably try and say 1995, maybe. It may have
18 been the early part of the -- the later part of 1994 as
19 well.
20 Q. Might it be that media attention perhaps was more 1995,
21 but the storm was brewing in late 1994? Is that perhaps
22 how it was?
23 A. I think, yes, November -- I would have to think of the
24 people that -- I think, probably, yes, that is right.
25 I think at the end of 1994 when the storm was brewing,
0073
1 yes, I think there was lots of things going on at the
2 end of 1994.
3 Q. I should take you to Mr Dhasmana's comments on your
4 paragraph 38. It is WIT 114/43. I mentioned this
5 document earlier. I do not think we actually saw it.
6 Perhaps we could just have a look at it. He says some
7 nice things about you in paragraph 1. If we go down to
8 paragraph 2, that is a passage I have mentioned earlier
9 about "elder statesman", do you see at the end of that
10 paragraph?
11 A. Yes.
12 Q. The passage we are dealing with now is paragraph 3. He
13 makes a point I made to you, that there is an apparent
14 conflict between paragraphs 38 and 37, and then he says,
15 if we go over the page, that he used to encourage all
16 members of the team for their input into the patients'
17 management. The ward rounds became rather disjointed in
18 the early 1990s because of the junior doctors' working
19 pattern and the partial shift system and that led to
20 a lack of continuity of junior staff.
21 Do you remember that as causing a problem, ward
22 rounds?
23 A. The junior doctors' hours? I do remember, we were doing
24 them and then suddenly we were not. We were doing them
25 for quite a long time and then suddenly we seemed to
0074
1 stop doing them.
2 Q. He says at the end:
3 "I do not recall exactly but I was unhappy on
4 a few occasions when messages were not conveyed and
5 I started on double-checking on my messages. This is
6 what I might have complained about to Mrs Thomas."
7 But that is not what you are referring to in
8 paragraph 38; you are referring to the specific incident
9 of being questioned regarding patient management?
10 A. Yes.
11 Q. You clearly remember that incident of --
12 A. I clearly remember the nurse on the ward telling me
13 the whole situation.
14 Q. Which nurse was that?
15 A. That was the one I was referring to --
16 Q. Which nurse was that?
17 A. It was an E grade nurse.
18 Q. An E grade nurse? Do you remember the name?
19 A. Yes, Heather Kaphuch.
20 Q. If we go in your statement to WIT 114/11, please,
21 paragraph 48:
22 "Nurses who cared for children had to be senior,
23 at least an E grade, with one year's experience in
24 cardiac nursing, preferably in cardiac intensive care.
25 The programme involved the new staff working full-time
0075
1 with another senior nurse such as an F grade or a G
2 grade ..."
3 If we just bear that paragraph in mind, if we go
4 over the page, page 12, paragraph 52, you say there was
5 another paediatric nurse whose name you cannot recall
6 who was a D grade and a registered sick children's
7 nurse?
8 A. Yes.
9 Q. She was employed to work in the nursery?
10 A. Yes.
11 Q. The nursery had two RSCNs caring for the children.
12 Again D and E nurses worked in the nursery, with
13 support?
14 A. Yes.
15 Q. So on the one hand --
16 A. No, I can explain that. In intensive care the aim was
17 that the E grade nurses or above who looked after the
18 children following surgery, and then there was this
19 F grade RSCN, and the F grade RSCN would work always in
20 the intensive care unit on a Tuesday, late shift and
21 a Thursday late shift, which was the days that the
22 majority of children's big cases were done in those
23 days, so she was there. She may not necessarily have
24 looked after those children, but she was actually in the
25 unit for support for the nurses caring for the children
0076
1 coming out of theatre.
2 In the nursery, which was the pre- or the
3 post-operative area, she would be working there and she
4 was also based there for the other 3 days of the week
5 that she worked. She worked with a D grade RSCN who was
6 a newly qualified paediatric trained nurse. She had
7 done no adult training so all her training was in
8 paediatrics. She was employed to work in the nursery
9 because she did not have the experience of any intensive
10 care to work in ITU.
11 Otherwise, we would have had D and E grade nurses
12 working in the nursery for support as well, so she would
13 not have been in there by herself, she would have had an
14 E grade on the other shifts or the F grade, Kathy
15 Warren, on the other shifts as well.
16 Q. You see why I --
17 A. I do see, but it was different depending on which area
18 of the ward one was at, and also, the constraints we had
19 with the staff that were able to care for the children.
20 Q. Now I just want to tidy up a few final loose ends. Can
21 we go back first of all in your statement to
22 paragraph 14? That is WIT 114/3, we touched on this
23 earlier, about equipment and cardiac surgery effectively
24 cross-subsidising other areas and Mr Wisheart's comment
25 that it went from subsidising other bits of surgery to
0077
1 subsidising cardiology.
2 At the bottom of the page you referred to
3 Professor Angelini getting angry about the equipment
4 being old and needing replacing. You mentioned earlier
5 that there is now a system that you employ of making
6 sure that there is no old equipment lying around or
7 still being used. Would that comment there, the
8 evidence you gave earlier, apply to the syringe pumps
9 that we dealt with earlier?
10 A. Yes. I remember specifically more so when Rachel began,
11 but it may have just been with the Trust, I do not know,
12 it is just that we had to put in -- it might have been
13 with Lesley as well, but I cannot remember that far
14 back -- we had to put in bids for capital equipment and
15 we had to -- I am sure we have had to do that for quite
16 a while, actually, I think. We had to put bids in for
17 capital equipment. Major equipment is usually over
18 œ25,000. Anything over that value, we have to, as
19 a directorate, make a list of requirements. That goes
20 off to Trust, to HQ, and they decide where the money
21 goes. That was the process and still is the process
22 now.
23 If we were not successful at getting those bits of
24 equipment, then we would have to wait for the following
25 year before we could put the bids in again and get the
0078
1 equipment, so that could mean that the unit may have
2 been working with equipment that we did not consider was
3 adequate, or we wanted new equipment -- if a new
4 techniques was coming on, you wanted new equipment,
5 dialysis machines and things like that. It was at that
6 stage that we thought, "Well, cardiac surgery has made
7 money this year, why can we not buy another ventilator
8 or buy a dialysis machine with the money we have just
9 made, because we did X amounts of contracts?" That is
10 really what I was getting at with this bit.
11 Q. Was it your impression that, of course, units would
12 always be looking for the latest equipment and no doubt
13 there is always new equipment that could be used?
14 A. Always, absolutely.
15 Q. Relatively speaking was it your impression that cardiac
16 surgery was well-resourced compared to other areas of
17 the UBHT?
18 A. I think the thing with cardiac surgery is, it has to
19 be well-resourced. If you do not have the equipment,
20 you cannot do the work. If you do not have a good
21 ventilator or heart lung machine, there is no point in
22 doing the work, if you have no nurse to look after the
23 patient afterwards. It is more expensive work than if
24 you do general surgery, for instance, and you do not
25 need any equipment to look after a patient
0079
1 post-operatively, whereas with cardiac surgery you need
2 to have the equipment. I think a lot of the equipment
3 was getting old and there was no maintenance or renewal
4 programme. We have set up a renewal programme of when
5 equipment definitely needs to be changed.
6 I suppose I inherited it as it was. It was not
7 that there were syringe pumps and equipment there and it
8 was a matter of just trying to maintain that and upgrade
9 them as equipment failed.
10 Q. Relatively speaking, did cardiac surgery have a longer
11 or shorter shopping list than other departments in the
12 Trust? What was your impression?
13 A. It would have had a longer list, but that is because you
14 needed to have the equipment to look after the
15 patients.
16 Q. 114/31, please. Paragraph 127. You never worked at the
17 Children's Hospital, so you never had any experience of
18 open heart operations that were carried out there after
19 October 1995?
20 A. No.
21 Q. But you did work for a few months at the BRI while
22 Mr Pawade operated on children?
23 A. Yes.
24 Q. That is what you are referring to here?
25 A. Yes.
0080
1 Q. Mr Pawade joined the paediatric team in May 1995. The
2 children started returning from theatre very quickly.
3 They spent very little time being ventilated in the
4 intensive care unit and they returned to the nursery
5 very quickly.
6 Those operations were carried out in the same
7 operating theatre as had been used previously for
8 children.
9 A. Yes.
10 Q. And using the same equipment.
11 A. Yes. I expect he had a bit of equipment of his own
12 that he brought. Most surgeons usually have their own
13 instruments; nothing major, no.
14 Q. And the same nursing quotas?
15 A. Yes.
16 Q. And same perfusionist team?
17 A. Yes.
18 Q. And carrying out the same type of procedure?
19 A. Yes. There was a lot of work done prior to him coming.
20 The anaesthetist and perfusionist did go and visit
21 Australia and visit his centre in Australia, so they
22 were prepared. They spent several weeks over there with
23 Mr Pawade, so when he started at the BRI, everybody was
24 aware of his techniques.
25 Q. Are you able to comment on the relative case mix before
0081
1 or after May 1995?
2 A. No.
3 Q. It was obvious, I assume, as you say here, to the
4 nursing staff that the operations were shorter and the
5 children were spending less time being ventilated and
6 got to the nursery faster. What conclusions did you
7 draw about the condition of the children, relatively
8 speaking?
9 A. If a child spends less time in intensive care, they go
10 through the system quicker and they go home quicker,
11 basically, they just go through the system quicker
12 because they have had a shorter operating time. Some
13 children could go home after two or three days less than
14 beforehand.
15 Q. So they were more well when they came out of the theatre
16 than if they had had a longer operation?
17 A. Yes, I think so.
18 Q. Mrs Ferris referred to there being, in the hospital,
19 a "culture of fear and blame", and the culture being --
20 it was important to be "in favour", I am not sure those
21 are her exact words, with the powers that be, in order
22 to have one's concerns listened to.
23 What would your comment on that observation of
24 Mrs Ferris be?
25 A. What was the beginning of your question?
0082
1 Q. Mrs Ferris said that there was a "culture of fear and
2 blame" at the Trust in the period up to 1995, and that
3 it was important to be "in with the right crowd", to be
4 in favour with the powers that be if one's concerns were
5 to be listened to. That is my paraphrase, but
6 Mrs Ferris is nodding.
7 A. I think it was that you had to know who to go and speak
8 to, to have your views heard.
9 Q. You say at page 24, paragraph 99, the last two
10 sentences:
11 "Through now more of a team approach to clinical
12 work" and generally you feel there is now more control
13 and direction from the Chief Executive's office and the
14 Trust Board.
15 "The last 4 to 5 years", that would be the period
16 since Mr Ross became Chief Executive, is that who you
17 are referring to? It may or may not be a causal link
18 between Mr Ross becoming Chief Executive, but as
19 a matter of fact, he has been Chief Executive for coming
20 on for 4 years.
21 A. I think there has just been a general -- I suppose
22 because of everything that has gone on, I suppose we are
23 much more aware of being a team and being open and
24 trying to be open about things.
25 I also feel that probably -- I know the Chief
0083
1 Executive; he knows me quite well. I know most of the
2 executives quite well, compared to several years ago
3 when I did not, but that might have been because of the
4 problems we have been through and that is why we are
5 here today. That might be my development and how I have
6 grown and I have learned to liaise with them, I do not
7 know.
8 Q. You have been a Clinical Nurse Manager in an acting
9 capacity since November 1992?
10 A. Yes, quite a long time.
11 Q. So you had plenty of time to get to know the previous
12 Chief Executive?
13 A. Absolutely -- well, yes, but I think I probably only met
14 him once or twice. There was not necessarily any need
15 to. It was not a fact of not wanting to. There was not
16 necessarily any need to, whereas I am much more involved
17 with the directorate as a whole now, so the approach is
18 very much different. It is much more of a team
19 approach. I will attend the directorate's review
20 meetings twice a year with the General Manager and
21 Clinical Director to give the nursing perspective, so it
22 is a different approach, clearly.
23 Q. You say there is more control and direction. What type
24 of control and direction of what?
25 A. I think that Hugh Ross seems to know what is going on,
0084
1 and I think he seems to direct his sort of philosophy
2 throughout the Trust. I also think that the working
3 executives try to be part of it, and I mean, they are
4 around if required. And also, the Director of Nursing
5 has made quite a big difference with nursing. She has
6 only been there a year and a half now, but she has made
7 quite a big impact into nursing, and hence by developing
8 nursing strategy, so we have a strategy for nursing now.
9 Q. That is Lindsay Scott?
10 A. That is Lindsay Scott, yes, which I think has changed
11 how nurses look at things, really.
12 And there is also clinical governance and a lot of
13 all these other issues that are coming on board or have
14 been around -- clinical governance has been around for
15 a little while, but it is all coming to fruition,
16 really, now.
17 Q. We have touched briefly on the position in 1995,
18 Mr Pawade coming to the BRI initially. I think this
19 comes across from Sheena Disley's statement. There was
20 obviously concern among the nursing staff at the BRI in
21 1995 that they were being criticised for the standard of
22 care they were giving.
23 I just want to take you to one letter about this.
24 It is a letter at UBHT 129/5, to you from Mr Pawade. Do
25 you remember receiving this letter?
0085
1 A. Yes.
2 Q. "Dear Fiona, As you know, today was the day when
3 I operated on the last child at the BRI. Personally,
4 I have found my last five months with you most
5 enjoyable. I have no complaints whatsoever regarding
6 the promptness, expertise and level of the care that the
7 children received, both in and outside theatre. I am
8 sure that the parents will echo my feelings.
9 "Please convey my gratitude to all those people
10 involved, including those in the operating theatre,
11 Wards 5A and 5B, and ancillary staff ..."
12 That was, I assume, a welcome reassuring
13 communication?
14 A. Yes, very.
15 Q. Unless those behind me have other things they want me
16 to ask, let me turn to one more topic. Can I take you
17 to WIT 25, please, at page 1?
18 This is a statement to the Inquiry from
19 Mrs House. You will see that she has set out that she
20 was the mother of Ryan Batt born on 6th April 1989.
21 Can we go into this statement, to page 6? Just go
22 back a little, please, to page 5, to pick up
23 paragraph 12. Perhaps we need to read paragraph 11 to
24 get it in context.
25 Ryan was to have his surgery on 12th February
0086
1 1990. She goes on to say:
2 "Before surgery, we looked after Ryan in the
3 nursery on Ward 5."
4 That would be normal, would it not?
5 A. Yes.
6 Q. "While the nurses there were helpful and appeared to do
7 their job very well, we were surprised how few of them
8 there were, particularly considering that there were
9 several children on the ward who had recently come back
10 from the intensive care unit and at times there were no
11 nurses in the room at all."
12 Would it be normal for there to be some nursing
13 staff actually in the nursery at all times?
14 A. This is 1990 we are in now, is it not?
15 Q. Yes.
16 A. Yes, it would have been.
17 Q. If we read on --
18 A. But the children only went back into the nursery from
19 the intensive care when they were well. I mean, the
20 children, in 1990, used to stay in intensive care for
21 quite a while, even once they were extubated and
22 breathing by themselves, they did not go back to the
23 nursery until they were fairly well, because there was
24 nothing in-between. We had intensive care and we had
25 the nursery, there was nothing in-between. To
0087
1 a parent's perception of somebody coming back from
2 intensive care, it may have just looked fairly dramatic,
3 I suppose,