Home Page Search Final Report Interim Report Evidence - Transcripts - Witness Statements - Submissions - CCNR Report and associated documents - Statistical Reports and associated documents - Background Papers - Expert Papers Inquiry Seminars About the Inquiry Help		Daily transcripts Hearing summary 20 July 1999   Today the Inquiry heard evidence from retired Medical Director and Cardiothoracic Consultant Surgeon at United Bristol Healthcare NHS Trust (UBHT), Mr James Wisheart. Mr Wisheart answered questions about his responsibilities as the Associate Clinical Director for Cardiac Surgery, to the quality of service, the development of standards and the achievement of service contracts within the Directorate. He then discussed Mr Janardan Dhasmana’s period as Clinical Director at UBHT, during which time tensions between clinical colleagues were an issue, and went on to discuss how different members of the clinical team could raise concerns. He also covered questions on his role as Deputy Chief Executive and his working relationship with Dr John Roylance (Chief Executive, UBHT). Mr Wisheart talked about audit and accountability and the involvement of clinical colleagues in paediatric cardiac surgical audit and pathology meetings following the death of a patient. He then discussed Parsonnet Scoring, the system used to assess operative mortality. The issue of the retention of tissue and post-mortems was then addressed with Mr Wisheart explaining his understanding of informed consent and listing the information passed to the coroner following a death in hospital. He concluded by discussing the Supra-regional status of Bristol for infant and neo-natal cardiac surgery, its funding, activity and applications for capital funding for developments.   Mr Wisheart will return tomorrow morning at 9.30 a.m. for re-examination from his legal representatives and to answer questions from the Inquiry Panel.

FULL TRANSCRIPT

   1                      Day 41, 20th July 1999
   2   (9.30 am)
   3   THE CHAIRMAN: Good morning, everyone. Good morning,
   4     Mr Langstaff.
   5   MR LANGSTAFF: Good morning, sir.
   6            MR JAMES WISHEART (RECALLED):
   7            EXAMINED BY MR LANGSTAFF (CONTINUED):
   8   Q. Mr Wisheart, once the Trust began in April 1991, was
   9     the quality of service provided in each directorate
  10     a matter for the Clinical Director of that directorate?
  11   A. He had a responsibility for audit. He had
  12     a responsibility to see that audit was carried out
  13     within his directorate. He had a responsibility for the
  14     organisation of the clinical work. He would clearly
  15     have had a responsibility if there had been complaints
  16     of any sort to deal with those. It is not my belief
  17     that he was responsible for the individual work of an
  18     individual clinician.
  19   Q. May we have on the screen, please, UBHT 60, and since
  20     it begins at 1, I will show you what it is, UBHT 60/1:
  21     it speaks for itself. And page 41(UBHT 60/41), please.
  22        Can we scroll down to "Quality of service", the
  23     opening sentence underneath the three bullet points:
  24        "Within the Trust, each contract will be the
  25     personal responsibility of a Clinical Director supported

   1     by a manager. Quality of service will therefore be
   2     their responsibility."
   3        What you are saying, is it, is that the quality of
   4     service was not so much their responsibility as audit,
   5     the organisation of the services, and -- I have
   6     forgotten the third point that you mentioned?
   7   A. I mentioned complaints of any sort.
   8   Q. And dealing with complaints?
   9   A. Yes.
  10   Q. So that is what this sentence means.
  11   A. I think that this sentence is more a general statement
  12     of principle and what I was saying was trying to address
  13     it at a more practical level, if you like.
  14   Q. Principle has to be translated into practice?
  15   A. Indeed.
  16   Q. How can one translate a high-sounding principle such
  17     as this under the bold heading "Quality of service" into
  18     practice?
  19   A. Through audit. I mean, I am not saying that I was
  20     saying something totally different, but it was on
  21     a slightly different wavelength. One has to ask what
  22     the "quality of service" means. There are two broad
  23     areas under which it could be considered there. There
  24     is the area of quality in the sense of the management of
  25     the organisation, the waiting times, the promptness with

   1     which letters were sent out, the adequacy of the food
   2     and so forth and so on. Then secondly, there is the
   3     quality of the clinical service, which would be dealt
   4     with in a general way within the directorate, within
   5     additionally medical audit and later clinical audit.
   6   Q. If we look at the next sentence:
   7        "They will continue the development of standards
   8     already set within the Trust's hospitals for many years,
   9     particularly in clinical care."
  10        The mechanism that both the Manager and the
  11     Clinical Director had, in your understanding, was audit,
  12     organisation and response to complaints. That was how
  13     the development of standards was to be achieved, was
  14     it?
  15   A. I think that the development of standards involves
  16     much more fundamental activity than that; it involves
  17     training, it involves study, it involves planning
  18     services together. There is all the positive side. The
  19     audit, if you like, without wishing to get into what
  20     audit is or is not, it is much more a monitoring of what
  21     you do, but the actual positive and constructive side is
  22     to do with, as I say, education, training, planning,
  23     development, you know, a whole tranche of important
  24     fundamental activities.
  25   Q. I will come back to audit, if I may, and deal with that

   1     as something of a discrete issue, but for the moment,
   2     just focusing on the management role of the Clinical
   3     Director, the Clinical Director also had a role, did he
   4     not, of making sure that the directorate remained within
   5     budget?
   6   A. Yes. His role was to deliver the service, remain in the
   7     black and to maintain the quality, in a nutshell.
   8   Q. To negotiate, maintain and deliver the contracts, in
   9     effect?
  10   A. Yes.
  11   Q. In a service which we heard yesterday was
  12     under-resourced and under pressure, was there not
  13     a conflict between the responsibility that the Clinical
  14     Director had for quality of service, however that was to
  15     be achieved, and his responsibility for ensuring that
  16     everything fell within the budgeted finance?
  17   A. Yes. There would be difficulties there at a number of
  18     levels and in the service to which you were referring
  19     yesterday, there is a sense in which that fundamental
  20     difficulty arose because the contract was for a finite
  21     amount of work, a number of operations, if you like, but
  22     the patients who were being sent to us exceeded that
  23     number and the purchaser was not prepared to join with
  24     us in any attempt to limit the number of referrals, so
  25     we were in the position of having an open door for

   1     referrals, at which point there were no limitations, but
   2     we were only expected to deliver a finite volume of
   3     work.
   4        So there was a difficulty there. We entered into
   5     prolonged discussion with the purchaser as to how we
   6     could work together to deal with that, control it, if
   7     you like, but the purchaser was unable to find a way to
   8     help us, so we were left entirely with the question of
   9     dealing with that extra load.
  10   Q. Each of the directorates had devolved responsibility.
  11     We touched on this yesterday when we were talking about,
  12     in effect, who might be responsible for the ITU and your
  13     answer was, "Well, it is the surgeon who looks after the
  14     patient who is ultimately responsible", and we
  15     investigated the problem of the ward rounds at different
  16     times and who might have been there and the absence of
  17     any protocol for discussions between the surgeons and
  18     the anaesthetists even though you would expect it.
  19        Can we look at UBHT 143/133?
  20        This is a document detailing the Directorate of
  21     Cardiac Surgery. Can we scroll down, please? It deals
  22     with physical resources. Then, when we come to the
  23     bottom, "Equipment", "Ward 5", there is a square box
  24     which has been put round "Ventilators and allied
  25     apparatus, discuss with anaesthetics."

   1        The writing on the right-hand side is yours,
   2     is it?
   3   A. No, I think it is the writing of either Dr Martin or
   4     Dr Brian Williams, who, on behalf of anaesthetics, have
   5     made those annotations.
   6   Q. "Whose budget, whose funding, whose maintenance?"
   7        Can we go overleaf(UBHT 143/124). "Anaesthetic and allied
   8     equipment discussed with anaesthetics, hours, query
   9     monitoring." This was an annotation to a document which
  10     I think you produced?
  11   A. Yes.
  12   Q. There was a problem, was there, of territory between the
  13     anaesthetic directorate and the proposed directorate of
  14     cardiac surgery?
  15   A. I never regarded it as a problem. It was really just an
  16     issue of definition. It was a matter that required
  17     discussion, and so the matters that required discussion
  18     were identified and they were discussed.
  19   Q. Who ultimately oversaw the relationship between the
  20     directorates if they came to loggerheads?
  21   A. Well, if there was a difference between two
  22     directorates, then it could be dealt with in a number of
  23     ways, either by the two talking directly to each other
  24     and resolving it; by the two being assisted by a third
  25     party to resolve it, and that is the sort of thing as

   1     a Medical Director I could have easily been involved in;
   2     or thirdly, at the monthly meeting of Clinical
   3     Directors, where all the Clinical Directors met together
   4     with the Chief Executive, then any interdirectorate
   5     issue could be aired and dealt with.
   6   Q. When it came to the perfusionists, who was it who took
   7     responsibility for their work?
   8   A. Historically, the surgeons had taken responsibility for
   9     their work and they were part of the surgical team.
  10     I would say that in the 1990s the realities of that
  11     changed a little bit because the anaesthetists became
  12     more interested in the work of the perfusionists, but of
  13     course at all points it was teamwork and within the
  14     teamwork, there were only a few occasions when that
  15     became an issue; it was a matter of working together.
  16     In practice, in working together for the care of
  17     a patient, these sort of lines of demarcation really did
  18     not figure very much.
  19   Q. So what you are describing, really, is a co-operative
  20     enterprise which, so long as people co-operated, it
  21     worked and worked well, with no one individual person or
  22     body overseeing the relationship, although a number of
  23     routes by which problems might be resolved.
  24        I think that is the description you have given.
  25     Have I got it wrong?

   1   A. I do not think I remember saying nobody was charged
   2     with overall responsibility. The activities of the
   3     subdirectorate of cardiac surgery, the Associate
   4     Clinical Director would have been charged with the
   5     responsibility. He might have had to go elsewhere to
   6     get help to resolve a problem, but it would have been
   7     his responsibility.
   8   Q. The emphasis you put, not only between directorates
   9     but I imagine you put it within directorates, is on
  10     teamwork, is it?
  11   A. Definitely, yes.
  12   Q. When Mr Dhasmana took over from you as the Associate
  13     Clinical Director of Cardiac Surgery, he chaired the
  14     meetings -- that was his role, was it?
  15   A. Yes, that is correct.
  16   Q. Was he a good and effective Chairman?
  17   A. I think he found it more difficult than some of his
  18     other duties.
  19   Q. I am not sure that is an answer to the question.
  20     Would you describe him as a good and effective Chairman,
  21     being frank?
  22   A. I think that most of the time he was, but there were
  23     occasions when the membership under discussion made life
  24     difficult for him when he was less effective than
  25     perhaps others might have been. So there were occasions

   1     when he was less effective.
   2   Q. Why would it be that he was less effective? What made
   3     him less effective?
   4   A. Well, consultants are all quite independent-minded
   5     people who are quite prepared to say what they think and
   6     stick to the point and have a robust dialogue, and
   7     I think that he sometimes found that possibly a little
   8     bit overwhelming and he was not quite sure how to, if
   9     you like, keep it within bounds. So it was a clash of
  10     personalities to some extent.
  11   Q. We have heard a description from others of the meetings
  12     under his chairmanship becoming, if I use the expression
  13     a "free for all" it is an overstatement of the picture
  14     we have had, but one in which there was a lack of
  15     control, perhaps, of the expression of very different
  16     opinions.
  17        How far is that description appropriate?
  18   A. I would have to say, I think it is a caricature.
  19     I think there were occasions, as I have indicated, to
  20     which that description might apply, and I can understand
  21     why they might loom large in somebody's memory, because
  22     those are always the bits you remember, but if one were
  23     to take the meetings overall, I think they would
  24     represent, really, quite a small proportion. I mean,
  25     I have not measured or counted anything, but that would

   1     be my impression. I mean, Mr Dhasmana was a very
   2     gentle, well-motivated, considerate individual, and most
   3     of the business was conducted entirely appropriately and
   4     in that sense.
   5   Q. You had been the Chairman immediately before he was?
   6   A. Yes.
   7   Q. When things got perhaps towards being out of hand, and
   8     again that may be a caricature of an expression but
   9     I use it to make the question, would it be the case that
  10     you might step in yourself and utter a few calming words
  11     or try and give assistance to the Chairman?
  12   A. You mean when Mr Dhasmana was Chairman?
  13   Q. Yes.
  14   A. Yes. I think, had I been present and had such
  15     a situation developed, I would certainly have sought to
  16     do my best in that respect, yes.
  17   Q. Can we have a look at JDW 7/95? This is 23rd January
  18     1995, so it is quite a bit later than a number of the
  19     other documents we have looked at. It is a letter from
  20     Professor Vann Jones to Mr Dhasmana.
  21        In the first paragraph, "I was dismayed", he says,
  22     "at the meeting of the cardiac surgery associate
  23     directorate last Tuesday to find out how divided and
  24     acrimonious the atmosphere is in cardiac surgery. I was
  25     also sorry to hear and indeed to see how our colleagues

   1     in less favoured positions in the directorate are being
   2     abused. I do not think we should be bandying terms like
   3     'disloyalties' or 'lack of co-operation' about. I also
   4     thought it was distressing to see the perfusionist so
   5     interrupted that he couldn't get a word in edgeways,
   6     particularly as the person berating him didn't even turn
   7     round to face him."
   8        The description given by Professor Vann Jones is
   9     stark, of that meeting. Were you at that meeting?
  10   A. No, I was not.
  11   Q. Is it the case that certainly by January 1995, the
  12     directorate of cardiac surgery, far from being a team
  13     and working as a team as you described the theory was,
  14     was in fact divided and acrimonious?
  15   A. Without going into details, I would remind you that
  16     there were events at the beginning of January --
  17   Q. I do not want to look at the reasons.
  18   A. But I think this letter cannot be understood without
  19     reference to the events that had preceded this. Because
  20     there had been events which had indicated or had
  21     reflected the fact that there were some very radical
  22     disagreements within the department. It was not
  23     surgeons versus anaesthetists; there were differences
  24     amongst the groups. I do not want to go into the
  25     details, but I think that you will appreciate that these

   1     had been very profound, very deep, very difficult, very
   2     hurtful and so forth. I do not want to get into the
   3     debate, but I think everyone will understand that people
   4     were feeling very raw at that time, and I think that
   5     without understanding that, whatever the events of this
   6     meeting were that Professor Vann Jones is describing,
   7     cannot be properly understood. I would have said that
   8     really prior to this time the difficulties reflected in
   9     the letter had not really happened -- did not happen.
  10     This is a new development.
  11   Q. That was my purpose for taking you to the letter. So
  12     it is not misunderstood by those who may be listening
  13     elsewhere to this, I am not asking and you are not
  14     intending to answer any questions at this stage about
  15     the immediate events that gave rise to this acrimony and
  16     this dissension at this time, but the question is
  17     related to management and what was being managed and the
  18     way that people worked together as a team. Plainly, by
  19     January 1995, at that stage they were not doing. The
  20     question, which you have anticipated partly by your last
  21     answer, is: was this, as it were, the visible face, as
  22     you see it, of tensions that had been there for some
  23     time?
  24   A. It may well have been that there is an element of
  25     mystery about that, because it is not clear to me, even

   1     now, but I think that clearly there had been activities
   2     and viewpoints which, as I know and remember events, had
   3     not come very clearly into the open until January 1995.
   4        So it is quite possible, therefore, that under the
   5     surface there were such opinions, but as I say, they had
   6     not come into the open until January 1995, so in that
   7     sense, you may well be correct.
   8   Q. So, looking back, it seems to be, does it, that there
   9     were strong opposing views within the directorate which
  10     had not in fact surfaced?
  11   A. I have difficulty in saying whether there were, simply
  12     because they had not surfaced. That is where I used the
  13     word "mystery" a moment ago. I cannot say.
  14   Q. Exploring that which I am interested in today, if that
  15     is the case, was there any reason that you can see why
  16     any disagreement as to any, let us suppose, clinical
  17     issue should not have come to light through an open and
  18     well-managed directorate structure?
  19   A. You mean prior to this?
  20   Q. Prior to this.
  21   A. Personally, I can see no reason why, if there were an
  22     issue in somebody's mind, it should not have come to
  23     light.
  24   Q. That would be whether the issue was clinical or whether
  25     it was interpersonal?

   1   A. I would have thought so, yes. I mean, I had been
   2     thinking more of clinical ones, so I am just reflecting
   3     on the personal ones, but there were plenty of people
   4     around whose good offices could have been used and were
   5     used when there was perhaps a tension between two
   6     individuals, to deal with that. That does not say that
   7     every problem can be successfully dealt with easily, but
   8     I mean, there were means and there were people of
   9     goodwill there to do it.
  10   Q. Going back from 1995, if it was, what, only within the
  11     year previous to that that the directorate of cardiac
  12     surgery had actually been established with a budget of
  13     its own, in 1994 --
  14   A. No, that is not correct.
  15   Q. Cardiac services, I am sorry.
  16   A. Cardiac services was established in 1994.
  17   Q. That is what I meant to say, you are absolutely right to
  18     correct me, I am sorry. So the Directorate of Cardiac
  19     Services had begun in April 1994?
  20   A. Yes.
  21   Q. And had been shadowed for a year before that?
  22   A. Yes.
  23   Q. Was it the cardiac services that brought together, as
  24     a directorate, cardiologists, anaesthetists and cardiac
  25     surgeons?

   1   A. No.
   2   Q. So they had been taking part, had they, in discussions
   3     about clinical issues before those three different
   4     groups?
   5   A. Yes. May I respond by explaining how that did happen?
   6   Q. Yes, certainly.
   7   A. In the previous document we saw, the one you said I had
   8     drawn up which was very much a first discussion
   9     document, it contains proposals as to how the surgeons
  10     and the anaesthetists, the nurses, the perfusionists,
  11     the physiotherapists, et cetera, would work together
  12     within the subdirectorate of cardiac surgery and how
  13     they could meet in meetings and so forth. This was
  14     a completely new departure, because while there had been
  15     some meetings at which some people met together, there
  16     had been no formal or regular ones.
  17        So, as far as the anaesthetists, the surgeons, the
  18     nurses, the perfusionists were concerned, they had been
  19     meeting together since whenever in 1991. What happened
  20     in 1994 was that the subdirectorate of cardiac surgery,
  21     the subdirectorate of cardiology, that is, adult
  22     cardiology, came together within the Directorate of
  23     Cardiac Services, so that at the level of the
  24     Directorate of Cardiac Services board, these groups
  25     met. But the surgeons, anaesthetists and others had

   1     been previously meeting, and continued to meet, within
   2     the subdirectorate of cardiac surgery.
   3        I hope I have used all the right words in trying
   4     to describe that.
   5   Q. If you have not, I am sure I shall do my best to make
   6     up for it.
   7        Can you then help me with this. Can we have on
   8     the screen UBHT 137/10. This is 1st February 1994 and
   9     it is the minutes. It is one of a number of minutes of
  10     cardiac surgical audit meetings. I am going to come to
  11     audit as a topic in a few minutes. If we look at the
  12     identity of those present and those absent, those
  13     present: are they all surgical?
  14   A. Those present are all surgical.
  15   Q. Is there, amongst the absentees, any cardiologist?
  16   A. No.
  17   Q. Is it the case, then, that for the purposes of audit of
  18     cardiac surgery, the cardiologists did not or were not
  19     expected to attend the cardiac surgical audit meetings?
  20   A. By February 1994 audit was still a unidisciplinary
  21     activity under the heading of medical audit, and the
  22     cardiac surgeons generally conducted their own audit.
  23     I may say that the surgeons were significantly more
  24     interested than the adult cardiologists in audit
  25     activities.

   1   Q. That may be, but it is really a reflection on what you
   2     have been saying about working as a team, and I want to
   3     get a feel for what the team consisted of.
   4        Here we have a surgical team looking at surgical
   5     issues. Before any operation was conducted on an adult
   6     or child, at some stage during the week before there
   7     would be a multidisciplinary meeting, would there, to
   8     review the case, if time permitted?
   9   A. Not necessarily. The cases had all been reviewed
  10     together at the time of referral, that is to say, by the
  11     cardiologists and the surgeons. At that time --
  12   Q. That was the point that I wanted to get to, and you have
  13     answered it.
  14        So for the purposes of referral and planning ahead
  15     for surgery, there would be cardiologists and surgeons
  16     meeting together to discuss what was to be done?
  17   A. Absolutely.
  18   Q. Joint input?
  19   A. Yes. There was one meeting a week with the adult
  20     cardiologists and there were two meetings a week, that
  21     is, two additional meetings, between the paediatric
  22     surgeons and cardiologists.
  23   Q. If, let us suppose, sadly things went wrong with
  24     a particular case in the sense that there was mortality,
  25     would it be the case that the cardiologists would not

   1     take part in an audit or review of that together with
   2     the surgeons as part of a general audit of the
   3     procedures that had been adopted?
   4   A. I think you would have to ask the cardiologists that
   5     question.
   6   Q. Were they invited?
   7   A. Were they invited? They were certainly invited from
   8     time to time to audit meetings. Later in the 1990s they
   9     did come, but that was really when the format had
  10     changed to a wider grouping, but at this stage I can
  11     remember personally inviting them to a number of audit
  12     activities, either before or after audit became a formal
  13     process, and I had to work hard to generate their
  14     interest.
  15        That, of course, does not apply to the paediatric
  16     cardiologists.
  17        The issue with the anaesthetists was a slightly
  18     different one, because I think at all times we perceived
  19     that it would have been right and proper, and
  20     appropriate, for our audit activities to be conducted in
  21     co-operation with the anaesthetists, if not at every
  22     meeting, at least at some meetings, but they were very
  23     much committed to the notion that all the anaesthetists
  24     had to meet together to conduct the anaesthetic audit,
  25     and again, it was not until the mid-1990s that

   1     a solution to the -- we could not resolve that problem,
   2     I am sorry. We could not resolve that problem. So that
   3     there was not consistent and regular attendance of
   4     anaesthetists at our audit in these early stages.
   5   Q. Again, looking before surgery, prior to surgery, did
   6     the anaesthetists play a part in planning ahead in the
   7     same way that cardiologists did?
   8   A. They played a part in a different way because their
   9     role was different, so they played a part in planning
  10     the basic programme of operating sessions and we knew
  11     what anaesthetist was there, when. As far as we were
  12     aware, they saw the patients beforehand, and it would
  13     not be uncommon, when they had seen them, that they
  14     would have a view or a suggestion that they would share
  15     with the surgeon. I well remember such suggestions
  16     being made and generally they were extremely helpful and
  17     they were incorporated into whatever we were planning to
  18     do.
  19        So the information of the earlier collaboration
  20     between the cardiologists and the surgeon was, of
  21     course, available to them in the notes within the
  22     records, so basically all the information was there.
  23   Q. The way in which the "team" worked, if I can piece this
  24     together -- please tell me if I am being too simplistic
  25     or if I have misunderstood -- was that at some stage

   1     prior to elective surgery, the cardiologists and the
   2     surgeons would meet to discuss that particular case?
   3   A. Correct.
   4   Q. At a later stage, the anaesthetist would be involved,
   5     having access to the notes and that which the
   6     cardiologists and surgeons had themselves discussed and
   7     agreed, and would plan the sessions so that the right
   8     anaesthetist would be available?
   9   A. Yes, so that is more immediately prior to the
  10     operation. That is in the run-up to the operation that
  11     that happens, yes.
  12   Q. But after the operation, at regular intervals, there
  13     would be a review of surgery which in terms is called as
  14     we see here a "surgical audit meeting", at which,
  15     amongst other things, the performance at surgery would
  16     be discussed -- I am using the words generally. But
  17     that would be between the surgeons?
  18   A. Yes.
  19   Q. The anaesthetists were for a while invited but preferred
  20     to have their own audit meeting?
  21   A. That was certainly how I understood it, yes.
  22   Q. And the cardiologists, the adults, were from time to
  23     time invited -- they were not expected as of right to be
  24     present, but they were from time to time invited, but
  25     were difficult to excite so far as the adults were

   1     concerned about the audit meetings?
   2   A. They would have been quite welcome -- they would have
   3     been extremely welcome.
   4   Q. And the paediatric cardiologists were much keener,
   5     from what you are saying?
   6   A. Yes. Let me say that if we had a heading of "audit for
   7     paediatric cardiac surgery", then cardiac surgical audit
   8     such as the document you have here would be one
   9     activity, and a second activity would be paediatric
  10     cardiological audit, where the paediatric cardiac
  11     surgeons met with the paediatric cardiologists and
  12     others and discussed the paediatric surgery.
  13   Q. If we can just scroll down here, in the second
  14     paragraph, the one which begins by the meeting being
  15     "dogged by lack of information", et cetera, the last
  16     two sentences:
  17        "In general the unit had been very active during
  18     December 1993 and January 1994 performing a total of 144
  19     open heart procedures. Of these 21 were in the
  20     paediatric age group. There were 9 deaths in the adult
  21     group and 2 deaths in the paediatric group."
  22        So paediatric surgery was discussed, it appears?
  23   A. Definitely. I am saying it was discussed in both fora.
  24   Q. I see. And that is, so I get it right, the cardiac
  25     surgical forum and the paediatric cardiologists forum?

   1   A. Yes. Paediatric cardiology embracing cardiology and
   2     surgery.
   3   Q. Did it occur to anyone at any stage that if one was
   4     operating as a team for adult and paediatric cardiac
   5     surgery, that teamwork might imply joint meetings
   6     before, after and a joint sharing of views, rather than
   7     the unidisciplinary approach?
   8   A. It certainly did, but if we are talking of audit, which
   9     is the area in which it was slow to develop because it
  10     was well-established in the pre-operative processes,
  11     I think we are talking of an evolution in which the
  12     surgeons had really been active in audit long before
  13     audit became a requirement. Initially, I think the
  14     different medical groups did their audit in their own
  15     area and then subsequently, as it evolved and developed,
  16     the obvious sense of groups doing their audit
  17     together -- it is like the directorate: it is
  18     a patient-focused audit as opposed to a medical group
  19     focused audit -- the sense of that became clear and was
  20     accepted and did eventually happen, but I think we are
  21     describing a developing scene.
  22   Q. I will come back to explore some of those issues in
  23     a minute or two. We have looked at the relationships
  24     and how they were managed within the directorate. You
  25     mention in your statement that there was a crisscross

   1     nature of identities and loyalties to outside bodies
   2     such as the Royal Colleges, the cardiothoracic surgeons,
   3     and so on, which you I think suggest may have created
   4     tensions for medical staff. It did not?
   5   A. I regarded those as highly constructive relationships,
   6     because if one had only an internalised set of
   7     relationships then one would be a very introverted group
   8     and all the members needed other professional
   9     relationships by which they would be informed, they
  10     would learn of new ideas, they would have debates, so
  11     they had something new to bring back to the group which
  12     was the team delivering the service. I regarded that
  13     crisscross, if I use the word "tension", then as an
  14     entirely creative tension.
  15   Q. The management style, the management approach, was for
  16     the delegation of power to directorates, we have heard,
  17     so that directorates were largely autonomous, although
  18     linked in the way that you have described?
  19   A. Autonomous, I think, is too strong a term to use.
  20     I know I have used it myself so I must own to that, but
  21     it is too strong. They were not autonomous. Partly
  22     autonomous, yes, but not autonomous.
  23   Q. At the head of the Trust was the Chief Executive. Can
  24     I ask you to look at UBHT 34/124? You had better go to
  25     the start, page 122(UBHT 34/122). This is 19th March 1993. It is

   1     the Executive Committee of the Trust. Page 124(UBHT 24/124), now.
   2     If we can go down to Deputy Chief Executives, the minute
   3     reads:
   4        "Dr Roylance reported that in his absence Mr Nix
   5     would deputise on financial and administrative matters,
   6     and he wished to recognise that Mr Wisheart acted as
   7     Deputy Chief Executive on medical matters. The Board
   8     gave its full agreement."
   9        A few questions arise. This appears to be
  10     Dr Roylance's sole decision to which the Board agreed.
  11     That is the way it appears from what is written. Is
  12     that right?
  13   A. I would have thought that was too literal. I would
  14     have thought that this is Dr Roylance suggesting how it
  15     would be and seeking the approval of the Board.
  16     Otherwise, why bring him to the Board? The Board gave
  17     its agreement. I think he is seeking the approval of
  18     the Board for that suggestion.
  19   Q. You appreciate the distinction between "discussion" and
  20     "rubber-stamping"?
  21   A. Indeed.
  22   Q. The way this is written looks like rubber-stamping
  23     rather than discussion?
  24   A. The Board was well able to state any opinion it
  25     felt, I can assure you.

   1   Q. So we cannot, from this particular episode, gain any
   2     view, can we, as to Dr Roylance's approach to the Board
   3     and to management generally?
   4   A. No, I would have thought this was a purely practical
   5     matter and he was suggesting this, and I do not think it
   6     would have been a matter of controversy.
   7   Q. The effect of having you as Deputy Chief Executive on
   8     medical matters and Mr Nix as manager on administrative
   9     matters preserved a division between the administrative
  10     and the medical right up to Dr Roylance himself, did it
  11     not?
  12   A. I would have looked at it in exactly the opposite way
  13     and said that this is recognising that problems could
  14     arise in a variety of areas and teamwork would be a good
  15     thing.
  16   Q. But teamwork by having two deputies rather than by
  17     having one combining both functions?
  18   A. Teamwork by recognising that different people had
  19     different knowledge and experience and skills.
  20   Q. Did you actually ever deputise as Deputy Chief
  21     Executive on medical matters?
  22   A. No, I do not think so.
  23   Q. So what did it actually mean, for you?
  24   A. Not a great deal. I think that what actually happened
  25     was that for practical purposes, Mr Nix acted as Deputy

   1     Chief Executive, that is to say, when Dr Roylance was
   2     away he was the Acting Chief Executive, and if a matter
   3     had arisen that was urgent on which he needed medical
   4     input, then he would have involved me in it.
   5   Q. But you were already Medical Director, were you not?
   6   A. Yes, so I was there, but he was the person who handled
   7     the post, if you like, and the messages coming in.
   8     I did not actually do that because I had other things to
   9     do. But Mr Nix and I worked well and constructively
  10     together and had there been an issue on which he would
  11     have wanted my advice, he would have approached me, and
  12     in a sense, because of this, I would have had the
  13     authority to help him in that matter.
  14   Q. Would you not have had that authority as Medical
  15     Director anyway?
  16   A. I guess so.
  17   Q. So what extra, apart from status or recognition, did
  18     being Deputy Chief Executive actually give you?
  19   A. None at all.
  20   Q. It may have been a measure, perhaps, of the regard that
  21     Dr Roylance must have had for you. You, for your part,
  22     I think, had considerable regard for him, did you?
  23   A. I did, yes.
  24   Q. Can we have a look at GMC 13/368? This is your
  25     handwriting, is it?

   1   A. It is.
   2   Q. If we just scroll down to the bottom so we can pick up
   3     the date, it is 3rd October 1995. This is as John
   4     Roylance retired?
   5   A. I think the context is important. This was at a party
   6     on the occasion of his retirement.
   7   Q. Can we go back up and read it through? You are probably
   8     a better person to read it than I am, because of the
   9     writing, because it is a bit faint on our screens.
  10     Would you mind? I am sorry.
  11   A. It says:
  12        "Thank you for creating a hospital, a Trust,
  13     where the values and commitment of its people are at
  14     once so challenging and so supportive. Here the focus
  15     is the care for our patient. I know that many of our
  16     colleagues who have not had an opportunity to write in
  17     this book join heartily in this sentiment."
  18        I should point out, I am only remembering this as
  19     I read it, that there was a book in which a large number
  20     of people had been invited to write something, so
  21     I think the context is very, very important.
  22   Q. So a bit like a visitor's book, only --
  23   A. This is not how we would have a normal daily
  24     conversation.
  25   Q. No.

   1   A. "Personally, I am deeply grateful for your guidance,
   2     inspiration and support over 20 years, but particularly
   3     over the last six, and very particularly through the
   4     vicissitudes of 1995."
   5        The other remarks are personal.
   6   Q. So you plainly intended those remarks, albeit in that
   7     context?
   8   A. Well, yes.
   9   Q. How, in general terms, would you describe your
  10     day-to-day relationship with Dr Roylance?
  11   A. They were cordial and professional, rather than
  12     personal.
  13   Q. Is it, do you know, the case that he was or had at some
  14     stage been a Freemason?
  15   A. Dr Roylance? No, I do not know of that.
  16   Q. Have you, for your part, been or are you a Freemason?
  17   A. I am not and never have been.
  18   Q. The way that you describe your relationship in the
  19     answer that you have just given me is as essentially
  20     a professional relationship rather than a social
  21     relationship?
  22   A. That is correct.
  23   Q. Was it both?
  24   A. No, it was essentially what I said.
  25   Q. I am sorry, you are dropping your voice.

   1   A. I am sorry. No, we did not have a personal or social
   2     relationship in the years prior to 1995.
   3   MR LANGSTAFF: I am going to turn to a separate issue, which
   4     is going to take me probably some three-quarters of an
   5     hour, an hour. We will deal with the question of
   6     accountability and audit, as I have promised you on
   7     a number of occasions in the questions I have asked.
   8        I am very much in your hands and that of our
   9     Chairman as to whether you would like me to begin that
  10     now, with something of a quarter of an hour to go before
  11     we have a break, or whether you would rather have
  12     a break now and then come to it, as it were, in one
  13     chunk. Which would you prefer?
  14   MR WISHEART: I will be guided by Professor Kennedy,
  15     I think.
  16   THE CHAIRMAN: I in all things defer to the witness in
  17     terms of not wanting either to make the sessions too
  18     long and also I have in mind the stenographer, so
  19     I would be greatly helped if you could make a decision
  20     on that.
  21   MR WISHEART: I would suggest, then, that we make
  22     a beginning and proceed for the normal duration of
  23     a session.
  24   THE CHAIRMAN: I am grateful; that is very helpful, thank
  25     you.

   1   MR LANGSTAFF: In your statement, you tell us that the
   2     surgeon had a personal responsibility for the care of
   3     his patient?
   4   A. Yes.
   5   Q. Essentially, that it was his professional duty to ensure
   6     the best care for each patient?
   7   A. Yes.
   8   Q. And to ensure that he, for his part, audited him?
   9   A. Yes, I regarded at all times in my consultant career
  10     that that was part of my professional duty.
  11   Q. It would follow that so far as competence or achievement
  12     in terms of surgery, one might use either word,
  13     depending on the circumstances, you would place the
  14     first responsibility upon the surgeon himself for
  15     monitoring the competence and achievement?
  16   A. Yes. That is correct. I would recognise that of
  17     course all elements of the achievement are not under the
  18     direct control of the surgeon, because we are talking
  19     about teamwork, but in terms of monitoring the eventual
  20     achievement, whatever the roots of it were, then I think
  21     that does lie with the surgeon.
  22        Might I just add one additional point, namely, of
  23     course, today we give quite a specific meaning to the
  24     word "audit". That is, if you like, a technical term
  25     which was a new concept in the late 1980s, so when we

   1     used the word "audit", and I said it from the beginning
   2     of my career, I am not necessarily referring to the
   3     concept and the technical meaning of it that we hold
   4     today.
   5        So in terms of how we thought of monitoring work
   6     at the time, I believed it was a professional duty to do
   7     so.
   8   Q. Perhaps we had better have your statement on the screen,
   9     WIT 120/15: you deal specifically with this period, as
  10     you pointed out in that last answer, from the fourth
  11     line down:
  12        "Consultants as clinicians exercising independent
  13     judgment had no formal requirement to be accountable for
  14     their work in this period, beyond their professional
  15     duty to maintain an acceptable standard. Only if this
  16     acceptability was in question would a question of
  17     accountability have arisen."
  18        I want to explore how it is that the acceptability
  19     might come into question. Let me give you
  20     a hypothetical example. Dr Roylance, throughout the
  21     time that he was the Chief Executive, maintained
  22     a clinical commitment, did he not? I think it was
  23     a session a week.
  24   A. He had one session a week when he attended
  25     a radiological meeting, yes.

   1   Q. Suppose that his performance in the course of that
   2     session had been poor by general standards. To whom,
   3     apart from himself, would he have been accountable?
   4   A. I would just like to say that he was not actually
   5     performing in that session, but I will accept your
   6     question as a general question. Who would have raised
   7     the question?
   8   Q. Yes.
   9   A. Then I think a person who can raise a question is
  10     a person who has some knowledge of the work of the
  11     clinician about whom the question has been asked.
  12   Q. Let me put it again in concrete terms, and I choose
  13     the name purely for the sake of example, I have to
  14     emphasise. Suppose Mr Dhasmana, when he was Associate
  15     Clinical Director of the Directorate of Cardiac
  16     Surgery -- suppose his performance was, in comparison
  17     with what was to be expected, poor. In terms of
  18     responsibilities at the time, it was a matter for him,
  19     is what you said. Was it a matter for anyone else?
  20   A. It was a matter for him in the sense that each
  21     individual surgeon is responsible for what he does, but
  22     it would also have been the responsibility of any of his
  23     colleagues who had a knowledge or awareness of what you
  24     are referring to, so those could be cardiologists,
  25     anaesthetists, fellow surgeons, amongst the medical

   1     staff.
   2        Is that what your question was asking?
   3   Q. It is asking, in effect, who is it that is going to
   4     raise any question of confidence? If it is not the
   5     surgeon himself it has to be somebody else and you are
   6     answering, it would be someone who has some knowledge of
   7     the work in question.
   8   A. Yes.
   9   Q. How is it that any of the persons you mention, the
  10     cardiologists, the anaesthetists, it may even be the
  11     nurse in the operating theatre, whoever it is, the
  12     Senior Registrar, how is it that they would know
  13     sufficient of the work which, again for the sake of
  14     example, Mr Dhasmana was doing, unless they regularly
  15     and consistently and always worked with him as part of
  16     the team?
  17   A. I think that in any situation it is unlikely that any
  18     individual such as the ones you have enumerated would
  19     actually be in the first instance in possession of hard
  20     facts. I think that what would happen in the first
  21     instance is that a person would have an impression or
  22     feel uneasy or have a concern which would not be based
  23     on hard fact, but what they perceived to be the case.
  24        So the first step really would be a voicing of
  25     that concern and an exploration of that concern in terms

   1     of establishing the facts.
   2   Q. Taking the people I have enumerated, suppose it was the
   3     Senior Registrar. The Senior Registrar is being
   4     trained, presumably, by the consultant?
   5   A. Yes.
   6   Q. So rather than questioning the consultant's performance,
   7     unless there is something very obvious, so dramatic, as
   8     it were, that it would be obvious to anyone, how is he
   9     going to be in a position to question the competence, to
  10     have the concern or to think that he can do anything
  11     with it?
  12   A. I think, you know, at any given time there were a number
  13     of surgeons in the group and the pattern of work for the
  14     trainee was to work with each one in turn for a length
  15     of time, so each trainee was, of course, known to all
  16     surgeons. So if a trainee had a concern, there would
  17     really be two courses of action, immediate ones, open to
  18     him. He could either go to the surgeon about whom he
  19     had the concern and express it, or he could go to any
  20     other surgeon and say, "Look, I am worried about X's
  21     work", and take it from there.
  22        And I may say that your example, I think, is
  23     a very appropriate one, because the trainee is the
  24     person who works most closely with the surgeon and
  25     therefore has the most intimate knowledge of the

   1     decision-making, the operating, the care, and so forth.
   2     It may seem strange, but a colleague actually has much
   3     less knowledge of those details because they are not
   4     normally involved with the individual in making or doing
   5     them.
   6   Q. The occasions -- let us take a for instance -- when you
   7     and Mr Dhasmana were together performing an operation
   8     once he became a consultant, were, I suspect, few and
   9     far between, if they existed at all?
  10   A. There were some, but they were few and far between,
  11     exactly.
  12   Q. So not enough for you, or for that matter he, to form
  13     any view of the other's general competence?
  14   A. Yes. I mean, in the example you have put forward, I, of
  15     course, knew about his technical ability and his
  16     decision-making ability when he was my Senior Registrar
  17     much better than I did five or ten years later, and vice
  18     versa, I expect.
  19   Q. So suppose that Mr Dhasmana, the Senior Registrar, comes
  20     to you and says "James/Mr Wisheart [whatever he would
  21     call you], I have this concern about what Mr Dhasmana
  22     has been doing in the operations, his cross-clamping
  23     times are too long", or something along those lines.
  24     You did, of course, know and have respect for your
  25     colleague consultant?

   1   A. Indeed.
   2   Q. The Registrar himself might feel inhibited, might he,
   3     from raising the issue with you because his own training
   4     might depend upon the reference that you and Mr Dhasmana
   5     would give at the end of his training?
   6   A. This is a point that arises from time to time in
   7     a variety of contexts and I have always had difficulty
   8     with. Let me say I have not had a Registrar come to me
   9     raising an issue of exactly the type we are now
  10     discussing, but I have certainly had Registrars come and
  11     raise issues of, let us say, a controversial nature in
  12     other areas. Where those have been dealt with openly,
  13     straightforwardly and on their merits, I do not believe
  14     that that creates a black mark against that trainee.
  15     I do not believe that at all. But again, I can only
  16     speak for myself and the people I know best. I do know
  17     that in the minds of trainees, or some trainees, such
  18     a concern exists, but I do not believe that that was an
  19     issue within our group, at least, certainly not in the
  20     days up to the early 1990s.
  21   Q. There is perhaps a distinction, is there, between an
  22     allegation which, by use of the word, one takes to be
  23     unfounded and perhaps wrong, and a legitimate concern,
  24     which again, by use of that expression, one might take
  25     to have the same factual content but having the merit of

   1     being well-founded. You appreciate the distinction
   2     I make for the purposes of the question that I am about
   3     to pose?
   4   A. Yes, I do.
   5   Q. The Registrar, in our example, would have to feel fairly
   6     confident, would he not, that what he was expressing was
   7     a legitimate concern rather than something that was
   8     likely to be treated as an allegation?
   9   A. I think that a form of words could be found to express
  10     a concern. Even if it were not clearly focused in that
  11     person's mind but he felt uneasy, then I think he could
  12     come to me or Mr Hutter or whoever, and use a form of
  13     words to express his concern that would ask the question
  14     and do so in a way that would be appropriate and would
  15     not create problems.
  16        Voicing any concern in a sense, the next stage is
  17     to try to evaluate the gravity and seriousness of it and
  18     whether it is something that needs to be carried further
  19     or not, and I believe that a concern could be expressed
  20     in a way that would not create problems.
  21   Q. What of the situation where, let us suppose a surgeon
  22     is not obviously slipshod in his approach but is simply,
  23     for whatever reason, much less successful in similar
  24     cases than is the usual run of comparison for a
  25     surgeon.

   1        The Senior Registrar attached to the surgeon
   2     I have used as an example would not know, would he, what
   3     to expect from others?
   4   A. After all, there are Senior Registrars who next week
   5     would be a consultant, so they are, really, essentially
   6     a consultant and they are full of knowledge and
   7     competence, usually, but the more senior ones of those
   8     are extremely well informed people and as specialists in
   9     training they would be familiar with the published
  10     literature, with the expectations, they will be members
  11     of our Society and they will therefore also have access
  12     to the UK Cardiac Surgical Register.
  13        So they will be well informed people who will know
  14     what to expect.
  15        Now I am just trying to recall exactly how your
  16     question was formulated.
  17   Q. In essence, it was how would he know, because he would
  18     have no real point of comparison?
  19   A. Thank you. So there are big issues about points of
  20     comparison, but if we just put those to one side for the
  21     moment and assume that there is a point of comparison,
  22     then it is quite likely that the Senior Registrar will
  23     know first what is normally achieved in this area, and
  24     he will also know what the centres at the leading edge
  25     of any activity are achieving.

   1        What he will see locally, with any individual
   2     consultant, will of course be a very small experience,
   3     so there will be difficulties of comparison for that
   4     reason. But I think you described a situation where
   5     a surgeon was not slipshod or obviously careless or
   6     inattentive to his patients, so is one doing a more
   7     careful job but for more subtle reasons, the results are
   8     not good.
   9        You see, I think through the process of audit, as
  10     we now talk about it, the Senior Registrar is deeply
  11     involved with that with us, so he will be aware of the
  12     figures, of the results of such a surgeon, so he might
  13     be in the position of saying, "Well, the results of
  14     surgeon X in this small series, very small series that
  15     I have experienced [because that would be the limit of
  16     his experience] do not look as good as I would have
  17     expected". I do not think he would actually be able to
  18     say much more than that. But by saying that, he is
  19     raising the question.
  20        So one would then want to look at the figures and
  21     perhaps a larger collection of figures than that Senior
  22     Registrar had experienced and if the figures seem to
  23     bear out -- I do not want to get into a statistical and
  24     sort of philosophical discussion about this, but if the
  25     figures seem to bear out, is the question, then of

   1     course the next question is, what reasons might there be
   2     for this? Then you are into a new level of discussions
   3     which are obviously essential if one is to understand
   4     the hypothetical problem that you have posed.
   5   Q. So in the case of the surgeon with more subtle deficits,
   6     let us assume, the only way I think that you are
   7     suggesting that this can be identified is really through
   8     a process of audit of some sort? And even then, one has
   9     the difficulty of numbers, interpretation of those
  10     numbers, and dealing with any hypothesised answer which
  11     may or may not be accurate as an explanation for an
  12     apparent shortcoming in a small series?
  13   A. Yes, I think all those points would need to be borne
  14     in mind. I think personally I seek to avoid the use of
  15     words like "audit" in this sense, because it is merely
  16     a current jargon word and while there is a sense in
  17     which it illuminates and brings forward a discussion,
  18     there is also a sense in which I think it limits it. So
  19     I would say that the figures in the experience need to
  20     be examined in detail.
  21   MR LANGSTAFF: Yes. Sir, it is now a quarter to 11. Shall
  22     we take a break?
  23   THE CHAIRMAN: I am grateful. We will take 15 minutes
  24     and reconvene at 11 o'clock. Thank you.
  25   (10.45 am)

   1               (A short break)
   2   (11.05 am)
   3   THE CHAIRMAN: Mr Langstaff?
   4   MR LANGSTAFF: Suppose that instead of being the Senior
   5     Registrar, it was the theatre nurse. How would you
   6     expect someone in his or her position to raise her
   7     concerns?
   8   A. I think the theatre nurse or other nurse could raise
   9     concerns in two ways. I imagine the more proper way
  10     would be to do so through the nursing structure, but we
  11     do work as a team and therefore I would include a second
  12     possibility and that is by sharing that with one of the
  13     medical members of the team.
  14   Q. Is one of the problems perhaps that the answer that she
  15     is likely to get is, "Well, this is a complex surgical
  16     issue and essentially, you are a nurse, you do not know
  17     enough"? Some approach along those lines?
  18   A. Yes. I think that is a realistic comment that you
  19     have made. You talked earlier about a surgeon who was
  20     not slipshod and if we are still in that framework, the
  21     theatre nurse is unlikely to be familiar with the
  22     results and the outcomes which happen many days after
  23     the theatre experience in a group of patients, so
  24     I think that her knowledge is actually likely to be
  25     quite limited.

   1        I think a theatre nurse would really be much more
   2     likely to be coming from a position of something
   3     unexpected but may be grosser than we have been thinking
   4     about earlier had happened in theatre and he or she was
   5     concerned about that, that that had happened, and was
   6     there a reason, was there a problem?
   7        My perception would be that it would be more
   8     difficult for a nurse because he or she would not
   9     necessarily have either the information about the
  10     surgeon or the knowledge on a comparative basis to raise
  11     the question. So I think a nurse is more likely to
  12     raise an issue about an untoward incident, let us call
  13     it that, than the results of a group of patients.
  14   Q. What about the anaesthetist?
  15   A. The anaesthetist, one would expect, would be in
  16     a position to have knowledge because one would have
  17     hoped he or she would have been involved in audit in
  18     some way. I think, if we take it in a looser sense,
  19     they were aware of the results, they talked to us, they
  20     knew, even if they were not at the particular meeting.
  21        So they would have had knowledge. They would
  22     either have, themselves, access to comparative
  23     information or, if they chose to ask for it, it would
  24     certainly have been provided. As it was on frequent
  25     occasions.

   1        Normally, anaesthetists would be appropriately
   2     assertive if they had a question to raise.
   3   Q. The process that we were describing before the break was
   4     essentially one which, in the case of the subtle
   5     deficits, as we hypothesised, puts the onus upon looking
   6     at figures, as we call them, and analysing those figures
   7     and any explanation that there may be for them, which is
   8     a complex and difficult process, is it not?
   9   A. Yes, it is.
  10   Q. In the Trust itself, was there perhaps a further
  11     problem -- can I raise it in this way: at UBHT 240/465,
  12     there is a note of the group of executive directors of
  13     23rd February. This is 1993. Can we go, please, to
  14     467(UBHT 240/467)? It is item number 22. The South West Regional
  15     Health Authority had written to Dr Roylance to say that
  16     UBHT had been shown to have very few clinical complaints
  17     and was the fourth lowest for the region. This follows:
  18        "He did, however, recommend that staff are
  19     extremely careful over making injudicious remarks when
  20     referring to colleagues, finance or treatment."
  21        Pausing there, there is plainly a distinction
  22     between having figures on the one hand, making concerns
  23     known within an institution on the other, and making
  24     them known outside the institution, publishing the
  25     figures or the concerns to a wider public, as a third.

   1        What is Dr Burman talking about here, as you
   2     understood it?
   3   A. I need to say that I am not absolutely sure what the
   4     term "clinical complaints" means, but at this stage the
   5     number of complaints made by patients -- what I am
   6     saying is, I am not quite sure what distinction was made
   7     between complaints about a waiting time or bad food or
   8     some health care professional did not do the right
   9     thing. I am not sure about the distinction within this
  10     phrase. But whatever that may have been, complaints
  11     were registered and a return was made to Region about
  12     the number of complaints --
  13   Q. Just pausing there, what he seems to have in mind may
  14     come out from the last three words, referring to
  15     "colleagues, finance or treatment", so it looks as
  16     though it is more than just the "hotel" services?
  17   A. It would suggest to me that whatever complaints were
  18     made, the patient may have said that some member of the
  19     staff of the hospital had made injudicious remarks about
  20     colleagues, finance or treatment, and he was advising
  21     people to be prudent, careful, before making such
  22     remarks.
  23   Q. Another way of putting it might be to be quiet rather
  24     than speaking up if the person is unsure about the force
  25     of the complaint they might like to make?

   1   A. I would not have thought that was correct. I think
   2     if one has a concern, let us say, and you are a member
   3     of the staff, there are channels through which you
   4     should progress your concern and that does not include
   5     the patient. I mean, I do not think that saying to some
   6     other patient that you have a concern about somebody is
   7     an appropriate channel, so I do not really think that
   8     the conclusion you are pointing to should be drawn from
   9     these remarks.
  10   Q. So you think the injudicious remarks referred to here
  11     are remarks made to patients rather than to others?
  12   A. It is in the context of "complaints", and complaints
  13     would be made by patients or their families. Therefore,
  14     I can only assume that these remarks are to be
  15     understood within that context. I do not think that
  16     that is, if you like, a new paragraph, a second point,
  17     saying that in general "you should not make remarks
  18     criticising your colleagues". I think it is stating
  19     that in the context of dealing with other patients or
  20     their families.
  21   Q. It does not go so far as to say "you should not make
  22     criticisms", but the words "extremely careful
  23     over making..." would suggest that people should be
  24     silent rather than speak unless they are pretty sure of
  25     their ground, I suppose is the implied message, is it

   1     not?
   2   A. I believe that this remark applies purely to what you
   3     are saying, that staff members would be saying to
   4     patients. I do not think it has any other significance.
   5   Q. So far as the complaints within the hospital were
   6     concerned, or the raising of concerns within the
   7     hospital, they could only be addressed, I think as you
   8     describe, concerns in relation to the subtle deficits,
   9     by a process of looking at figures, as we have
  10     discussed.
  11        What you say in your witness statement is -- can
  12     we look at WIT 120/23, the foot:
  13        "Paediatric cardiological audit took place on
  14     a monthly basis but lapsed for a period during and after
  15     1992 because of the presumed breach of confidentiality
  16     which was involved in Private Eye publications. This
  17     audit programme was led by one of the surgeons, once
  18     a ..."
  19        It goes on to deal with that.
  20        The Private Eye publication in 1992 is this, is
  21     it, at SLD 2/6. It is the left-hand column. Can we
  22     scroll down, please? We can see the second of the
  23     bullet points in the left-hand column:
  24        "The sorry state of paediatric cardiac surgery
  25     at the United Bristol Healthcare Trust has been

   1     confirmed by an internal audit of the last two years'
   2     operations. The results of procedures to correct
   3     two ..."
   4        I am not asking you to comment on the accuracy of
   5     the results, it is the process I am interested in. Then
   6     there is a criticism of you and a reference to the use
   7     of UBHT money.
   8   A. Sir, it was not this that I was referring to in my
   9     evidence.
  10   Q. It was not?
  11   A. No.
  12   Q. So essentially, I can go back and get up the other
  13     Private Eye comments on the screen, but can we go back
  14     to your statement, please? What Private Eye had raised,
  15     had it, were concerns, let us call them that, about the
  16     success or failure of operative treatment for children
  17     at the Bristol hospitals, in broad terms?
  18   A. Yes. Amongst other things, that is what they had
  19     raised, yes.
  20   Q. What I want your comment on at this stage, because as
  21     I have indicated I will ask you about those concerns and
  22     reactions to them in the autumn: but why should it be
  23     that because the Trust was said publicly to have bad
  24     results, that the Department should fail to consider, at
  25     all, what the results actually are? That is the way

   1     that it might be read, as a reaction --
   2   A. You mean in my statement that audit had lapsed? Is that
   3     what you are referring to?
   4   Q. You are describing that audit of examining results
   5     continues. Outside in the national media, there is
   6     a publication which says the results are bad. The
   7     reaction is, "Let us not look at the results at all",
   8     is one way of reading the reaction.
   9   A. May I explain what happened?
  10   Q. Certainly.
  11   A. In June, although I might have got the month wrong, but
  12     I think it was in June 1992, a surgeon presented an
  13     audit to the paediatric cardiological audit group, that
  14     is the cardiologists, surgeons, and whoever else. It
  15     was an open group who were usually nurses, radiographers
  16     and quite a wide variety of people. So this was open
  17     multidisciplinary audit in 1992.
  18        The particular work which was presented was a new
  19     work and all the results were not very good, but the
  20     details are not our concern today. But the point I wish
  21     to make is that those results were presented in full.
  22     Everything was put on the table frankly, openly and
  23     honestly.
  24        I know you are going to ask me questions about
  25     audit later, but let me just say that in all the

   1     guidelines about audit at the beginning, there was
   2     a discussion about the confidentiality of the process.
   3     A month or six weeks after the meeting at which these
   4     open and honest findings were put on the table so that
   5     they could be discussed constructively, it is those
   6     results which were published in one of the Private Eye
   7     documents. It was therefore not too difficult
   8     a deduction to make that the information had leaked from
   9     somebody who was in that group. I do not know who it
  10     was today, but it had to be somebody.
  11        Therefore, some of the members of the group were
  12     very, very upset and their confidence in -- that is
  13     a bad word to use, but their readiness to put
  14     controversial data on the table so it could be discussed
  15     openly and honestly was really undermined because they
  16     did not have confidence that the group would maintain
  17     the confidentiality which had previously been assumed.
  18        This is just a very difficult real situation for
  19     the people concerned.
  20   Q. So the consequence -- you may say the publication would
  21     not have happened if the results had been good, but let
  22     us suppose, had the results been so good that Bristol as
  23     a Trust might have wanted to boast about them, do you
  24     think the reaction would have been the same in terms of
  25     breach of confidentiality?

   1   A. I think that is a difficult question to answer, but
   2     I think it might have been, because after all, if
   3     confidentiality is breached on one issue, then it is
   4     even more likely to be breached on a more difficult
   5     issue.
   6   Q. The reason that I ask you that, in part arises because
   7     of -- I am dipping into audit here and I will come back
   8     to it -- a contrast perhaps between two documents which
   9     I would like to show you:  JDW 4/465, 7th April 1993,
  10     Bristol and District Health Authority, the notes of
  11     a meeting on medical audit, clinical standards and
  12     outcome measurement. If we can scroll down, the meeting
  13     considered a paper on audit. We see the third bullet
  14     point:
  15        "Individual clinicians would not expect to be
  16     identified separately during the monitoring process."
  17        Am I to take it that that was the general policy
  18     and approach in respect of audit?
  19   A. This clause, if I understand it correctly, has been
  20     taken from a paper prepared by Keiran Morgan, who was
  21     the Director of Public Health for the purchaser, so,
  22     first of all, I would say that this is an expression of
  23     his view, but to answer your question more precisely,
  24     I think that that view is one that you would find
  25     reflected in quite a number of documents about audit in

   1     the early 1990s.
   2   Q. So it was certainly in 1993 a generally held view, was
   3     it, that the individual surgeon should not be identified
   4     even though the Department or Directorate or the Trust
   5     might be?
   6   A. I am not quite sure what you mean by saying "the
   7     Department or the Trust might be".
   8   Q. If one has results for cardiac surgery, let us suppose,
   9     there may be a number of surgeons, if we are looking at
  10     adult cardiac surgery, possibly four or five surgeons
  11     who do it. One would have the results for the purpose
  12     of audit, and you could, if you wished, publish them.
  13     We will come to issues about that in a moment. But I am
  14     trying to understand whether the policy would be to say,
  15     "Well, that is our collective results, that is okay to
  16     publish, but we are not going to deal with any
  17     individual surgeon and separately publish the individual
  18     surgeon's results"?
  19   THE CHAIRMAN: And Mr Langstaff, perhaps Mr Wisheart
  20     in responding to that question could -- if I take you to
  21     the document on your screen, although the paper was
  22     prepared by Keiran Morgan, the bullet points seem to be
  23     observations made by the committee when it met to
  24     consider that paper.
  25   MR LANGSTAFF: Yes.

   1   A. Yes, thank you. I was not present so I cannot actually
   2     give an account of everything that was discussed at that
   3     meeting, but that is clearly correct, from the top.
   4        I think that we were at a time in the evolution of
   5     this process when what you say is correct as a general
   6     statement and there would have been a reluctance to
   7     identify individuals. I say that within cardiac
   8     surgery, we had begun a year or two before that to
   9     actually put individual data on the table.
  10   Q. Amongst yourselves?
  11   A. Amongst ourselves, and the information was available to
  12     others. I am just trying to make sure that what I tell
  13     you is correct, but it certainly was made available to
  14     a number of purchasers, voluntarily.
  15   Q. So the information which found its way into Private
  16     Eye arising out of the multidisciplinary meeting might
  17     well, within months, have been supplied to purchasers or
  18     others with a proper interest?
  19   A. I am referring mainly to adult cardiac surgery in my
  20     earlier remark. That was consistently done year by
  21     year. In paediatric cardiac surgery, my recollection is
  22     that the individual results were published for one year
  23     around this time, and then were not for the next couple
  24     of years, and that brings us to the end of the period.
  25        So I think it all reflects an evolution.

   1   Q. What inspired my reference to this document and the
   2     next one which I am going to show you, UBHT 38/235 --
   3     a document from July 1993 -- was my saying to you, what
   4     if, in fact, the results publicised in Private Eye had
   5     been marvellous results rather than poor results: would
   6     that have caused the same problems over
   7     confidentiality? You said, "Well, it might have done".
   8        This letter, July 1993, and I appreciate it is
   9     a year on from October 1992, or the middle of 1992, if
  10     we scroll down, it is to the South Western Region,
  11     "Cardiac services, comparative outcomes". It is from,
  12     I think, Dr Roylance. It says:
  13        "I have discussed the matters you have raised in
  14     the letter with Mr Wisheart."
  15        It is the last two sentences of the first
  16     paragraph:
  17        "As Dr Mason will be able to confirm, the result
  18     in Bristol [dealing with the adult surgery] compared
  19     extremely favourably with results published from one
  20     major London centre and one major provincial centre.
  21     Consistent results were also reported amongst the
  22     different surgeons within our unit."
  23        So, so far as the Trust was concerned, and indeed,
  24     so far as the information you were supplying to
  25     Dr Roylance was concerned, you were making, as it were,

   1     a virtue out of the inter-unit comparison between the
   2     adult cardiac surgeons?
   3   A. Sir, this is not information I provided to
   4     Dr Roylance. I mean, it was to enable him to write
   5     the letter, but the substance of it was information
   6     which I provided to the Directorate of Public Health of
   7     the South West Region, who, if you like, are the medical
   8     representatives of the purchasers. It was to that group
   9     that I presented the information about our surgery, the
  10     Parsonnet scoring system as a system of risk
  11     stratification and within that, I identified the results
  12     of the individual surgeons.
  13   Q. So was it the case that when it appeared that results
  14     were praiseworthy and when it appeared that surgeons
  15     were, each of them, producing praiseworthy results, that
  16     would find its way to the South Western Region? Did
  17     that differ if the results were not praiseworthy?
  18   A. I also provided this meeting with the results of
  19     paediatric cardiac surgery, including the results of the
  20     work that appeared in Private Eye.
  21   Q. I will come back to the question of audit in a moment or
  22     two. We are touching on it and really I have been
  23     exploring with you the question of how one would go
  24     about raising a concern, other than by the audit
  25     procedure, in the case of the subtle deficit that we

   1     have discussed.
   2        If one is looking at the question of individuals
   3     raising clinical concerns, the Senior Registrar, the
   4     nurse, the anaesthetist, were any steps that you can
   5     recall taken to encourage the expression of any such
   6     concerns throughout the Trust in the 1990s?
   7   A. Throughout the Trust as a whole?
   8   Q. Yes.
   9   A. There were steps taken to encourage people -- I would
  10     have to say, this was mainly to the medical staff and
  11     I would hesitate to state what advice was given to
  12     others, but the medical staff were certainly encouraged,
  13     repeatedly, to use the mechanism of the "three wise men"
  14     if they had a concern. I myself drew the attention of
  15     my colleagues to it on quite a number of occasions when
  16     I was either Chairman of the Medical Committee or
  17     Medical Director.
  18   Q. Can you pause there for a moment? To confirm that,
  19     because you are entitled to the confirmation, UBHT 2/14,
  20     this begins on the previous page but I do not think we
  21     need look at it. If we just scroll down, please:
  22        "The Chairman [this is you; this is the Medical
  23     Committee] referred to recent events in Birmingham where
  24     communications appear to have failed. He stressed the
  25     importance of invoking the mechanism available to any

   1     member of the medical staff."
   2        If we go overleaf(UBHT 2/15), we can see there you are
   3     offering to be approached yourself, indeed separately
   4     from the "three wise men" mechanism, although you were
   5     part of the "three wise men"?
   6   A. I think a better minute would have said that either I or
   7     the "three wise men" could be approached at any time,
   8     because that was the case. There were of course four
   9     "wise men", not just three, because the Chairman of the
  10     Division of Psychiatry was nearly always brought in to
  11     join the other three when something was under
  12     discussion, so there were actually four people.
  13   Q. In any event, you were saying, and the minute confirms
  14     it, that you raised on occasion the availability of
  15     yourself or the "three wise men" as a procedure?
  16   A. Yes, and this was triggered by an incident which is
  17     irrelevant to this Inquiry, and it happened on other
  18     occasions as well that this reminder was made.
  19   Q. Was it your experience that anyone in fact came forward
  20     in any part of the Trust to make a complaint of this
  21     nature about the competence of another surgeon, leaving
  22     aside for the moment cardiac surgery?
  23   A. There were certainly complaints. They were not all
  24     about performance in the sense in which maybe you mean
  25     it, but there certainly were a number of complaints over

   1     the years that I was involved with it and I believe they
   2     were handled appropriately and constructively, yes.
   3   Q. In those cases, would the person making the complaint be
   4     identified, generally, or would his or her identity
   5     remain probably confidential to the person to whom he or
   6     she spoke?
   7   A. I think my memory would be that within the group,
   8     usually it would be known who had spoken to somebody
   9     about the person who was being complained about.
  10   Q. So what, if any, steps were taken to protect that
  11     individual? What sort of steps?
  12   A. Nobody outside that group knew who they were. It was
  13     not perceived that there was any need to protect the
  14     individual. It was not perceived that the individual
  15     was at risk.
  16   Q. So the feeling that somebody might be, as it were, "sent
  17     to Coventry for being a snitch" did not arise?
  18   A. I would not have been conscious of it in the context of
  19     the "three wise men".
  20   Q. In any other context where concerns of this sort were
  21     raised, if not with the "three wise men", with others?
  22   A. I can certainly understand that it might have been
  23     a concern in people's minds, but I can recall a number
  24     of incidents, I think the number might be two, when
  25     Dr Roylance very specifically said that on the one hand,

   1     while there are appropriate ways to make a complaint,
   2     raise a concern, whatever, that even if it is done
   3     inappropriately, no action would be taken against that
   4     person, because there were Trusts who provided for
   5     disciplinary action to be taken against such activity
   6     and we very specifically and publicly reassured all
   7     members of the staff that that would not be the case.
   8   Q. In the record of the meeting in 1995, which I took you
   9     to earlier -- I am not going to get it back up on the
  10     screen -- the acrimonious meeting in cardiac surgery,
  11     there is considerable reference to obviously feelings
  12     running high, people not looking at others when they are
  13     being quite offensive to them, is the tone of the
  14     letter. Was it part of the inspiration for that
  15     behaviour that it was perceived that concerns had been
  16     raised but not addressed? Just a "Yes" or "No" would
  17     do.
  18   A. Raised but not addressed? I think these agreements
  19     were concerning the appropriateness of what had been
  20     raised and how it had been raised and I think we were
  21     very much "in the heat of the moment" at that time.
  22   Q. So how appropriate would it be to make any general
  23     conclusion, do you say, from that atmosphere at that
  24     time as to the way in which people raising concerns
  25     might be treated? The letter talks about accusations of

   1     disloyalty, and so on.
   2   A. I would not have thought so, because I would have
   3     thought an understanding of what had happened at that
   4     time required quite a detailed discussion about the
   5     events of that time, or how people perceived them, which
   6     I know -- at least, I do not think you wish to go into
   7     just now. Better to say how people perceived them.
   8     I think the roots of it lay there, and I think that what
   9     we are talking about there are fundamental disagreements
  10     between colleagues which they were airing freely at that
  11     stage. Nobody was penalising anybody else and those
  12     people are working together today. Nobody was
  13     suggesting that somebody should be victimised. I think
  14     they are airing their disagreements.
  15   Q. An instinctive reaction of your being disloyal by
  16     raising the concern about whatever it is, is plainly
  17     a reaction which would inhibit the raising of any such
  18     concern and would need to be met, would it not, by at
  19     least encouraging an atmosphere in which people
  20     recognised that concerns needed to be fully and frankly
  21     addressed and taken responsibly and seriously?
  22        Are you saying that that atmosphere was the
  23     general atmosphere, whatever the meeting in 1995 may
  24     have suggested?
  25   A. If I have misunderstood the question, please say so,

   1     but I would take the discussion in January 1995 that is
   2     referred to in that letter to be about -- I mean, we are
   3     at perception level, I am not discussing substance --
   4     the appropriateness and accuracy of what had been done,
   5     and I would actually take it as a statement that we want
   6     to do it openly and accurately, because that is
   7     basically how we had conducted our affairs, and part of
   8     the disagreement reflected in that letter was
   9     a perception that it had not all been conducted openly
  10     and accurately. I mean, our culture and ethos, as we
  11     understood it, was that we were putting our numbers on
  12     the table, we were putting our results on the table, we
  13     were discussing when people died, be they adult or
  14     child, why they died and there was an opportunity and
  15     openness for people to express a view, and that that was
  16     the correct way to go, in the first instance.
  17   Q. So far as the system that you described, the
  18     availability of yourself or the "three wise men", what
  19     would happen if the complaint was itself about one of
  20     the "three wise men"?
  21   A. Then there are two other "wise men" and there are other
  22     people, there are other channels. It is by no means an
  23     exclusive mechanism. If a complaint had cropped up
  24     about one "wise man" then the other two could have
  25     considered it, they could have co-opted other wise

   1     advice, if they felt that necessary. I mean, the
   2     position was totally flexible. And of course, there
   3     were also other lines through Clinical Directors
   4     directly to the Chief Executive, through the Professor,
   5     and so forth and so on.
   6   Q. Can I turn from the issue that we have been focusing
   7     upon, the expression of concerns, to deal with what we
   8     have been touching upon, which is the question of
   9     audit?
  10        One could, I suppose, distinguish between the
  11     personal audit which the surgeon conducts of himself and
  12     the audit of the service and the results which the
  13     service produces.
  14        So far as personal audit is concerned, you make
  15     the point in your statement that the surgeon would have
  16     his logs?
  17   A. His logs?
  18   Q. His logs.
  19   A. Yes.
  20   Q. You kept logs?
  21   A. I kept logs.
  22   Q. Logs of what sort of operations? All operations?
  23   A. I kept a log of all the operations I carried out in
  24     the Infirmary, which were in fact all open-heart
  25     operations on adults, children, whatever. I began at

   1     the beginning of my work in Bristol in 1975.
   2   Q. So if one looks at your logs -- I mention for the record
   3     that you have supplied your logbook to the Inquiry; for
   4     obvious reasons of patient confidentiality, it has not
   5     been and would not be without very heavy redaction ever
   6     published, but we have seen it and thank you for it.
   7        That contains, does it, each and every patient
   8     upon whom you performed an open-heart operation?
   9   A. To the best of my knowledge and belief.
  10   Q. What about closed-heart operations?
  11   A. What about closed-heart? I did not keep a similar
  12     personal log of those, but there was a card index system
  13     with the secretary in the Children's Hospital that
  14     I always had access to the names and to those events.
  15     That existed and that seemed to be satisfactory and for
  16     my purposes sufficient.
  17   Q. So in order to check on your own performance, whether
  18     you had been getting better or worse at doing
  19     a particular operation or series of operations, you
  20     would go to your log and add up the numbers?
  21   A. Yes.
  22   Q. You could go to, what, the card index?
  23   A. Yes.
  24   Q. And ask somebody else to extract the data, or extract it
  25     yourself?

   1   A. I would normally do it myself.
   2   Q. Did you do it yourself?
   3   A. Yes, every year. This did not happen right at the
   4     beginning, but it began early on and evolved to the
   5     point where each year I published an annual -- what
   6     I have called a "statistical summary". So in the
   7     preparation of that, I would have reviewed the cards in
   8     the Children's Hospital and used that information.
   9   Q. Was that a statistical summary for yourself, or for the
  10     service?
  11   A. It was for the service, so my colleagues, or colleague,
  12     whatever was the situation at the time, provided their
  13     information to me, and I collated it.
  14   Q. Do I understand that the information was, with odd
  15     exceptions, one of which you have referred to,
  16     aggregated rather than broken down by surgeon?
  17   A. The summaries that I am referring to were aggregated
  18     and I continued to produce those up until, I think,
  19     1992. When I handed over the clinical directorship of
  20     cardiac surgery to Mr Dhasmana, then he undertook that
  21     responsibility subsequently, because I basically had
  22     done it from the late 1970s in one shape or form.
  23   Q. I was going to ask you what happened after 1993,
  24     because we have a certain shortage of recorded results
  25     post-1993 that have come through to us in the papers.

   1     Can you help on that at all?
   2   A. I think I might be able to. I certainly have some and
   3     I would have thought you had everything that I had,
   4     but --
   5   Q. I would hope so.
   6   A. Yes, but I would be more than happy to check and confirm
   7     that. If there is anything you do not have that I have,
   8     then it will certainly be available.
   9   Q. Would you, please? So far as an audit is concerned,
  10     obviously one is looking for results compared to
  11     expectations?
  12   A. Yes.
  13   Q. When we come to morbidity rather than mortality, how did
  14     you measure results against expectations?
  15   A. We --
  16   Q. You personally, from your logs.
  17   A. The answer is that I did not count morbidity very
  18     frequently. I think I did sometimes, but not regularly,
  19     whereas I counted mortality regularly or whenever I was
  20     reviewing a group of patients.
  21   Q. By "mortality", would that be in-hospital mortality?
  22   A. The definition which we used was the definition set out
  23     in the cardiac surgical register in the early days,
  24     which was death within 30 days, or beyond that if the
  25     patient were still in hospital. In other words, any

   1     death of a patient in a hospital would be included but
   2     if a patient had gone home, let us say, on the tenth day
   3     and died on the twentieth day or the twenty-ninth day,
   4     then, when that information was provided to us, we would
   5     include that patient within the group of those who had
   6     died and attributed that death, if you like, to the
   7     operation.
   8   Q. You then kept the logs from 1975 onwards. Can we have
   9     a look on the screen, please, at UBHT 61/10? This is
  10     September 1989. It encloses a review by Dr Bolsin. Can
  11     we go two pages on to the page I want to ask you about
  12     which is page 12(UBHT 61/12)? It is in the paragraph which we see
  13     at the bottom of the screen there:
  14        "For both paediatric and adult work, the surgeons
  15     and anaesthetists must establish mandatory convenient
  16     morbidity and mortality meetings to fulfil both training
  17     and audit requirements ..."
  18        So what he is reflecting there appears to be
  19     a situation in which there were no regular audit
  20     meetings of mortality and morbidity in adult and
  21     paediatric cardiac surgery.
  22        Was that in fact the position in 1988/89?
  23   A. There were not regular mortality and morbidity meetings
  24     attended by the surgeons and anaesthetists. There were
  25     in existence such meetings attended by the surgeons.

   1   Q. So he is talking there, is he, about the need for
   2     surgeons and anaesthetists to get together, rather than
   3     for there to be such meetings?
   4   A. He is expressing that view. I should say, however, that
   5     it would be quite wrong for anybody to think that the
   6     surgeons and the anaesthetists did not meet. They did
   7     not meet in the form of a regular mortality and
   8     morbidity meeting, but they met occasionally to review
   9     the policies, work and goals of the team in paediatric
  10     cardiac surgery.
  11        One of the matters discussed and reviewed
  12     regularly in those meetings was the annual statistical
  13     summaries, so, in other words, the surgeons and
  14     anaesthetists did have an opportunity to review those
  15     results together from year to year. That is just what
  16     I want to point out.
  17   Q. So far as the surgeons are concerned, then paediatric
  18     figures were produced, were they, separately from adult
  19     figures throughout the period that we are concerned with
  20     from 1983 to 1995, annually?
  21   A. They were separate in the sense that they were
  22     identifiable, but they were produced in the one document
  23     with the adult figures.
  24   Q. So far as you personally were concerned, in your
  25     personal audit from your logs, how did you know how your

   1     performance, as disclosed to yourself, compared with any
   2     other surgeon doing similar work in Bristol or
   3     elsewhere?
   4   A. Up until 1986, for practical purposes, all the
   5     paediatric work was done by myself, so whatever the
   6     results in paediatric surgery were, they were mine.
   7        Subsequent to that, in terms of comparison between
   8     surgeons in Bristol, then whichever one of us was
   9     compiling a summary would gather together their own
  10     figures and receive the figures of their colleague from
  11     the colleague. So each one of us would be looking at
  12     our figures at that stage.
  13        In terms of comparing it with people outside
  14     Bristol, the only comparator available to us was in the
  15     most recent annual report of the register that was
  16     available to us. So, for example, say we were compiling
  17     the report for 1988 some time in the early months of
  18     1989. The probability is that we would have available
  19     to us the report for 1987 but not for 1988.
  20        As we went on from year to year, that would be the
  21     situation. We recognised, of course, that the register
  22     figures had to be viewed in a guarded sort of way, for
  23     a whole variety of reasons which are probably the
  24     subject of another discussion. So they were taken as
  25     a broad indication of what was being achieved across the

   1     country.
   2        The value of the register figures, on the other
   3     hand, is that, if we just assume their accuracy for the
   4     moment, they then reflected the work in the whole
   5     country. That is quite different from information that
   6     is available to us in the literature for any particular
   7     operation or group of operations, because mostly work in
   8     the literature is the work of a particular unit.
   9     Obviously, that unit may or may not be representative of
  10     the work in a country.
  11        So it had that value and it has to be
  12     distinguished, therefore, from other sources of
  13     information that we would tap into.
  14   Q. So the comparison of figures, if one looks at paediatric
  15     cardiac surgery, would be a comparison which would look
  16     back to what had been the historical picture as best it
  17     could be revealed by the Cardiothoracic Register one or
  18     two years earlier. One would make the assumption,
  19     I suppose, that on the whole success rates improved
  20     across the country over time, would one?
  21   A. If you review the register, which is the best way to
  22     answer your question, over the years that it has been
  23     published, you can track that progress very precisely.
  24   Q. That would give you, in Bristol, a reflection of how
  25     well you were doing comparatively as a unit, as compared

   1     to units aggregated elsewhere in the country?
   2   A. That is correct.
   3   Q. It would not, I suspect, tell you whether you, as
   4     a surgeon, were doing very much better or very much
   5     worse than quite a number of other surgeons elsewhere in
   6     the country, because individual data would be subsumed
   7     in the whole?
   8   A. Yes. I mean in that sense what you say is correct, but
   9     of course I know my individual data; I know the data of
  10     our individual unit, and those two things I can compare
  11     with the aggregated data.
  12        I should add, because I am not sure if I made it
  13     clear, that when I prepared the annual statistical
  14     summaries, I included the figures for each operation
  15     from the most recently available, so it was there for
  16     everybody to see. I am not sure that I said that.
  17   Q. When there was a death following surgery, was there
  18     any system of review of that individual death?
  19   A. Yes, there was.
  20   Q. What was that?
  21   A. Excuse me if I am getting a little hoarse. I hope
  22     you understand.
  23   Q. Do help yourself to water if you have not.
  24   A. In paediatric cardiac surgery, from quite an early
  25     time, we had a practice that if a patient died, the

   1     cardiologist, the surgeons and the paediatric
   2     pathologists would meet together and review all the
   3     circumstances leading to the death of that child, so we
   4     would be looking at the investigation and its adequacy,
   5     we would be looking at surgery, we would be looking at
   6     post-operative care, we would be looking at findings, at
   7     autopsy, we would be looking at perhaps how the child
   8     was managed between investigation and surgery. In other
   9     words, it was an open discussion of anything that could
  10     have been a factor leading to the death of that child.
  11        Obviously, there were two reasons for doing that.
  12     One was so that we could reach the best possible
  13     understanding of what had happened in that particular
  14     case, and secondly, hopefully, so that if there was
  15     anything to be learned, we could learn it.
  16   Q. On occasions, did that process of review illuminate
  17     avoidable error?
  18   A. Your question says "avoidable error". I think I would
  19     need notice of that one. If I may answer a slightly
  20     different question, which I know I am not meant to do,
  21     we certainly learned from that review, regularly -- it
  22     was actually one of the most beneficial meetings we
  23     had. To the question about the avoidable error, I do
  24     not think I have anything in my mind that would enable
  25     me to answer that at the moment.

   1   Q. Let us suppose the pathologist said, "I have examined
   2     the heart and it seems to me [I use this for the sake of
   3     example] that there may be a problem here with the
   4     surgical repair which has been done; it is
   5     inappropriate". Suppose it was that.
   6        In such a case, you have your personal response to
   7     that, you or whichever surgeon it might be, to say
   8     "Obviously I must not do that again". In such a case,
   9     were the next of kin told that is what had happened, or
  10     not?
  11   A. Where the next of kin were -- okay. If a patient died,
  12     and we are talking now of children, it was my practice
  13     to suggest to the parents that if they thought it would
  14     be helpful, would they please come back to see me after
  15     a period of time, or whenever they wished to have the
  16     conversation, so that we could discuss all of the
  17     circumstances and events surrounding their child's
  18     death. That would include information that had been
  19     gained from the postmortem, and perhaps -- again, I did
  20     not keep a record so any figure is a guess, but my guess
  21     is that probably half the parents would come back to
  22     talk to me. Of course some of them lived very far away.
  23   Q. So if it happened to be one of those parents and if it
  24     happened to be that the pathologist had identified
  25     surgical error, the parent would be told?

   1   A. Well, there are a few "if"s there. There were very few
   2     instances in which surgical error of the type that
   3     I think you are suggesting was identified and I would
   4     doubt -- I am actually trying to think. You see, I know
   5     that Dr Berry published a paper on this subject --
   6     Professor Berry -- in the late 1980s and there are some
   7     facts and figures there. He did report a small number
   8     of autopsies in which something was found about the
   9     surgery which might have been done differently -- and
  10     I am avoiding the use of the word "error" -- but I am
  11     just saying it might have been done differently, and it
  12     was quite a small number.
  13        You see, a surgical error could include
  14     a situation where there was something wrong in the heart
  15     that we were unaware of and therefore what we did, if
  16     you like, was inappropriate, but we did have not that
  17     knowledge at the time. So there are a whole range of
  18     errors. Certainly, if there were some additional
  19     findings of that sort, that would have been told to the
  20     parents, but if there was a frank surgical error which
  21     was an error without qualification, I am not sure that
  22     that would have been told to the next of kin.
  23   Q. Why not?
  24   A. I said I am not sure because I am really talking about
  25     a situation where I am not absolutely sure. I am not

   1     sure about how frequently, I am not sure about the
   2     precise circumstances and I am not sure that there were
   3     not instances in which I did say it, so ... it is facts
   4     and instances and reasons for it that I am searching
   5     for, which I cannot really recall.
   6   Q. If, with reflection between now and the next time you
   7     come back to give evidence to us, you recall what the
   8     reason was or probably was, will you let us know?
   9   A. I shall revisit Professor Berry's paper and I shall try
  10     to see if I can establish any factual basis for doing
  11     that, certainly.
  12   Q. It may also be that if there is a specific case which we
  13     have, that we will let you know in respect of that, and
  14     you can focus your comments?
  15   A. That would be very helpful.
  16   Q. Moving away from personal audit and the meeting -- one
  17     thing you can tell me about the meeting after death:
  18     were such meetings minuted?
  19   A. No, they were not. Not until -- when Dr Ashworth came
  20     in, I think 1993, he began to keep a record of what
  21     patients were considered and who was present at the
  22     meeting. I think that was all.
  23   Q. In terms of the unit and the performance of the unit and
  24     the audit, you have told us about the annualisation of
  25     figures. We know that there were monthly audit meetings

   1     in 1992 because we have looked at the reflection in your
   2     statement of the fact that they stopped for a while
   3     following Private Eye and issues over confidentiality?
   4   A. That was only the paediatric cardiological audit.
   5     Cardiac surgical audit continued.
   6   Q. When did the paediatric cardiological audit begin on
   7     a monthly basis?
   8   A. I was hoping you would not ask me, because I am not
   9     actually quite sure.
  10   Q. Roughly?
  11   A. I know that Dr Martin put out a programme for 1983 and
  12     I do not think --
  13   Q. 1983 or 1993?
  14   A. I am sorry, 1993, I beg your pardon. The events we have
  15     been talking about were 1992. You quoted the bit where
  16     I said that subsequently it lapsed. I know that there
  17     was a programme for 1993. It may even be in the
  18     documents. I am not sure.
  19   Q. I can help you with some references --
  20   A. That of course does not necessarily mean, you know --
  21     given the circumstances we are in, I am not off-the-cuff
  22     able to say to you that the meeting scheduled for
  23     January 1993 definitely happened. That is my
  24     difficulty.
  25   Q. Can I take you back before 1993 to the beginning of

   1     1992? UBHT 61/153. It is 3rd January 1992. This is
   2     again Dr Martin writing, in this case to Dr Jordan:
   3        "Audit of paediatric cardiology. I think it is
   4     very important we recommence our audit sessions in
   5     1992."
   6        The audit of paediatric cardiology, that is
   7     distinct, is it, from the audit of paediatric surgery?
   8   A. No, what he is referring to is an audit programme, if
   9     I might use that word loosely, which embraced both
  10     cardiology and paediatric cardiac surgery.
  11   Q. He talks about recommencing the audit sessions, "It is
  12     important that we recommence...", which might suggest
  13     they had not been done for a little while?
  14   A. I think what happened was this -- and I have a feeling
  15     that it was in 1989 -- that Dr Martin first proposed
  16     a programme of audit meetings, so in a sense in terms of
  17     formal audit that was really quite early in its
  18     evolution. I think there was some problem -- initially
  19     I think those problems were scheduled for 8.00 in the
  20     morning or some time -- it does not matter what the time
  21     was -- but it did not prove to be a time that people
  22     found practical, so attendance was poor and it lapsed
  23     a bit.
  24        What he is doing here is to suggest that we
  25     recommence the audit sessions in a different format,

   1     a different time. It will be a wider discussion, and
   2     this was in fact on a particular Wednesday at lunchtime
   3     each month. This format, basically, worked very well.
   4   Q. The earliest reference that I can find to regular
   5     meetings -- I want to know if regular meetings began
   6     before this -- is UBHT 61/107. This is 18th December
   7     1989. It is the foot of the page.
   8   A. I think this is the letter to which I was referring.
   9   Q. That does appear to be the origin of the regular
  10     clinical audit meetings?
  11   A. Yes.
  12   Q. So can we take it that there may be some inaccuracy in
  13     it, but can we take it that broadly, from the beginning
  14     of 1990, thereabouts, there were attempts made to
  15     conduct regular audit meetings?
  16   A. Definitely.
  17   Q. Which had not been held as such before in --
  18   A. Not as such. This was in response to the government's
  19     White Paper of 1988 or 1989.
  20   Q. Yes. We have heard about that from other sources. I am
  21     going to explore this afternoon with you some further
  22     issues which arise in relation to audit, the publication
  23     of audit results, and the difficulties that there may
  24     have been in audit, in conducting it.
  25        First, sir, I think we have come to the half an

   1     hour break that we normally have on a Tuesday,
   2     a 40 minute break, for lunch.
   3   THE CHAIRMAN: It is ordinarily 45 minutes, Mr Langstaff.
   4     Are you suggesting something to me "sub silentio", as
   5     they sometimes said in the old days?
   6   MR LANGSTAFF: I am entirely in your hands.
   7   THE CHAIRMAN: Shall we say 35 minutes, then and come back
   8     in whatever 35 minutes is from now, because my
   9     arithmetic will let me down again. You will tell me.
  10   MR LANGSTAFF: 10 to 1.
  11   THE CHAIRMAN: Thank you.
  12   (12.15 pm)
  13            (Adjourned until 12.50 pm)
  14   (1.00 pm)
  15   MR LANGSTAFF: The purposes of audit were, were they, to
  16     inform and educate the clinician -- at least, that was
  17     the way it was seen in the late 1980s?
  18   A. I think the most fundamental purpose of audit is to
  19     improve the quality of care delivered to the patient,
  20     but of course, in order to do that, then what you have
  21     referred to needs to be achieved.
  22   Q. In order to understand the figures, if one was looking
  23     at an audit which consists of the figures -- there were
  24     other measures you have referred to in your statement
  25     and I do not trouble you with those -- one would need to

   1     understand something of what the figure signified?
   2   A. Yes.
   3   Q. Can we look at HA(A) 11/372, 11th July 1990, the
   4     Bristol & Weston Health Authority, in relation to
   5     contract development. Medical audit is the first of the
   6     issues. Mr Wisheart presented a paper which outlined an
   7     approach to medical audit, and there is a stratification
   8     of adults and children that we see there.
   9        We go on:
  10        "It was felt that this approach was appropriate
  11     in terms of operative risks and costs of procedures."
  12        So far as operative risks are concerned, was it
  13     the view that children under 1 year of age were to be
  14     distinguished from children over 1 year of age?
  15   A. That was clearly the intention, because those are two of
  16     the four groups.
  17   Q. The reason I ask is that it is not only operative risks
  18     but also costs of procedures that is referred to, and
  19     I just wanted to make sure that it was perceived, by you
  20     because you were presenting the paper, that there was
  21     a distinction in general terms in operative risk between
  22     the two children's groups?
  23   A. I think it is important just to acknowledge for the
  24     record that the distinction at the end of the day is not
  25     an official one, or an arbitrary one, but having said

   1     that, it has some uses. Possibly the most practical
   2     importance of that is that it would conform with the way
   3     in which results were reported in the cardiac surgical
   4     register.
   5   Q. You go on to outline that audit was considered under
   6     two headings, firstly outcome, secondly process. And
   7     you say what outcomes would be considered. This is
   8     obviously to inform the Bristol & Weston Health
   9     Authority contracting, but so far as audit of process is
  10     concerned, that is distinguished from outcome, the
  11     process no doubt would be evaluated against standards as
  12     to the length of stay, the ITU length of stay,
  13     the hours, days ventilated and so on, because audit
  14     would not make sense unless there was a standard to
  15     measure against?
  16   A. That is correct but it is an ideal statement because
  17     I am not aware that any such standards existed. Perhaps
  18     therefore take what I have said here as a goal to be
  19     worked towards, but not something that could be achieved
  20     tomorrow, because the bits and pieces to do it were
  21     simply not available.
  22   Q. We know, because you have told us, that figures were
  23     derived annually, at least until the time that you
  24     ceased to be the Associate Clinical Director of Cardiac
  25     Surgery. What about audit of process in relation to

   1     those items. Was that documented anywhere?
   2   A. Not generally. But it was the goal and of course, it
   3     was in order to do this that I wanted the cardiac
   4     surgeons to introduce the use of computerised
   5     information because I think that it is probably only
   6     possible to either collect or process the sort of
   7     information I have set out in this paragraph if it is
   8     done in that way.
   9        First of all, it means that it is there and
  10     available and you have an established process of
  11     recording it, and secondly, it can be processed in an
  12     accessible way. If you have to do it manually it will
  13     be incomplete, there will be errors and it is very hard
  14     to process.
  15   Q. Can we move on from July to 5th September 1990, UBHT 98,
  16     which begins at 204? It identifies the meeting of the
  17     Hospital Medical Committee when Mr Dean Hart was the
  18     Chairman. It is page 205(UBHT 98/205).
  19        This is Dr Thomas tabling a paper in which you had
  20     an input as author, recommending a District Audit
  21     Committee. He then goes on to say:
  22        "There were unclear lines of responsibility for
  23     audit, but the routes that were clear were those between
  24     the Colleges and those districts that needed recognition
  25     for training ... audit was to be part of a consultant's

   1     contract but there was no definition of the type or
   2     standard of audit."
   3        Stopping there, was it the case that there were
   4     unclear lines of responsibility for audit? This is
   5     1990.
   6   A. I think it is definitely the case. What we see, over
   7     a period of time, is how a proposal, an idea virtually,
   8     that was embodied in the White Papers was being
   9     translated into something that would be done and
  10     eventually would be seen as part of everybody's
  11     obligation, but it took time to move from the idea
  12     position to the implementation position, so in essence
  13     what Dr Thomas says is absolutely correct.
  14   Q. We see in the next paragraph, at that stage members felt
  15     that audit should be medically led. That was the
  16     general feeling at the time, was it?
  17   A. As I recall, that was consistent with what the White
  18     Paper suggested, and it is certainly consistent with
  19     whatever guidelines and publications appeared in 1988 or
  20     1990, that I can recall.
  21   Q. We know that over the next few years they developed the
  22     idea that audit should be clinical audit involving other
  23     disciplines, other than the medical?
  24   A. Yes.
  25   Q. What was your response personally to that. Was that

   1     to be welcomed?
   2   A. To the development of the idea of clinical audit?
   3     I felt that in essence it was the right thing to do. It
   4     was part of how I generally thought of things, but
   5     a service that is delivered to a patient is delivered by
   6     a group of people, not just nurses, not just doctors,
   7     not just whoever, so the team of people who deliver the
   8     service I think should appropriately audit it so that
   9     they can each look at their own contribution and they
  10     can each feel responsible and accountable for the final
  11     product.
  12        So that is number 1. Number 2: I continue to
  13     believe that there was a place in terms of education and
  14     peer review for audit to be an activity conducted by
  15     doctors in the interests of their education and so
  16     forth, so initially I felt we should not totally throw
  17     out unidisciplinary audit, I thought that it continued
  18     to have a place, and on the whole, I still think that.
  19   Q. You refer to it, if we look at UBHT 98/17. This is
  20     5th January 1994. We see the reference to the
  21     Chairman. The Chairman was you. "But we must be
  22     perceived to be carrying out the national guidelines
  23     lest we lose audit monies. We must also maintain
  24     medical audit ..."
  25        The reasoning that you were expressing -- I want

   1     to know if the minute is accurate, is "as a valuable
   2     educational and peer review activity."
   3   A. I am sorry, this is a committee of which I was the
   4     Chairman, is it?
   5   MR LANGSTAFF: Yes. I am sorry, shall we --
   6   A. That is fine. I see the year, so I am sure that is
   7     correct. Yes, that last sentence expresses the view
   8     that I have just said to you.
   9   Q. As I say, this is 5th January 1994?
  10   A. Thank you. Is that a Steering Committee?
  11   Q. Shall we go back to page 13?(UBHT 98/13) It is my fault for not
  12     identifying the document, trying to be too quick, I am
  13     sorry.
  14   A. Yes, thank you very much.
  15   Q. So back again to 17(UBHT 98/17). Implicit in the comment that you
  16     make there and the comment you made a moment ago where
  17     you sit, was that clinical audit is less valuable as an
  18     educational and peer review activity?
  19   A. I think different. I do not think I was making any
  20     value judgments as to the superiority of one over the
  21     other; I was simply saying that there was a place for
  22     both.
  23   Q. What would you get out of medical audit that you would
  24     not out of clinical?
  25   A. I think the problem is -- what I felt is simply this:

   1     that if you have a group of people from different
   2     disciplines, you can probably pursue a question so far
   3     down the road together, before some members of the group
   4     will be losing interest. I am not confining this to
   5     doctors, I am confining it to any one discipline, but if
   6     you have a group of people in one discipline, they will
   7     probably follow their interest in that area of audit
   8     rather further down the road and in more detail, and
   9     maintain the interest of the group. I think that is
  10     really what I mean.
  11   Q. So it is a question, really, of motivation, is it, to
  12     take part --
  13   A. No, I think it is a question of they are in different
  14     positions, their remits and responsibilities are
  15     different. It simply reflects the fact that although
  16     people worked together as a team, they have differing
  17     responsibilities, different professional commitments,
  18     and it is right and proper that they should explore
  19     their individual professional responsibilities as
  20     individual professional responsibilities, as well as
  21     being right and proper that they should explore it with
  22     members of the team from other disciplines.
  23   Q. In the appli