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FULL TRANSCRIPT

   1                    Day 44, 6th September 1999
   2    (10.40 am)
   3   THE CHAIRMAN: Good morning, everyone. Good morning
   4     Mr Langstaff.
   5            STATEMENT BY MR LANGSTAFF
   6   MR LANGSTAFF: Good morning, sir. Since it is now some time
   7     since we last met in public, it is probably right that
   8     I should take a moment or two to say what has been
   9     happening and bring everyone in what we call our "wider
  10     public" up to date.
  11        Since we last met, a number of important
  12     developments have taken place, both in terms of the way
  13     in which this Inquiry is managing the evidence, in terms
  14     of moving towards finality in the timetable, and indeed,
  15     looking ahead to Phase II of the Inquiry, which will
  16     begin early next year.
  17        Although a number of us may have been on holiday
  18     over the August period, work has continued here in
  19     Bristol in the Inquiry offices and an analysis of
  20     evidence which has been heard and collected during the
  21     period of March to July has been under way and has been
  22     consolidated. That has involved a lot of reading,
  23     inevitably, and has resulted in the commissioning of
  24     further evidence and further work.
  25        Amongst those from whom we appealed for evidence

   1     were the junior doctors and nurses who had been at the
   2     Bristol Royal Infirmary or the Bristol Children's
   3     Hospital during the period covered by our terms of
   4     reference, 1984 to 1995.
   5        We think, it has to be said, that we know most of
   6     the people who might be described -- all the people who
   7     might be described as major participants in the events
   8     which unfolded, but we are, of course, keen to hear from
   9     anyone who thinks they may have anything to say.
  10        The doctors, from whom we have yet to hear in
  11     numbers, although we have heard from some of them, are
  12     junior doctors and nurses, and it may well be the case
  13     that perhaps they feel that they have little of
  14     importance to say: a reflection, perhaps, of their
  15     status at the time as doctors, or a reflection of the
  16     fact that some of them may only have spent a matter of
  17     months here in Bristol.
  18        It is difficult for us to trace them because there
  19     are no off-the-shelf lists of all those who worked at
  20     the BRI during the 12 year period. Accordingly, we
  21     would, through me, this morning, add to the appeal which
  22     has already been made: if anyone has not yet heard from
  23     the Inquiry -- we have contacted many of them -- who
  24     worked as a junior doctor or nurse in the Bristol Royal
  25     Infirmary or the Children's Hospital during the period

   1     of our terms of reference, please get in touch with us.
   2     For those who feel they may have nothing useful to say,
   3     could I just observe that we would rather be the judges
   4     of that and that they should trust the Inquiry to know
   5     whether they will have something which can add to the
   6     knowledge that has already been accumulated, or not.
   7        There is a very different picture, I have to say,
   8     so far as doctors who referred children to Bristol is
   9     concerned. There can I pay credit to the number of
  10     doctors, virtually all of whom we have contacted,
  11     virtually all of the doctors who referred patients on to
  12     Bristol have responded to the Inquiry, and those who
  13     have something material to say will of course be invited
  14     to say that in the usual way.
  15        Turning from evidence which we have yet to hear to
  16     the further appeal for people to contact the Inquiry.
  17     It is now common knowledge, because it has been set out
  18     on the Internet that a clinical case note review is
  19     under way. There are 80 sets of medical records which
  20     are being scrutinised by teams of medical experts. We
  21     made undertakings which we intend to honour in respect
  22     of the confidentiality of those records. It is
  23     difficult to contact all the families involved, although
  24     we think we have contacted most. Those parents with
  25     whom the Inquiry has been in regular contact will know

   1     whether their child is or is not one of the cases
   2     involved in the detailed clinical case note review.
   3     However, there are some parents whose identity is yet to
   4     be ascertained and have yet to be traced. It is not an
   5     easy job, as anyone listening will understand. Parents
   6     whose child underwent heart surgery at the Bristol Royal
   7     Infirmary or the Bristol Children's Hospital between
   8     1984 and 1995 and who have -- and I emphasise this --
   9     never been in contact with the Inquiry, should please
  10     get in touch if they have any reason to think that their
  11     child's case may be part of the current review.
  12        For those who are reading this on the Internet,
  13     there is a local freephone telephone number for anyone
  14     who wishes to enquire, and as I say, I emphasise that
  15     this is parents who have never yet been in contact with
  16     the Inquiry. The number is 0845 3000 613.
  17        We are currently trying to trace 20 of the 80.
  18        The expert teams who are looking at those sets of
  19     case notes in the initial sample are five in number:
  20     a cardiac surgeon, cardiologist, anaesthetist,
  21     intensivist, pathologist, and paediatric nurse or
  22     intensive care nurse. There are a number of such
  23     teams. I am happy to report that we now have a cohort,
  24     if that is the right description, of 51 experts in total
  25     advising the Inquiry, and again, I am pleased to report

   1     that virtually everyone who has been invited to join the
   2     expert panel from the number of qualified experts in the
   3     country, invited of course after nomination by those who
   4     might have an interest in the Inquiry, has been happy to
   5     give of their services. For that we are grateful.
   6        One expert to the Inquiry who will not be involved
   7     in the clinical case note review but is present with us
   8     today and who I shall invite in a moment or two to say
   9     a few words about herself is Valerie Mandelson who sits
  10     to my right on what has become known as the expert
  11     table. She has a particular expertise in counselling,
  12     which is appropriate, because that is where we shall
  13     begin the autumn's programme.
  14        If I can turn, then, to the programme for this
  15     autumn, we will sit for hearings for the next three
  16     weeks and then take a break for a week, so that there
  17     will be no hearings in the week which begins
  18     27th September. After that, we start again on Monday
  19     4th October.
  20        We will go on from then until 25th October, and
  21     have a reading week for us, a break for others, until
  22     1st November. We will then continue with the oral
  23     hearings all the way through up until just before
  24     Christmas.
  25        So far as the first three weeks are concerned,

   1     what we have in store for you, members of the Panel, is
   2     this. Today we shall hear once again from parents.
   3     There are four parents who are going to tell us their
   4     stories. Can I emphasise that we are today, this week,
   5     considering Issue I, which is counselling, the
   6     information and support. That is the focus of the
   7     hearing.
   8        Each of the parents who is going to give evidence
   9     today has a story to tell, which in part may be
  10     distressing. It would be wrong if I were not to say
  11     something about why it is that some of the details of
  12     their story and their child's story will almost seem to
  13     be "skated over" in evidence. It is not that this
  14     Inquiry does not wish to pay proper respect to what has
  15     happened. It is not that those details are unimportant;
  16     they are there in writing on each of the statements. It
  17     is merely because, in order to conduct this Inquiry in
  18     an efficient way, and to get at the details which you
  19     have to get at in order to complete your report, we must
  20     necessarily focus upon certain aspects of the care. It
  21     would be entirely wrong if anyone were to feel that, by
  22     focusing upon certain aspects, that other perhaps, to
  23     the parent, more important aspects of their child's care
  24     and life were in some way being given less attention
  25     than they deserve. I apologise if that is an impression

   1     that they are left with. I am sure -- I hope -- that
   2     the parents giving evidence today will understand. It
   3     is important that those who listen also appreciate what
   4     today's programme is about.
   5        We will hear this morning from Mrs Brenda Spicer
   6     and Erica Pottage. It will be this afternoon when we
   7     hear from Julie Johnson and Helen Johnson. Tomorrow is
   8     by way of exception to this particular issue. It will
   9     be the first of the expert evidence sessions when we
  10     shall take evidence, expert evidence, to assist the
  11     Inquiry panel as to broadly the nature of congenital
  12     heart defects, their problems, the nature of the
  13     surgery, investigations, appropriate treatment and the
  14     like. This begins with Professor Robert Anderson, who
  15     is a Professor of Paediatric Cardiac Morphology, who
  16     will, tomorrow, give us his input from very considerable
  17     experience of dealing with the development and structure
  18     of the paediatric heart.
  19        That begins at 10.30. We normally, of course, on
  20     a Tuesday start at 9.30, but by reason of his travel
  21     arrangements we begin at 10.30 tomorrow, not 9.30.
  22        Wednesday and Thursday: we will hear on Wednesday
  23     from the Reverend Cermakova, the Chaplain at
  24     St Michael's Hospital, and from Helen Stratton, who was
  25     for much of the time with which we are concerned

   1     a cardiac liaison nurse and support nurse specialist,
   2     amongst other things researching into parents' reactions
   3     to their child's treatment at the BRI.
   4        On Thursday we will hear from Jean Pratton, the
   5     former Honorary Secretary of the Bristol and South West
   6     Children's Heart Circle which provided much of the
   7     finance for counselling services and accommodation,
   8     amongst other things, at the BRI, and from Mrs Helen
   9     Vegoda, who was a counsellor in paediatric cardiology at
  10     the Bristol Royal Infirmary.
  11        Next week is largely a week given to, again,
  12     expert evidence as to the nature of the problems which
  13     confront the clinicians. But on Monday, finishing off
  14     some of the issues we were looking at before the summer
  15     break, we will hear from Sir Donald Irvin, President of
  16     the General Medical Council.
  17        There will follow seminars on Tuesday, Wednesday
  18     and Thursday, first of all from cardiologists, expert
  19     evidence; then from a cardiologist and two
  20     cardiothoracic surgeons; and on the Thursday, from
  21     a cardiac surgeon, an intensivist and cardiologist and
  22     a cardiac nurse clinician, as to the importance of
  23     intensive care.
  24        The third week in the three-week batch we will
  25     hear from Sir Graham Hart, the Permanent Secretary of

   1     the Department of Health from 1992 to 1997, and then, on
   2     Wednesday 22nd September and Thursday 23rd September, we
   3     will revisit Issue J. It is likely that on
   4     21st September we will hear from parents in respect of
   5     Issue J, Issue J being the question of the retention of
   6     organs. We will, in that week, hear from Dr Michael
   7     Ashworth and on 23rd September, from Professor Berry,
   8     Professor of Paediatric Pathology at St Michael's
   9     Hospital.
  10        The Coroner for Avon, Mr Forrest, has agreed to
  11     give evidence, but for timetabling reasons it is not
  12     possible for his evidence to be heard during that week,
  13     but it will be at a soon and convenient date after that.
  14        Broadly speaking, the work which will then follow
  15     will be: in October, we will look at the history of and
  16     the details of concerns which were raised in Bristol by
  17     those, and amongst those other than clinicians directly
  18     involved in treatment. We expect that before we come to
  19     dealing with clinicians, we will have the results of the
  20     first stage in our approach to statistics which, if you
  21     remember, was outlined to the Inquiry, which took advice
  22     from Dr David Spiegelhalter just before we broke for the
  23     summer. It is likely that the clinicians who were
  24     principally involved in the treatment of children will
  25     deal with both the question of adequacy and the question

   1     of the concerns raised, and answer such questions as
   2     arise in respect of informed consent in the November and
   3     December periods.
   4        So that is a broad map of where we are going,
   5     having reminded you of where we are coming from.
   6        In the more distant future, there is Phase II of
   7     the Inquiry, where you, the Panel, will wish to consider
   8     the evidence that you have heard and consider what, if
   9     any, recommendations you feel it appropriate to make to
  10     the Secretary of State, and for that end, will intend,
  11     I know, to canvass various possible recommendations with
  12     those who have something to say in particular about them
  13     in a series of seminars.
  14        The proposals which have been made by this Inquiry
  15     in respect of Phase II were sent out for consultation,
  16     and I am pleased to report that thus far we have had 24
  17     detailed responses, so it is plain that although it is
  18     some months distant yet, it is already exciting
  19     considerable interest in what one might describe as
  20     circles which have something to add.
  21        Sir, that is enough, I think, from me. It was,
  22     perhaps, more than a moment or two! Before Mrs Spicer
  23     comes to give her evidence, Mr Maclean will be asking
  24     her the questions, I wonder if I may just ask Valerie
  25     Mandelson to introduce herself, and anticipate that

   1     perhaps later during the course of the evidence, she may
   2     have something useful to contribute publicly to us in
   3     respect of counselling and information services.
   4        It is better, I think, that she introduces
   5     herself, rather than that I do.
   6   MRS MANDELSON: Thank you. Good morning. My name is
   7     Valerie Mandelson and I am employed as manager and
   8     senior counsellor at the Alder centre. The Alder centre
   9     is based at Alder Hey Children's Hospital and is
  10     a centre to offer support and counselling to anyone
  11     affected by the death of a child. It has been open for
  12     the past ten years and we provide a range of services to
  13     bereaved parents, from parents who have lost a child
  14     through miscarriage right through to the death of an
  15     adult child. Not only children from the hospital, but
  16     from the whole of the North West, particularly
  17     Merseyside. As a centre we offer training and
  18     consultation to other professionals and carers who may
  19     be supporting bereaved families.
  20   THE CHAIRMAN: Thank you very much, first, for that, and
  21     secondly, for being with us during the next days while
  22     we take this range of evidence.
  23        Mr Maclean?
  24   MR MACLEAN: Sir, good morning. Can I invite Mrs Spicer to
  25     come to the witness table, please.

   1            MRS BRENDA SPICER (SWORN):
   2            Examined by MR MACLEAN:
   3   Q. Your full name is Brenda Jean Spicer?
   4   A. That is correct.
   5   Q. And you are, I think, a member of the Bristol Heart
   6     Children's Action Group?
   7   A. I am, yes.
   8   Q. Could I ask you to look at the screen beside you,
   9     please, and could I have document WIT 253/1? That is
  10     the front cover, is it not, of the written statement
  11     that you have made to the Inquiry?
  12   A. It is, yes.
  13   Q. If we go over the page, please, to page 2, that is the
  14     first page of that statement and that is your signature
  15     at the bottom?
  16   A. It is, yes.
  17   Q. As you say there, you and your husband Robert William
  18     Spicer, who is present, I think, here this morning, had
  19     a baby boy Gary, and Gary was born on 13th July 1988?
  20   A. That is correct, yes.
  21   Q. Obviously I will explore that a little more in
  22     a moment. Can I just take you to page 13? That is the
  23     last page of the statement, is it not?
  24   A. It is, yes.
  25   Q. And that is your signature again?

   1   A. It is, yes.
   2   Q. You also submitted very helpfully to the Inquiry, if we
   3     go to page 15, some annotated notes. These have been
   4     typed up, if you go to page 17. The heading there is
   5     "Dr Martin - Consultant. Questions put to Dr Martin".
   6     As is clear from the contents of your statement, those
   7     are notes that you made at a meeting with Dr Martin some
   8     considerable period of time after your son was operated
   9     on at the hospital?
  10   A. Yes, correct. It was a friend that took the notes. She
  11     was with me. We saw Dr Martin in February of 1998.
  12   Q. We will come back to that. Page 20: would you explain
  13     the provenance of that?
  14   A. This is the diagram that Dr Martin drew for us on the
  15     day, showing us the four repairs that had to be --
  16   Q. When you say "on the day", you mean at the meeting in
  17     1998?
  18   A. That is right, yes.
  19   Q. I think those are all the documents that you have
  20     submitted to the Inquiry, are they not?
  21   A. That is correct, yes.
  22   Q. Can I take you back in time then, Mrs Spicer, to 1988,
  23     and to paragraph 7 of your statement at page 3.
  24        At this stage your son Gary had been born at
  25     a healthy weight of 7 pounds and 11 and a half ounces

   1     and although a heart murmur had been detected when the
   2     paediatrician examined Gary, he had been discharged home
   3     and appeared to be perfectly normal?
   4   A. That is correct, yes.
   5   Q. Then paragraph 7, you say that about a month later,
   6     a month after the outpatient appointment at Gloucester,
   7     there was an appointment to see Dr Martin, the
   8     cardiologist?
   9   A. That is correct, yes.
  10   Q. At what age would Gary have been at that stage?
  11   A. Probably about six weeks, a month to six weeks.
  12   Q. He told you that Gary was suffering from tetralogy of
  13     Fallot?
  14   A. That is right, yes.
  15   Q. Had you ever heard of tetralogy of Fallot before?
  16   A. No.
  17   Q. What did Dr Martin explain was the problem?
  18   A. I cannot remember too much about it. I know that it
  19     would have to be four repairs done, but he said that
  20     initially Gary would have a smaller operation, probably
  21     at about six months old, they would take a vein from his
  22     leg to help the heart, and the full correction would be
  23     done when Gary was three years old.
  24   Q. So as we see from paragraph 9 at the foot of the page,
  25     you understood that Gary was going to hopefully undergo

   1     two operations?
   2   A. That is right, yes.
   3   Q. A full correction being three years or so --
   4   A. When he was older and stronger and could cope, yes.
   5   Q. So having been told that your son was suffering from
   6     this congenital heart condition, the next contact which
   7     Gary had with the Bristol hospital was in February 1989,
   8     was it not, when he came here?
   9   A. He came to have the catheter test. That was in the
  10     February, yes.
  11   Q. That is paragraph 12, page 4.
  12   A. Yes, that is right, yes.
  13   Q. In the interim, Gary had been seen by Bristol
  14     cardiologists at clinics which they held in Gloucester,
  15     because it was closer to your home?
  16   A. That is right, yes.
  17   Q. At this stage, in February 1989, when Gary was just
  18     a little over six months old, was there some discussion
  19     at that stage about the operation options for Gary's
  20     condition?
  21   A. No. There was no discussion. Gary had the tests done
  22     at the Children's Hospital, and Dr Martin came to us and
  23     said that he was "in fine stead for the big one", but he
  24     said it was not our concern, he would go away and
  25     discuss it with the surgeons, and then they would decide

   1     what operation Gary would have and they would notify us
   2     at a later date, which is what they did.
   3   Q. What did you understand by "he is in fine stead for the
   4     big one"?
   5   A. Well, the full correction.
   6   Q. So you understood that in fact it was now being
   7     suggested that Gary should undergo the full correction
   8     in one go?
   9   A. That is right, because he was thriving and doing very
  10     well, and they thought it would be more beneficial that
  11     Gary had one major operation rather than two.
  12   Q. When you saw Dr Martin, you were accompanied, I think,
  13     by your husband, were you?
  14   A. Yes, we were together, yes.
  15   Q. Who else was present at the discussion with yourself,
  16     your husband and Dr Martin?
  17   A. Dr Martin came on to the ward with other doctors. I do
  18     not know who they were. He said to us that Gary was in
  19     fine stead and that the success rate was 90 per cent,
  20     and that was excellent, and because I remember saying to
  21     him, "What happens to the other 10?". I had not thought
  22     of death at this time. He explained to us that the
  23     other 10 meant "we would lose them".
  24   Q. In other words, those patients died?
  25   A. That is right.

   1   Q. You understood that happened to the other 10 per cent?
   2   A. Yes. So when he said 90 per cent, we thought, "Well,
   3     Gary has an excellent chance", so we sort of went with
   4     what they said.
   5   Q. Can I just ask you to look at an extract from Gary's
   6     medical records? It is MR 2506/0051. It is the
   7     right-hand side of the page. It is that paragraph,
   8     perhaps we could look at that, please. We will blow it
   9     up for you, Mrs Spicer, to make it a bit easier. This
  10     is 15th February 1989, so a day or two after the
  11     catheter had been carried out. Presumably the results
  12     of that were to hand, were they?
  13        It says:
  14        "Patient referred from cardiac catheter. Parents
  15     seen by Dr Martin and told the pulmonary valve has
  16     narrowed. He also briefly discussed the two operative
  17     options: either a full correction or a shunt. Gary's
  18     [I think the next word is 'arteries'] are at present
  19     a little too small for the full correction, but
  20     Dr Martin will see parents in Gloucester in a couple of
  21     weeks, having liaised with the surgeons. Gary will be
  22     reviewed in the morning prior to discharge."
  23        Can you tell me -- I appreciate it was a long time
  24     ago and probably nobody has asked you this since: can
  25     you tell me what you remember about the brief discussion

   1     which this note suggests you had with Dr Martin --
   2   A. We did not have one. He walked -- I can see him now.
   3     He walked down the ward, he held out his hands and he
   4     said "He is in fine stayed for the big one", so from
   5     that day on, we understood Gary would go for the full
   6     correction.
   7   Q. Did you say "Dr Martin, we understood it was going to be
   8     a two-stage process"?
   9   A. No. He said it was a 90 per cent success rate and he
  10     was almost excited by this, so we just went along with
  11     what he said. The only time we discussed the two
  12     operations we were in Gloucester.
  13   Q. What did he say there?
  14   A. That was when Gary was very young, and he said that he
  15     would have a smaller operation when he was about six
  16     months old. That was when he discussed the vein being
  17     taken from his leg, but that was the only time that he
  18     spoke to us of that operation.
  19   Q. We discussed that at the beginning: that your initial
  20     contact with Dr Martin, when Gary was six weeks or so
  21     old, suggested that he would undergo a two-stage
  22     process?
  23   A. Yes.
  24   Q. Here we have the note of 15th February 1989 suggesting
  25     that there are two operative options: either a two-stage

   1     process or a full correction in one go. It is suggested
   2     in this note that there was a brief discussion at this
   3     stage. You have told me you do not remember a brief
   4     discussion?
   5   A. No, I do not, no.
   6   Q. Do you remember a discussion about options, either
   7     a two-stage process or a one-stage process, any other
   8     time?
   9   A. No, because on this day he said that it was not our
  10     concern; he would go away and discuss it with the
  11     surgeons, and they would decide as to what Gary was
  12     going to have.
  13   Q. The note does suggest, it is fair to say, that Dr Martin
  14     suggested that your son was not quite ready for the full
  15     correction at that stage. You see the line "Gary's
  16     arteries are at present a little too small for the full
  17     correction, but Dr Martin will see parents in Gloucester
  18     in a couple of weeks, having liaised with the surgeons."
  19        What do you recall the feedback to you being from
  20     Dr Martin, he, Dr Martin, having liaised with the
  21     surgeons?
  22   A. As far as I recall, it came by post, telling us that
  23     Gary would be admitted on April 7th, because these tests
  24     were in the February. We did see Dr Martin in the
  25     meantime and he said something about Gary's oxygen being

   1     fairly low in the body, so they needed to do something:
   2     "he does need an operation". If I remember rightly, it
   3     came in the post, what they were actually going to do.
   4   Q. But do you remember any further feedback to you, to your
   5     husband, discussing these options?
   6   A. No, no, definitely not, no.
   7   Q. Or was it, as far as you were aware from the 15th --
   8   A. The smaller operation was only told to us in the first
   9     instance. It was never mentioned again.
  10   Q. So there was no question of choosing between the two
  11     options?
  12   A. No, because he said it was between him and the surgeon
  13     to discuss it together. He said it was not our
  14     concern.
  15   Q. Did this strike you as being peculiar or odd? Did it
  16     cause you any concern?
  17   A. No, because I had never had any dealings -- we just went
  18     along with what we were being told.
  19   Q. So you are not perhaps in a position to help us with the
  20     content of the discussion that might have taken place
  21     between Dr Martin or other cardiologists on the one hand
  22     and the surgeons on the other?
  23   A. No, not at all, no.
  24   Q. The operation that Gary had was conducted by which
  25     surgeon?

   1   A. I am sorry, I was just reading that (indicating
   2     screen). If Dr Martin had said to us that Gary was not
   3     ready for the full correction, we would have stopped it
   4     anyway. If he had said that to us, what he has written
   5     down here, we would not have gone along with the full
   6     correction anyway.
   7   Q. That is why I was asking what feedback you had?
   8   A. No, we did not. There is no way we would have put our
   9     child in for that, knowing he was not ready.
  10   Q. This note suggests that there is --
  11   A. No.
  12   Q. -- as I said, a question mark over Gary's --
  13   A. No, we were not told at all, no.
  14   Q. -- there was a question mark over Gary's fitness for the
  15     full correction at this stage. He did in fact have the
  16     full correction operation?
  17   A. He did, yes.
  18   Q. I was wanting your help with whether you had received
  19     any information which would have suggested to you that
  20     in fact Gary was capable of undergoing --
  21   A. He said, Dr Martin said, "He is in fine stead". He put
  22     his hands out as he said it to me, and he said it was
  23     90 per cent success rate, so everybody seemed to have
  24     the opinion that they could do this; that it would be
  25     okay. That is the first time I have seen that.

   1   Q. Do you recognise the name, it may be "Howell" in the
   2     right-hand column, the person who has signed these
   3     notes?
   4   A. No.
   5   Q. So the position was, then, that Gary had been
   6     catheterised in February 1989, and he eventually had
   7     surgery in April of 1989, I think on 11th April?
   8   A. He did, yes.
   9   Q. By that time he would have been perhaps a little bit
  10     bigger and a little bit stronger?
  11   A. Yes, he was doing very well, actually, considering.
  12   Q. So might it not have been that whilst Gary's arteries
  13     were, as the note says, at present a little too small
  14     for the full correction, by April --
  15   A. Well, possibly. I do not know.
  16   Q. But you were not --
  17   A. Definitely not, no.
  18   Q. At all events, Gary did have the operation on 11th April
  19     1989, did he?
  20   A. Yes, he did.
  21   Q. He had that operation at the Bristol Royal Infirmary?
  22   A. He did, yes.
  23   Q. Before that operation took place, prior to the immediate
  24     period before that operation, had you or Gary ever been
  25     in the Bristol Royal Infirmary before?

   1   A. No.
   2   Q. Did you have any information or communication from the
   3     Bristol Royal Infirmary before Gary was admitted to lead
   4     you to -- so you would know what to expect?
   5   A. Yes, we had a package come with Gary's dates of
   6     admission. Yes, there was quite a bit of information in
   7     there, I recall.
   8   Q. Do you remember what was said, what type of material it
   9     was?
  10   A. No, I do not, no.
  11   Q. Does the name Helen Stratton ring a bell?
  12   A. It was Helen Vegoda, when we were there.
  13   Q. Yes, you are quite right, Helen Stratton had not -- you
  14     are quite right. Helen Vegoda was at that stage working
  15     at the Children's Hospital and the Bristol Royal
  16     Infirmary?
  17   A. Yes, that is right, yes.
  18   Q. 10th April 1989 was the day before Gary's operation?
  19   A. That is correct.
  20   Q. I think you met Mr Dhasmana that day?
  21   A. Yes. I think it was that evening. It was either that
  22     evening or the one before. I cannot really remember.
  23   Q. Had you ever met him before?
  24   A. No.
  25   Q. Had you heard his name prior to that stage?

   1   A. No.
   2   Q. This is paragraph 22 of your statement, at WIT 253/6,
   3     paragraph 22. If we go to the bottom of the page,
   4     paragraph 24, your statement deals with the discussion
   5     that you had with Mr Dhasmana on 10th April.
   6        If we go over the page, page 7:
   7        "He explained to us the surgery was not so
   8     straightforward as working on an adult because of the
   9     smaller scale. Mr Dhasmana went on to say he never knew
  10     what he might find until he opened up."
  11        Was there any difference in your mood or
  12     expectations after the meeting with Mr Dhasmana compared
  13     to the earlier discussion with Dr Martin?
  14   A. Definitely.
  15   Q. In what way was it different?
  16   A. Mr Dhasmana, the way he spoke to us and said, "This is
  17     a very big operation for such a small and young child",
  18     and it shocked us, really, because we thought we had
  19     such great expectations of, you know, they could do
  20     this, and Dr Dhasmana put a completely different picture
  21     to us, really. The fact that he said, because we were
  22     led to believe it was Fallot's tetralogy without
  23     complications, but Mr Dhasmana said "I never know until
  24     I open up what I will find; I could find other
  25     complications and things", it was awful, really.

   1   Q. Dr Martin had told you that the success rate was 90 per
   2     cent?
   3   A. He did.
   4   Q. You understood that to mean that 1 in 10 patients died?
   5   A. That is right.
   6   Q. But notwithstanding that, having spoken to Dr Martin,
   7     you felt fairly confident?
   8   A. We did.
   9   Q. Did not Mr Dhasmana give you a different assessment of
  10     percentage risk than Dr Martin?
  11   A. He did not talk percentage at all to us, no, he did
  12     not. But he was definitely putting a different picture
  13     to it, to us: quite distressing, really.
  14   Q. He painted a gloomier picture?
  15   A. He did, definitely, from the other doctors and people we
  16     had spoken to.
  17   Q. Did you ask him whether or not the number of patients on
  18     average who died was more than 1 in 10?
  19   A. No, we did not, no. I think we were in shock then. We
  20     did not say too much.
  21   Q. Did it strike you as being -- did it jar with you that
  22     you were being given what you thought to be a different
  23     impression?
  24   A. It did, definitely.
  25   Q. You say at paragraph 26, just below where the screen is,

   1     that there was no mention of brain damage or other
   2     non-fatal injury?
   3   A. No, nothing.
   4   Q. Was that something that had passed through your mind,
   5     that Gary might be left with brain damage after the
   6     operation?
   7   A. At the time? No. Not at all. It never occurred to us
   8     at all.
   9   Q. 11th April 1989 was the day that Gary had his operation?
  10   A. Yes.
  11   Q. And if we go over the page, please, to page 8, a nurse
  12     went down with Gary to theatre, and this is about
  13     8 o'clock in the morning?
  14   A. Yes.
  15   Q. You were told that it would be a good idea to ring back
  16     at 1.30?
  17   A. That is right, yes.
  18   Q. Did you take Gary down to be anaesthetised? Were you
  19     with him at that stage?
  20   A. No, we went to the lift and asked one of the nurses to
  21     go with him, because we found it too distressing.
  22   Q. You were given the option, were you?
  23   A. We were, yes.
  24   Q. And you declined?
  25   A. That is right.

   1   Q. Then initially, as you say in your statement at 30 and
   2     31, things seemed to go well, did they not?
   3   A. Yes. They all seemed, when Gary first came on to the
   4     ward, you know, the nurses and -- they all seemed very
   5     pleased.
   6   Q. So at this stage, you understood that Gary had undergone
   7     the full correction?
   8   A. Yes.
   9   Q. And that if everything went well, that would be it?
  10   A. Yes.
  11   Q. You spoke, I think, that day to Mr Dhasmana -- this is
  12     paragraph 31.
  13   A. Yes.
  14   Q. He had some bad news in the sense that Gary had a faulty
  15     heart valve and so in fact this was not to be the end of
  16     the operations for Gary at all?
  17   A. That is right.
  18   Q. What did Mr Dhasmana say at that stage about the
  19     surgery?
  20   A. He said that Gary had a faulty valve and that he would
  21     need another operation at a later date, and I was quite
  22     shocked. I said, "Oh, when is that going to be?" He
  23     said "Let us deal with this problem first. Let us get
  24     him better and we will talk about another operation at
  25     a later date". That was all that was said.

   1   Q. Did he seem surprised that the faulty valve had been
   2     found?
   3   A. I do not know. I do not think so. I do not think so.
   4     He was quite matter-of-fact about it. I do not know,
   5     really.
   6   Q. Did you ask him, "Well, why did you not know about this
   7     before?"
   8   A. No, I did not. I just wanted my child to get better.
   9     I could not take on board something else that was going
  10     to happen later on. I could not deal with it, really.
  11   Q. Looking back now, is that a question that has occurred
  12     to you since?
  13   A. Yes, definitely, because we had just understood it was
  14     Fallot's tetralogy and no complications. To me, that
  15     was a complication.
  16   Q. Jumping ahead a little bit, we know you saw Dr Martin in
  17     February 1998, I think, it was -- during 1998. Was that
  18     one of the questions you asked him then?
  19   A. Yes. I think we did mention it.
  20   Q. What did you understand the response or the answer to
  21     be?
  22   A. I cannot remember. I cannot remember at this moment,
  23     actually. It is on the notes. I got the impression
  24     that Dr Martin knew about the valve, actually.
  25   Q. If you go to page 17, paragraph 10, the question to

   1     Dr Martin was [adding some words to make more
   2     grammatical sense]: if a faulty valve had been picked up
   3     in the operation, why had it not been picked up before,
   4     and if it had been picked up before, would it have
   5     changed the recommendation?
   6        I assume that is the recommendation as to the
   7     surgery that Gary underwent?
   8   A. Yes.
   9   Q. The response is recorded as being:
  10        "It was recognised pre operation and discussed
  11     with the surgeon".
  12   A. But I do not remember ever being told about the faulty
  13     valve at all.
  14   Q. That is why it was a shock to be told about it
  15     immediately after the operation?
  16   A. It was, yes.
  17   Q. Back to your statement at page 8. Mr Dhasmana seemed
  18     pleased by Gary's progress, did he not?
  19   A. Initially he did, yes.
  20   Q. Paragraph 32, and not surprisingly, that pleased you
  21     too?
  22   A. Oh, definitely, yes.
  23   Q. You then refer, at paragraph 33, that evening, that is
  24     the evening of the operation, 11th April, to Gary's
  25     blood pressure dropping and to the nurses appearing

   1     concerned for his condition?
   2   A. That is right, yes.
   3   Q. Over the page, please, paragraph 34, one nurse said "He
   4     is very, very poorly". 11th April 1989 was a Tuesday.
   5     Then you say, at 35, the following day the nurses seemed
   6     to be "backing off": so there was an air of concern?
   7   A. Yes. They were not so attentive to Gary. They were not
   8     sort of like they were the day before, you know, as
   9     if --
  10   Q. You mean they were not being so social, they were being
  11     more professional, as it were, they were spending more
  12     time actually doing things with him, rather than giving
  13     him more general nursing care?
  14   A. What, the day before, from surgery?
  15   Q. Yes.
  16   A. Yes, there was definitely a change.
  17   Q. You say at 35: "If we asked anyone, such as an enquiry
  18     as to how Gary was progressing, we were told we would
  19     have to speak to Mr Dhasmana"?
  20   A. That is right.
  21   Q. When did you next speak to Mr Dhasmana?
  22   A. To be truthful, I cannot really remember. I think
  23     probably between the Tuesday and the Saturday. We did
  24     probably talk to him, but I cannot really remember, to
  25     be truthful.

   1   Q. What did you understand the prognosis to be at that
   2     stage between the Tuesday and the Saturday?
   3   A. Gary's blood pressure had stabilised, and one doctor
   4     said, "Well, we think Gary is going to be in intensive
   5     care for probably, you know, two weeks", which was sort
   6     of a week longer than they expected, it was going to
   7     take a bit more time for him to come round, but we did
   8     not mind so long as he was going to be all right.
   9     I seem to remember during those couple of days they had
  10     to restart Gary's heart, something had gone drastically
  11     wrong, and they sent us off the ward.
  12   Q. So you knew he was very sick?
  13   A. By this time we did, yes. We knew things were not
  14     right, but we did not really know what was happening, to
  15     be honest with you.
  16   Q. Did you think at this stage that it looked as if Gary
  17     might be going to die?
  18   A. No, not until the Saturday.
  19   Q. The Saturday is paragraph --
  20   A. I am not too clear on those days between sort of the
  21     Wednesday, Thursday and Friday. I cannot really
  22     remember.
  23   Q. It would be fair to say that on the day of the
  24     operation, initially everything seemed to be going well?
  25   A. It was. By the teatime things had started to change.

   1   Q. Deterioration by the evening of the operation?
   2   A. Yes, the blood pressure was the cause for concern that
   3     day, as far as I understood it.
   4   Q. Tell me about the Saturday?
   5   A. The Saturday we were sat with Gary, Mr Dhasmana walked
   6     around the ward, put his hand on my shoulder and said
   7     "We think he is brain-damaged" and walked away. Rob
   8     and I sat there, in shock, really. We went back to our
   9     room, and I said to Rob, "How can he be brain-damaged?
  10     Nobody has ever said anything about brain damage". So
  11     I went back to speak to Mr Dhasmana, but he had gone.
  12     They said I would have to wait until he did his rounds
  13     to speak to him; he would not come back to talk to me.
  14   Q. Did you speak to him?
  15   A. Not that day, no.
  16   Q. Did you talk to anybody else?
  17   A. I spoke to the nurses but they would not talk to me
  18     about it at all. They said I would have to wait until
  19     Mr Dhasmana came back. I was in such a state.
  20     I remember saying, "Does this happen?", you know, and
  21     they just said I would have to wait.
  22   Q. You mentioned you and your husband went back to your
  23     room?
  24   A. Yes.
  25   Q. Where were you staying throughout this period?

   1   A. Initially we were in a house, but when things were not
   2     going well they gave us a room in the hospital.
   3   Q. Was that one of the two rooms on the same floor as the
   4     Intensive Care Unit?
   5   A. Yes.
   6   Q. Initially, had you been staying in one of the rooms,
   7     houses or flats provided by the Heart Circle?
   8   A. Yes, we were.
   9   Q. Having received this distressing news on 11th April, was
  10     there anyone else you were aware of who was there to
  11     support you, to help you?
  12   A. No.
  13   Q. Is that because you would not have welcomed such
  14     assistance, or because it was your impression that it
  15     was not there?
  16   A. Helen Vegoda was actually on leave. She went on leave.
  17     She did come and tell us she was going, so I cannot
  18     remember exactly the day she went, but she was not there
  19     this day, that this happened.
  20   Q. When did you next see a doctor about Gary's condition,
  21     this news that he was brain-damaged?
  22   A. I think probably the following day they decided to take
  23     Gary, take some of the drugs off to see if he was -- to
  24     get him to come round, because they said he would start
  25     twitching as he was taken off the sedation, et cetera.

   1   Q. They were reducing the sedatives in order to see if he
   2     was going to wake up?
   3   A. That is right. This did not happen, so probably
   4     Mr Dhasmana -- I honestly do not remember -- someone
   5     came and spoke to us and said somebody from Frenchay
   6     would be coming in to do a brain scan. I think it was
   7     the Monday and Tuesday, they came.
   8   Q. What did you understand the purpose of that to be?
   9   A. To see if Gary was brain dead, or brain-damaged,
  10     I presume. But Mr Dhasmana did talk to us in-between
  11     times, but I cannot remember the discussions, to be
  12     truthful.
  13   Q. If we go to MR 2507/23, this is a letter which I think
  14     you have seen this morning from your son's medical
  15     notes. It is dated -- it looks like the 18th of the
  16     11th, but I think actually it is a 4. It is 18th April
  17     1989:
  18        "Dear Dr Schutt,
  19        "Thank you very much for seeing this unfortunate
  20     child. I operated on him a week ago when tetralogy of
  21     Fallot was repaired without any technical problem.
  22     Post-operative he did well for the first 4 hours, after
  23     which his haemodynamic state deteriorated rapidly. For
  24     about 12 to 18 hours, his blood pressure was ranging
  25     around 45 to 55 systolic, despite a very high dose of

   1     adrenalin ...
   2        "Unfortunately, his neurological state has not
   3     improved. For the last five days, his pupils have
   4     remained dilated and fixed. Paralysing agent and
   5     sedation has been stopped. EEG has just been carried
   6     out which is waiting for Dr Morgan's report, but to my
   7     unskilled eyes looks very distressing. I would value
   8     your assessment and advice for further management of
   9     this very unfortunate child."
  10        That is signed by Mr Dhasmana. That is
  11     18th April, which was, as Mr Dhasmana says, exactly
  12     a week after Gary's operation.
  13        Then, if we go back to your statement at 253/10,
  14     just before we come to paragraph 40 -- it is difficult
  15     to remember, I know, but what was your mental state by
  16     19th April 1989? Did you by now expect that Gary was
  17     going to die?
  18   A. Oh, yes. I think it had happened long before we were
  19     told. But, yes, we really did expect the worst now.
  20   Q. And the worst came, did not it, on 19th April?
  21   A. Yes, round about, I think we saw Mr Dhasmana about 5.30,
  22     6 o'clock in the evening on the 19th.
  23   Q. Do you remember who was present?
  24   A. No, I do not, actually. I know Mr Dhasmana took us into
  25     a room, just the three of us, and spoke to us and said

   1     that Gary was a very sick child and we had to take him
   2     there and there was nothing more they could do. He said
   3     that we could have some extra time before everything was
   4     switched off if we needed it, but he had pressures as
   5     well, you know, so he left the room and gave us some
   6     time. So we went back on the ward and the anaesthetist
   7     came and switched everything off. They put screens
   8     around us.
   9   Q. Let me just take you back a little. Do you remember
  10     where the room was that you spoke to Mr Dhasmana?
  11   A. We went off intensive care. I think it was to the left.
  12   Q. Was it his office?
  13   A. No, it was just a room with some chairs in.
  14   Q. It did not leave any lasting impression, the room?
  15   A. No, this little room was where he took us when he needed
  16     to talk to us each time.
  17   Q. You say in the statement that you spoke to Mr Dhasmana
  18     about 5.30 in the evening. I do not think we need to go
  19     to this, but I think that in fact the note suggests
  20     Mr Dhasmana -- perhaps he made the note -- at 6.30,
  21     saying he discussed the matter with you and your
  22     husband; that you had been told about Dr Schutt's report
  23     and Dr Maisey's findings: "Unfortunately the child is
  24     now brain dead. They want time to think it over, think
  25     over stopping the ventilating support", and in fact Gary

   1     died at about a quarter past 7 that evening.
   2        Over that period, between speaking to Mr Dhasmana
   3     in the room with your husband and Gary actually dying,
   4     do you remember who else was around, who else played
   5     a role in supporting you or your husband?
   6   A. No-one. There was no-one else. As I say, we went back
   7     to the ward and they put some big screens around us and
   8     the nurse stood at the head of the bed whilst the
   9     anaesthetist switched everything off. I think he asked
  10     us, or the nurse may have asked us, if we wanted to hold
  11     Gary, which we did, and he then left.
  12   Q. Was there anyone who offered to make any practical
  13     arrangements, funeral arrangements or transportation of
  14     Gary's body?
  15   A. No, nothing.
  16   Q. Were you offered any such assistance?
  17   A. No.
  18   Q. You say in paragraph 41 Mr Dhasmana said you could go
  19     back to see him at a later date?
  20   A. Yes, he did.
  21   Q. He said that to you on that date, did he?
  22   A. Yes, he did, yes.
  23   Q. But you chose not to?
  24   A. No.
  25   Q. Did you have any further communication from the hospital

   1     subsequently?
   2   A. No.
   3   Q. Concerning Gary?
   4   A. No.
   5   Q. Do you remember when you left the hospital that night?
   6   A. We went back to our rooms, we packed our case and we
   7     left. We drove home.
   8   Q. The Inquiry has heard some evidence from some parents --
   9     I will just source this: Mr Parsons, Day 2, 17th March,
  10     transcript page 106; Mr Curnow, Day 3, page 96, both of
  11     whom referred to feeling as if they were put under
  12     pressure to get off the scene quickly.
  13   A. Definitely. Mr Dhasmana's attitude, as far as we felt
  14     that day was, switch off, you know, "Let us get moving,
  15     let us switch things off and go". The nurses, no-one
  16     spoke to us. They all looked away and looked down.
  17     I think quite a few of them were upset, you know. But
  18     no, the only nurse we spoke to was when we asked how
  19     much we owed them for staying in the house, which they
  20     did not accept, they said no, and that was the only
  21     people we spoke to.
  22   Q. Perhaps you will tell me if you accept this, but there
  23     is perhaps a balance to be struck between some bereaved
  24     parents who want privacy and time on their own and other
  25     parents who might welcome support from outside agencies

   1     and it is sometimes difficult to strike the right
   2     balance with everyone?
   3   A. Yes, I can understand that, yes.
   4   Q. What was not done for you which you think ought to have
   5     been done in terms of making this difficult time easier?
   6   A. I think it was just done so quickly. You know, I look
   7     back now and I think, we just left Gary on that bed. We
   8     did not -- we just packed up and went so quickly. We
   9     were not given any time, you know, even Mr Dhasmana,
  10     when he wanted us to switch off, it was, "Well, I can
  11     give you a little time but I have got pressures", so you
  12     just felt rushed. I just regret that day that we did
  13     not sit with Gary longer or where was he moved to, what
  14     did he do? We just left.
  15   Q. Do you know what happened to him immediately after?
  16   A. No. I presume he went to the mortuary.
  17   Q. We know that you had a meeting with Dr Martin years
  18     later, after the events at Bristol had come to public
  19     attention, but other parents -- for example, Mr Bwye,
  20     Day 6, 24th March, page 41 -- have told the Inquiry that
  21     they received letters from, I think in his case
  22     Dr Martin weeks after the death of his child, inviting
  23     him back to discuss the matter, to discuss the
  24     treatment.
  25   A. No, definitely not.

   1   Q. You did not receive that?
   2   A. No.
   3   Q. Just briefly, just before we come to the end of my
   4     questions, a postmortem was carried out on Gary, was it
   5     not?
   6   A. Well, I found out in recent years it was. I did not
   7     know at the time.
   8   Q. I think this morning, for the first time, you saw the
   9     postmortem examination report?
  10   A. That is right.
  11   Q. I think you had become aware that some of Gary's organs
  12     were removed and retained?
  13   A. They were, yes.
  14   Q. Which were those?
  15   A. The brain and the heart.
  16   Q. When did you first discover that?
  17   A. A few months ago. This year. I cannot remember the
  18     date, but they took Gary's brain. Gary died in the
  19     April and they disposed of it in July. They still have
  20     the heart at the BRI.
  21   Q. To this day?
  22   A. Yes.
  23   Q. Can we look, please, on my screen only first, at
  24     MR 2506/21?
  25        That is the postmortem examination report on Gary,

   1     is it not?
   2   A. That is right.
   3   Q. If we look at the end of the first paragraph, do you see
   4     the heading "History" on the left-hand side, near the
   5     top?
   6   A. Yes.
   7   Q. "A 9 month old child", do you see?
   8   A. Yes.
   9   Q. Take a moment to read that paragraph. At the end of the
  10     paragraph it says:
  11        "Post-operative recovery was uneventful".
  12   A. Yes.
  13   Q. Then over the page, the top of the page deals with the
  14     cardiovascular system, that first paragraph. Then
  15     towards the bottom half of the page:
  16        "In my opinion, the cause of death was cerebral
  17     infarction due to or as a consequence of cardiac failure
  18     due to or as a consequence of Fallot's tetralogy
  19     surgical repair."
  20        That is signed at the bottom by Professor Berry
  21     who conducted the post-mortem.
  22        Do you understand why your son died after the
  23     operation which was, it seems, technically a good repair
  24     of his congenital heart defect, when his post-operative
  25     recovery was initially uneventful?

   1   A. All I know is that Gary was brain dead. I have never
   2     been given an explanation as to why.
   3   Q. This is the final matter I want to deal with: you did
   4     have a meeting with Dr Martin?
   5   A. That is right.
   6   Q. As we have mentioned a few times. That was in February
   7     1998, I think?
   8   A. I think it was, yes.
   9   Q. If we go to page 17, WIT 253/17, question 3:
  10        "What is the success rate? We were told 85 to
  11     90 per cent. Where did these stats come from?"
  12        Dr Martin replied that the mortality now [February
  13     1998] was between 3 to 5 per cent, but between 5 and 10
  14     per cent in 1989.
  15        That would suggest, would it not, that the risk
  16     assessment you were given was, if anything, slightly
  17     conservative?
  18   A. Yes, that is right.
  19   Q. Then, at question 6: why was the big operation chosen in
  20     Gary's case as opposed to the small one to tide him
  21     over? You asked whether Mr Dhasmana was at the table
  22     when the decision was taken because in the ward he shook
  23     his head and said "This is a very big operation for
  24     a baby of this size".
  25        The answer does not actually reveal whether the

   1     decision was taken for Gary to have the single
   2     correction. Do you understand when that decision was
   3     taken? We have seen the note of 15th February 1989.
   4   A. No, I do not. No.
   5   Q. The fact that you asked the question, whether
   6     Mr Dhasmana was at the operating table when the decision
   7     was taken to have the single correction, might suggest
   8     that you were not, in February 1989, at all clear which
   9     operation had been decided upon when Gary actually went
  10     into the operating theatre?
  11   A. I am sorry, I am not --
  12   Q. I am sorry, that was a long question. We have seen the
  13     material which suggests that in February 1989 two
  14     different options were being discussed. As I understood
  15     it, you told me a little earlier that after February
  16     1989, there was no further discussion of the two-stage
  17     repair?
  18   A. That is right.
  19   Q. And that Gary was going to have a single repair.
  20   A. That is right, yes.
  21   Q. Here, in question 6, Dr Martin was being asked when the
  22     decision was taken to go for the single repair.
  23   A. Yes.
  24   Q. And specifically, you asked Dr Martin whether the
  25     decision was taken when Mr Dhasmana was in the operating

   1     theatre?
   2   A. I think it was because Mr Dhasmana gave us a whole
   3     different view to Gary's operation at the time, that we
   4     wondered, was he at the table? did he really make this
   5     decision for Gary? Because Dr Martin was all excited
   6     about the operation, "Oh, yes, let us go ahead and do
   7     the big one", but Mr Dhasmana did not seem to share his
   8     enthusiasm at all, the night before the operation. It
   9     was a whole different attitude. I just wondered, was he
  10     at the table when all this was discussed?
  11   Q. When Gary went into the operating theatre, did you think
  12     he was going for one big correction?
  13   A. I did, yes, definitely, yes.
  14   Q. Question 8, Mrs Spicer:
  15        "What is the incidence of brain damage following
  16     this operation and why were we not warned of it before
  17     the operation?
  18        Answer: He was not brain-damaged after the
  19     operation."
  20        But he was a while after the operation. What did
  21     you understand that explanation to be?
  22   A. I do not know. I cannot remember now. I think on this
  23     day Dr Martin, I just wanted to hear that Gary was not
  24     involved in this investigation, and I cannot remember
  25     now what --

   1   Q. Was Dr Martin making the point that the operation
   2     technically was a success?
   3   A. Was a success, and it was just "one of those things" why
   4     Gary died and he could not really give an explanation on
   5     that day as to why, but he said they did all they could
   6     and Gary was in the best place.
   7   Q. Question 4, at the time of Gary's operation you asked
   8     Dr Martin where was the best place for this operation to
   9     be done. No answer is recorded to that question.
  10   A. No.
  11   Q. Did you not obtain an answer to that question?
  12   A. No, I think we went on talking about other things.
  13   Q. Did you ask it?
  14   A. It could have been my friend, actually. One of us
  15     asked.
  16   Q. Do you recall it being asked, or are you not sure?
  17   A. I think it was probably asked, but I seem to remember
  18     Dr Martin saying he was in the right place. I think he
  19     was convinced he was in the right place.
  20   Q. You see question 11. You asked what was the exact cause
  21     of death and Dr Martin's answer is as per the postmortem
  22     report we have now seen: cerebral infarction leading to
  23     heart failure.
  24        Do I take it then that as far as you are aware,
  25     Gary's operation was technically a success?

   1   A. So they tell us, yes.
   2   Q. Even with his subsequent deterioration on the day of the
   3     operation, and death just over a week later, the precise
   4     reason for that is unknown to you?
   5   A. Well, we were told that Gary went into a state of shock
   6     after the operation causing the blood pressure to drop,
   7     hence the brain damage. That is as we understood it at
   8     the time.
   9   Q. I am sure it has been far from easy to answer questions
  10     about these distressing events in your life. But I do
  11     not want to ask you any more. Is there anything else
  12     that you want to say to the Inquiry at this stage,
  13     either about Gary's treatment specifically or about the
  14     Children's Hospital or the Bristol Royal Infirmary in
  15     general, anything at all?
  16   A. I cannot think of anything at the moment, no.
  17   MR MACLEAN: Mrs Spicer, it is possible the Panel may have
  18     some questions, it may be there are questions from
  19     Mr Lissack as well, but for my part, can I thank you
  20     very much for that evidence?
  21   THE CHAIRMAN: Mrs Spicer, we have no questions.
  22     Mr Lissack?
  23   MR LISSACK: No, thank you very much.
  24   THE CHAIRMAN: Thank you. I repeat what Mr Maclean said:
  25     thank you very much for coming and telling us about

   1     Gary. If there are other matters that come to your mind
   2     that you would like to let us know about, please know
   3     that you can do so: whether you want to tell
   4     representatives or write to us or whatever means you
   5     wish, we will be here. We will obviously take account
   6     of anything else you may have to tell us. For the
   7     moment at least, thank you very much indeed for coming
   8     today.
   9            (The witness withdrew)
  10   MR MACLEAN: Sir, I am told that the decision has been
  11     taken, I know not by whom, to have a 15 minute break now
  12     before Mrs Pottage, the next witness, who will be
  13     examined by Mr Langstaff.
  14   THE CHAIRMAN: Shall we say, therefore, that we reconvene at
  15     12.15? Thank you very much.
  16   (12 noon)
  17               (A short break)
  18   (12.25 pm)
  19   MR LANGSTAFF: Sir, Mrs Pottage, please.
  20        Mrs Pottage, would you, in our usual way, please
  21     stand to take the oath?
  22            MRS ERICA POTTAGE (SWORN):
  23            Examined by MR LANGSTAFF:
  24   Q. You are Erica Jane Pottage?
  25   A. That is right.

   1   Q. And you are going to tell us about the life and death of
   2     your son Thomas, who was born on 3rd July 1993?
   3   A. Yes.
   4   Q. You discovered shortly after his birth that his great
   5     arteries were transposed and he required an operation
   6     for that?
   7   A. That is right.
   8   Q. You have given us a statement. Let us just identify
   9     that on the screen in front of you, beginning at
  10     WIT 260/1. Is that the start of your statement?
  11   A. That is right.
  12   Q. Does it go through five pages to page 5, where you sign
  13     it?
  14   A. That is right.
  15   Q. And the contents are true?
  16   A. That is right.
  17   Q. As you know, today our focus is essentially on
  18     counselling, information and support. Some of the
  19     details which you set out in the statement we will take
  20     as read, and it will not be necessary to go into them in
  21     depth, but if there is anything that you wanted to add,
  22     then I will ask you to do that at the end, and I hope
  23     you will take that opportunity?
  24   A. Thank you.
  25   Q. You have told us already about the birth of Thomas,

   1     which we see in paragraph 1 of your statement, page 1.
   2     Within 24 hours, the diagnosis was made. I am going to
   3     skip forward and concentrate on paragraph 10 for
   4     a moment. I will come back to other details.
   5     Paragraph 10, page 4. You set out here a number of
   6     criticisms of the care that you received as a parent.
   7     You were in Bristol from 3rd July until 13th July?
   8   A. That is correct.
   9   Q. It was on 13th July, was it, that Thomas died?
  10   A. Yes.
  11   Q. You say you were moved three times in 10 days?
  12   A. That is right.
  13   Q. So where were you first?
  14   A. First of all I was admitted to the maternity unit, which
  15     is across the road from St Michael's Hospital, because
  16     I needed care because, having given birth 24 hours
  17     previous, they suggested I was admitted there initially
  18     with Martin, in a private room. I was then --
  19   Q. Martin is your husband?
  20   A. Martin is my husband, yes. He was given a put-up bed
  21     beside me and the midwives came a couple of times a day
  22     to take blood pressure and medical checks as they do for
  23     most people who have just given birth.
  24   Q. The second move was a few days later, to St Michael's
  25     Hospital where Thomas was in special care?

   1   A. The conditions there, I can describe it only like
   2     a Portacabin. It was at the back of the Special Care
   3     Unit. You had to go outside, and then it was a couple
   4     of Portacabin units as I recall it. They were quite
   5     badly decorated inside. They had the facilities; there
   6     was a bed and washing facilities and a shower room, but
   7     it was very drab and it looked very temporary, I think.
   8   Q. The third move you made?
   9   A. The third move was actually at the BRI. We were there
  10     only for the one night, the night prior to Thomas's
  11     operation. That was a double bedroom, that was quite
  12     nicely decorated, in there.
  13   Q. I think that was called the Wiltshire Room?
  14   A. It might have been.
  15   Q. I will tell you why I say that in a moment or two. Why
  16     do you complain -- it may be obvious, but you tell us in
  17     your own words about why you complain about moving three
  18     times in 10 days?
  19   A. It was traumatic enough being in a city that was so far
  20     away from my home town with a sick baby, but the
  21     upheaval of actually moving -- Martin, my husband, was
  22     self-employed so he had to go back to Teignmouth
  23     in-between, so I spent a lot of time on my own in the
  24     hospital for those 10 days and having to physically move
  25     three times in 10 days I thought was quite excessive.

   1   Q. Just having given birth as well?
   2   A. Yes. I was having to walk across from the hospital, the
   3     maternity unit, across the road to St Michael's Hospital
   4     anyway, after giving birth. I think it was actually
   5     less than 24 hours I was walking between the two.
   6   Q. You say in the third sentence, paragraph 10, that you
   7     were initially placed with new mothers or expectant
   8     mothers, which you found very difficult to come to terms
   9     with. That was in the maternity hospital?
  10   A. That is right.
  11   Q. These are your feelings about it, which you are
  12     expressing here?
  13   A. Yes, everyone, when they have just given birth -- it was
  14     our first child and you are quite excited about having
  15     a baby, even though Thomas was not very well, and you
  16     wanted to talk about him, and I felt that when I went in
  17     to eat in the maternity unit, there was a restaurant
  18     there, and there were some mothers that actually had not
  19     given birth at that time. I did not want to talk about
  20     Thomas because I did not want to worry other mothers
  21     that my child was in a Special Care Unit, I thought it
  22     might be distressing for other mothers. But also those
  23     giving birth were talking about the sorts of things
  24     mothers do when they have given birth. I wanted to talk
  25     about Thomas but I felt very isolated from them because

   1     I did not have my baby with me.
   2   Q. What would have helped, looking back on it now, to
   3     reduce your feeling of isolation?
   4   A. In the first instance, I would have wanted to stay with
   5     Thomas in St Michael's Hospital. I would rather have
   6     been with him the whole 10 days across the road.
   7   Q. Do you mean in St Michael's?
   8   A. In St Michael's, yes, I am sorry.
   9   Q. Or do you mean in the Children's Hospital?
  10   A. It was at the Hospital for Sick Children. Is that
  11     St Michael's?
  12   Q. You wanted to be in the Sick Children's Hospital with
  13     Thomas?
  14   A. Yes, where he spent most of his time. Also, I think the
  15     staff at the Sick Children's Hospital, they were in and
  16     out a lot more than they actually were at the maternity
  17     unit. I was quite isolated at the maternity unit.
  18     I only saw the nurses twice a day to do checks. Some of
  19     us, it was not their fault because I was going across
  20     the road to see Thomas, so it was hard for them to catch
  21     me, but in so doing, I did not see very many medical
  22     staff over there at all.
  23   Q. So if you had been with Thomas, you would not have felt
  24     so much on your own?
  25   A. No, that is right.

   1   Q. You describe your feelings in the next few sentences,
   2     and make a note about the nurses who were very kind.
   3     That is the nurses in all three hospitals or just in the
   4     maternity unit you were talking about there?
   5   A. No, when we were, when Thomas was in special care at the
   6     Sick Children's Hospital, the nurses were very
   7     supportive there, because I was there nearly all day,
   8     and they were toing and froing to see to the monitors,
   9     so they had more occasion to actually talk to me a lot
  10     of the time about Thomas, and one nurse in particular
  11     got quite attached to Thomas, because she had no
  12     children of her own. When we lost Thomas, she used to
  13     send birthday cards for him and things like that. So
  14     the nurses were very helpful across the road.
  15        In the other hospitals, I never saw the same nurse
  16     twice, I do not think, at the maternity unit. Because
  17     I was toing and froing, as I say I think it was quite
  18     difficult for them to keep a track on me. At the BRI,
  19     we only ever saw Helen Stratton, we did not come into
  20     contact with any other nurses at all.
  21   Q. You say that you did not receive any counselling and you
  22     had no-one to talk to about your worries and concerns.
  23     This is despite being in one or other of the three
  24     hospitals for 10 days.
  25        When you saw Helen Stratton, did you understand

   1     her role to be counselling or not?
   2   A. No, I was given to believe that she was actually just
   3     a contact, a mediator, between the operating theatre.
   4     She was going to tell us what would happen, the
   5     operation, the anaesthetists, telling us what time
   6     Thomas would be going down to the theatre. She showed
   7     us the room, the ward where Thomas would be in
   8     overnight, and she showed us around the Special Care
   9     Unit and explained that Thomas would be in there for
  10     some time recovering after the operation.
  11   Q. So you had been shown by her what was where in the BRI?
  12   A. That is right.
  13   Q. And you had an idea what you might expect when Thomas
  14     came out of his operation?
  15   A. That is right.
  16   Q. So far as counselling at the Children's Hospital or the
  17     Maternity Hospital are concerned, did you ever see
  18     anyone called Helen Vegoda?
  19   A. Yes, we did see Helen Vegoda. She saw us once in the
  20     Sick Children's Hospital, and she -- because Martin was
  21     self-employed as I say and he had to go back to Devon,
  22     she actually helped us financially with I think œ25 at
  23     the time. She took us once to our room in the Sick
  24     Children's Hospital, and chatted to us and she had
  25     pictures on the wall of other children from the Heart

   1     Foundation.
   2        I was not really clear that she was a counsellor,
   3     to be honest. I thought she was a very kind lady who
   4     sat down and listened to how we felt, what problems we
   5     were having in the hospital. She asked us if we were
   6     comfortable. I was not aware that she was actually
   7     a counsellor.
   8   Q. So she was someone who was obviously official?
   9   A. That is right.
  10   Q. And you found it useful?
  11   A. I thought she was a very kind person, as I say, and it
  12     was useful -- it was nice to see her and she did help us
  13     out, but I think in retrospect that I needed to see
  14     a counsellor more on a regular basis because I spent
  15     a lot of time on my own and apart from medical help
  16     I had nobody really to talk to about how I was feeling
  17     at the time, and I was very isolated. Although my
  18     family came up from Devon for two or three days and
  19     Martin came back after a couple of days, there were
  20     times that I spent a lot on my own with Thomas.
  21   Q. So again, in retrospect, what do you think could and
  22     should have been done that was not?
  23   A. I think daily somebody, a counsellor, should have come
  24     and visited me and asked me how I was coping with Thomas
  25     and if there was any help that I needed, and also to

   1     talk to me about how I felt and ask me perhaps probing
   2     questions like how was I coping with looking after
   3     Thomas; did I find it alarming with all the equipment
   4     around me, which I did; did I have enough support; what
   5     sort of things I was worried about; how I felt, really.
   6   Q. It is obvious from what you have said that at least one
   7     of the nurses took a considerable interest in Thomas and
   8     she and you -- it was a she, I take it?
   9   A. Yes.
  10   Q. Got on well?
  11   A. Yes.
  12   Q. So did you talk about your worries and concerns to her
  13     or someone in her position?
  14   A. Not really, because having sat in there, I was aware
  15     that they were all very busy, they were very
  16     short-staffed, the nursing staff in there. There were
  17     a lot of sick babies in the unit. Obviously all of them
  18     in their own way were as sick as Thomas and often there
  19     were alarm bells ringing in different units and they
  20     were always under pressure, so you could only talk very
  21     quickly with them, and that was generally motherly sort
  22     of things that you do about your child. But there was
  23     never any time to sit down and talk about how I was
  24     feeling at the time, and coping.
  25   Q. Would they have appreciated, do you think, how alone and

   1     concerned you felt?
   2   A. No, I do not think so.
   3   Q. You describe the cubicles in the Children's Hospital and
   4     the effect of those cubicles to make you feel more
   5     isolated. Can I go on to paragraph 11, and just scroll
   6     that up on to the screen? You say there, you complain
   7     about the information or lack of it, rather, that you
   8     were given. What I want to do now is to find out what
   9     was said to you and how you think it should have been
  10     handled and what your criticisms are that you summarise
  11     in paragraph 11.
  12        When you first came to Bristol, did you see
  13     a doctor to talk about why Thomas was there and what was
  14     wrong with him?
  15   A. Yes, initially when we got to the Sick Children's
  16     Hospital, we saw Dr Joffe right away. He performed
  17     a heart scan to confirm Thomas's medical condition,
  18     which had already been diagnosed in Exeter, but he
  19     actually confirmed that Thomas had transposition of the
  20     great vessels.
  21   Q. Can we have a look, please, at medical report 2510/59?
  22     My screen first, please.
  23        This is from the nursing notes. It is a nursing
  24     care plan. It is dated 5th July, so a couple of days
  25     after you come to Bristol. "The patient's problems,

   1     family. Thomas's parents need to be kept up to date
   2     with his condition and treatment."
   3        Stopping there, your need was recognised. That
   4     was a need you had, was it?
   5   A. Yes.
   6   Q. The aims: "For parents to feel as relaxed and reassured
   7     as possible."
   8        Stopping there, how far was that achieved?
   9   A. I would not say I felt relaxed. I do not think, to be
  10     fair, we could have, in that situation --
  11   Q. I think it says "as far as"?
  12   A. I think it would be fair to say that we had every faith
  13     in them at Bristol that they seemed to have all the
  14     knowledge and expertise that we had hoped for and we had
  15     no reason to doubt their abilities.
  16   Q. The next sentence: "For parents to be as involved as
  17     possible in Thomas's care without feeling intimidated."
  18   A. Yes. In the Sick Children's Hospital, they did actually
  19     move Thomas out of an incubator into a cot, in order
  20     that I could take him out most days and hold him, so
  21     I think they were thinking of me as a parent, that
  22     because I was in there every day, I could get closer to
  23     Thomas and spend more time with him. So I think they
  24     did actually consider my feelings at that time.
  25        I just feel that there was a lack of -- as

   1     I mentioned earlier, that there was nobody actually to
   2     sit down with me to find out how I was feeling about the
   3     situation and how I was coping mentally with having
   4     Thomas there. It was a tremendous shock. As I have
   5     said before, we had no idea that Thomas was poorly at
   6     all, so within 24 hours he had gone from a normal
   7     maternity hospital into a unit with monitors and alarm
   8     bells ringing, and it was quite distressing and
   9     confusing for us both as parents, really.
  10   Q. I think it was Dr Joffe, the first doctor that you saw?
  11   A. That is right.
  12   Q. Did he describe what sort of operation Thomas was going
  13     to have?
  14   A. He described two operations. He drew a diagram. He
  15     said that one of the operations -- he described the
  16     switch operation first of all, which had to be done in
  17     the first 14 days of birth. That is because the heart
  18     changed after 14 days. He said that the switch
  19     operation, when successful, meant that Thomas would have
  20     a normal life, there would be no further operations.
  21        The other operation that he described as at
  22     18 months, which in layman's terms, he said, was
  23     described as "extra plumbing", an extra bit of tube to
  24     rectify the fault, but that Thomas would have to have
  25     further operations as he grew up, obviously when the

   1     heart got bigger.
   2   Q. Did he say which of those two operations Thomas was to
   3     have?
   4   A. He said it was for Mr Dhasmana to decide what
   5     operation. He did say that the switch operation was
   6     quite a new operation; that they had been performing it
   7     for two or three years, but they were very pleased with
   8     the success of that operation.
   9   Q. When he said they were very pleased with the success of
  10     the operation, did he give you any more details? Did
  11     you ask for any more details of what that meant?
  12   A. We did not ask for any more details at the time. We
  13     assumed when we spoke to Mr Dhasmana we would raise
  14     those sort of issues.
  15   Q. You did, I think, hear, before you saw Mr Dhasmana, that
  16     he had decided to perform the arterial switch operation?
  17   A. Yes. Dr Joffe had said that he had spoken to
  18     Mr Dhasmana when he came back from his holiday, and that
  19     he had decided to perform the switch operation and we
  20     were transferred that afternoon, about 4 o'clock, to the
  21     BRI, for Thomas to be operated on the following morning.
  22   Q. When you arrived at the BRI, what happened? Who did you
  23     see?
  24   A. When we got to the BRI, we first of all saw Helen
  25     Stratton, who took us into the ward where Thomas was.

   1     There were two other children that had either had heart
   2     operations or were due to have them. They were toddling
   3     around with their families and there was a small bed for
   4     Thomas. We were also taken around that floor and there
   5     were mature cardiac patients in there as well, which
   6     I found rather strange. I had assumed it was going to
   7     be a hospital for children on that level.
   8   Q. By "strange", how did you react to it as a parent?
   9   A. I found it a bit alarming that there were -- that the
  10     babies were not separate or the children were not
  11     entirely separate from adults: more alarming when we
  12     went into the Special Care Unit, because that was not
  13     screened off in any way, and everything was very
  14     cramped, and there were very sick mature people in bed.
  15     Obviously had Thomas gone as far as special care, it was
  16     evident he could be right next-door to an adult who was
  17     critically ill. I never imagined it to be that way.
  18     I was assuming that it was going to be similar to the
  19     Sick Children's Hospital, where it was a dedicated ward
  20     to children and babies.
  21   Q. Paragraph 7 of your statement is page 3. You call Helen
  22     Stratton the "nurse in charge". That is how you saw
  23     her, was it?
  24   A. Yes. I thought she was the nurse in charge of that
  25     cardiac unit.

   1   Q. Her official title was Cardiac Liaison Nurse rather than
   2     nurse in charge. Was that ever explained to you?
   3   A. It might have been. I cannot honestly remember.
   4     I suppose she was a liaison nurse. I just assumed that
   5     she was in charge, her role was to liaise between the
   6     parents and the consultant.
   7   Q. And you have described there going to see Mr Dhasmana.
   8     Tell me about that. I know you put it down in the
   9     statement, but in your own words, from what you
  10     recollect.
  11   A. We went to see Mr Dhasmana the evening prior to the
  12     operation. That must have been about 6-ish. It was
  13     a very brief consultation; it was less than half an
  14     hour, I would have said. He again drew us a diagram of
  15     the operation and we asked him -- I asked him -- what
  16     the chances of success were for Thomas with this
  17     operation. He said that Thomas was a small baby -- he
  18     was 6 pounds 4 -- and that it was a very serious
  19     operation. Then he went on and said --
  20   Q. If I can just ask you to pause there for a moment, when
  21     you said "the chances of success", what were you
  22     thinking of?
  23   A. I knew it was a big operation, but I wanted to know
  24     whether Thomas was likely to survive, what the chances
  25     of his survival were.

   1   Q. So that is what you were asking, really, about survival?
   2   A. Yes.
   3   Q. That is when he said, "He is a small baby"?
   4   A. Yes.
   5   Q. What else was said, then, by him? I am sorry, I cut you
   6     off there.
   7   A. He actually diverted from my question and said that only
   8     one child had had to come back to him to receive further
   9     surgery after the switch operation.
  10   Q. What did you think he meant by that? What information
  11     was he giving you?
  12   A. I had no idea at the time. I felt he did not answer my
  13     question and I did not really know how to follow it up,
  14     I suppose, when I look back.
  15   Q. He said only one child had had to return to surgery.
  16     What did you think had happened to the others, at the
  17     time?
  18   A. I had assumed they had all survived because we were led
  19     to believe that the switch operation, when successful,
  20     they would never have to have further surgery, so
  21     I assumed what he was saying to us was that sometimes it
  22     did mean, you know, in one instance a child had had to
  23     come back and have further surgery, but the rest had
  24     been fine; like we assumed that Thomas would have been
  25     fine after the operation.

   1   Q. And you signed a consent form at that meeting, did you?
   2   A. Yes.
   3   Q. What were the main things in your mind as to why you
   4     wanted the operation for Thomas?
   5   A. We assumed that we had no choice; that Thomas was very
   6     poorly and he desperately needed the switch operation.
   7     Dr Joffe had given us no reason to doubt the abilities
   8     of Mr Dhasmana and everybody had been quite positive
   9     about the switch operation. On that basis, we assumed
  10     that we had left Thomas in the best possible hands to
  11     have the switch operation.
  12   Q. Dr Joffe had told you it was a new operation, you have
  13     already mentioned that.
  14   A. That is right.
  15   Q. Did you ask, or think of asking, how many such
  16     operations had been done?
  17   A. No. When he told us that it was a new operation, he
  18     said that they were pleased with the success rate at
  19     that time. When we saw Mr Dhasmana, we had no reason to
  20     doubt that it was not the best possible place for the
  21     operation to have been carried out. In retrospect now,
  22     it is evident, and we feel quite strongly, that what
  23     Mr Dhasmana should have said at that point in time was
  24     that it was indeed a serious operation, the switch
  25     operation, but they, at Bristol, did not have the

   1     expertise to carry out that operation, and Thomas's best
   2     possible chances for survival would have been at another
   3     hospital. At that point, we did not know which
   4     hospital, but we both felt strongly that it was up to
   5     them to advise us where to take Thomas to have the best
   6     possible chance of a successful operation.
   7   Q. This is very much hypothetical and it is very much
   8     looking back at it, but suppose something had been said
   9     to you like: "Three out of every four operations, sadly,
  10     does not succeed. You have to realise, it is a very
  11     serious operation and you should be under no illusion as
  12     to the prospects."
  13        If something like that had been said, just that,
  14     would you have asked any further question, do you think?
  15   A. I think, unless they could have actually given us
  16     a comparison, telling us the results of Bristol would
  17     have meant nothing to either one of us. I mean, if they
  18     had said that three out of four children had died in
  19     Bristol, if they had said that had happened throughout
  20     the country, then we would have had no choice but to
  21     have given our consent and hope for the best in
  22     Bristol. But if they had actually said that three out
  23     of four children die in Bristol but three out of ten
  24     children have been lost in Birmingham, then we would
  25     have stayed on the motorway for the further half an hour

   1     and the outcome might well have been different.
   2   Q. Again, just to examine and push you on this, at this
   3     stage Thomas was obviously ill?
   4   A. Yes.
   5   Q. Had he had any difficulty breathing?
   6   A. Immediately when we were admitted to the Sick Children's
   7     Hospital, he had stopped breathing until they actually
   8     got him on some drugs -- I think it was Prostin, I am
   9     not sure. Once he was stabilised, he seemed to be
  10     okay. Later, when Martin and I had consulted the
  11     solicitors and had medical records down from Bristol, we
  12     found that there were no other complications with
  13     Thomas, other than the switch.
  14   Q. Looking at it as a parent, and from what you knew at the
  15     time -- here was your son, sick and ill in a hospital
  16     where an operation could be attempted -- do you think
  17     you would have taken him out of the hospital in an
  18     ambulance or in your car and taken him two, three,
  19     four hours, when time was critical, perhaps, down the
  20     motorway to Birmingham or London, or wherever?
  21   A. I suppose the thing is, you can argue it that perhaps
  22     when he was diagnosed in Exeter, should we have been
  23     referred to Bristol in the first instance? I mean, if
  24     it was the case that there was a better cardiac unit in
  25     Birmingham, then it would have been half an hour extra

   1     for us from Exeter. I think Thomas was stabilised for
   2     10 days in Bristol. He actually did seem to improve.
   3     As far as I was concerned, he looked a much better
   4     colour when he was in Bristol. He was starting to take
   5     feeds after about seven days -- I was feeding him
   6     myself, so he was actually taking breast milk and he was
   7     actually stabilising quite a lot. So it would have been
   8     up to the medical staff to have told us whether Thomas
   9     could have survived a journey by ambulance or air
  10     ambulance to another hospital.
  11        So we would have expected that information from
  12     them, but in retrospect, I think perhaps we should have
  13     avoided Bristol all together and been sent to Great
  14     Ormond Street, Birmingham, wherever.
  15   Q. One of the points you want I think particularly to make
  16     is that you feel very strongly -- and perhaps it is
  17     obvious from your last answers -- that the operation
  18     should never have taken place at Bristol at all on
  19     Thomas?
  20   A. Yes.
  21   Q. Is there anything more you want to tell us about the
  22     reasons why you feel so strongly about that that you
  23     have not already covered in what you have said?
  24   A. No. I think possibly I have covered it all. I feel
  25     that Mr Dhasmana in particular was not -- he did not

   1     have the expertise to carry out this particular
   2     operation on young babies, and what we know now is that
   3     he was quite unsuccessful on young babies; and to
   4     a certain extent, they were being used as guinea pigs.
   5   Q. Obviously you rely for this on information which you
   6     have discovered some time since?
   7   A. That is right.
   8   Q. You describe, after that meeting, how you spent the rest
   9     of the time in the BRI and you tell us about the day of
  10     the operation, paragraph 9 of your statement, and the
  11     information that you were given during the progress of
  12     the operation.
  13        Do you have any complaints about the amount of
  14     information that you were given during the operation, or
  15     the way in which that information was given to you?
  16   A. No, not during the operation because I think Martin and
  17     I had been advised to leave the hospital and call back
  18     at 3 o'clock to see what the progress was, so we did try
  19     to get out and try and think about something else, for
  20     the day.
  21        Then, when we came back and saw Helen Stratton,
  22     she had told us that she could not get Thomas off the
  23     bypass machine. But this was not unusual. This quite
  24     often happened in heart operations. She told us to call
  25     back an hour later and gave us the same answer.

   1        Then the third time I think it was Mr Dhasmana had
   2     come back and said that Thomas had had a massive heart
   3     attack and he was not able to maintain his blood
   4     pressure, I believe.
   5   Q. You obviously were very upset at the news. Were you
   6     asked whether you would wish to see Thomas?
   7   A. Yes. Mr Dhasmana seemed quite distraught when he came
   8     back and told us. I think he was actually quite tearful
   9     at the time. I think Helen Stratton came in and said,
  10     did we want to go and see Thomas, but to me and Martin,
  11     the thought of going down to the theatre and I suppose
  12     the sight of blood, we did not want to go down there; we
  13     preferred to try and remember Thomas as he was as we had
  14     taken him down there that morning.
  15   Q. Were you here this morning when we were told about an
  16     almost indecent haste to push a parent out of the doors
  17     following a bereavement?
  18   A. Yes, I think I caught the tail-end of that.
  19   Q. How far does that accord with what happened to you?
  20   A. That is exactly the same. I think I would probably say
  21     we were there about half an hour with Mr Dhasmana and
  22     Helen Stratton in total, and we were told that most
  23     parents in the same situation, most of them preferred to
  24     leave the hospital immediately and return home, so we
  25     felt under pressure, then, to leave and we were still,

   1     the pair of us, in shock, but you did have that feeling
   2     that you wanted to run away. But looking back, I think
   3     that it was quite dangerous for Martin to get in the car
   4     and drive for an hour and a half back to Devon.
   5   Q. Because of what was on your mind?
   6   A. Well, I think we were just in shock. I mean, one minute
   7     we had been admitted to the hospital with a baby, and
   8     the next minute we had lost him. We both felt
   9     completely lost, I think, and in shock. I think we
  10     needed to sit down and get our thoughts together and
  11     perhaps, I think that would have been the time to have
  12     had a counsellor, to sit down with the pair of us.
  13   Q. So what you would have wanted was time, was it?
  14   A. Yes.
  15   Q. And someone to talk to who was experienced?
  16   A. Yes.
  17   Q. Again in retrospect, where do you think that should have
  18     taken place?
  19   A. I think I would have liked to have been away from the
  20     hospital, even if it was just across the road, some
  21     distance, and just time to have a cup of tea and time to
  22     get your thoughts together as to what was going to
  23     happen next, really.
  24   Q. Did anyone discuss arrangements with you in terms of
  25     postmortem or funeral?

   1   A. I think it was Helen Stratton, because that is the only
   2     person we actually spoke to there, had said that there
   3     would be a postmortem. This was normal procedure. She
   4     also said that Mr Dhasmana would contact us, probably by
   5     letter, on our return to Devon, but we never heard from
   6     him. We never received any letter.
   7   Q. So when you left, that was it, was it?
   8   A. That was the only contact we had.
   9   Q. Was anything said to you about the need or possibility
  10     of keeping Thomas's heart?
  11   A. No. It was just never mentioned.
  12   Q. How have you reacted to the news that a number of hearts
  13     were in fact kept, following cardiac surgery?
  14   A. We found that very distressing. In our own personal
  15     situation, we did not want to know whether Thomas's
  16     organs had been retained because that would have been
  17     too distressing for both of us.
  18   Q. Thomas came back to you for burial?
  19   A. That is right, yes.
  20   Q. There are one or two documents which I would welcome
  21     your help with and comments on, as to how far they
  22     matched up to your own experience.
  23        Can we have a look, please, at UBHT 136/35? This
  24     is an information document for parents. Do you remember
  25     seeing this or anything like it?

   1   A. No.
   2   Q. If you look down the page, "Parent facilities", this is
   3     what the UBHT were saying as to the Bristol Children's
   4     Hospital: "Whichever ward your child is on, you would be
   5     welcome to stay with us as well. We have a variety of
   6     facilities for parents, including rooms to stay in."
   7        You felt welcome, did you, at the Children's
   8     Hospital?
   9   A. Yes. I think the Children's Hospital, although I think
  10     the facilities there looked very temporary and were not
  11     very accommodating, the actual unit that we stayed in,
  12     but the staff there were very helpful as far as they
  13     could be.
  14   Q. You were not at the Infirmary for very long. Did you
  15     notice any difference as between the Children's Hospital
  16     and the Infirmary?
  17   A. The accommodation and facilities were newer and more
  18     welcoming, but I would say it was not as welcoming.
  19     There was not as much contact with people. You felt
  20     more isolated at the BRI.
  21   Q. If we have a look at UBHT 167/76, this is a document for
  22     reference purposes for others, which begins two pages
  23     earlier. It is the Annual Report 1989 in respect of
  24     Bristol cardiac surgery, so it is some three years
  25     earlier, that this was published. One assumes that

   1     standards of patient care should have improved over the
   2     period.
   3        At the end of the first paragraph there, the last
   4     sentence, talking about Ward 5:
   5        "Traditionally the nursing team has played a major
   6     role in promoting a liberal and happy atmosphere for
   7     patients, families and staff. In so doing, it has
   8     created a corps d'esprit which is one of the strengths
   9     of the unit and the envy of others."
  10   Q. Accepting you were not in Ward 5 for long, how far is
  11     that sentiment reflected in your experience?
  12   A. I do not feel it was a happy atmosphere. I suppose, to
  13     be fair, no hospital would have been a very happy
  14     atmosphere in the circumstances, but because it was
  15     mixed with adults, it seemed a very strange sort of
  16     layout, to me. I expected it to be a dedicated ward to
  17     children, and the only contact we had was with Helen
  18     Stratton and that seemed very to the point. We were
  19     shown the rooms, where the special care was, where the
  20     toilets were, where Thomas would be, and then an
  21     anaesthetist came to explain what time he could be
  22     taking Thomas down to theatre and such like, but apart
  23     from that, you were on your own, really.
  24   Q. The last document I wanted to ask you about is
  25     DOH 4/16. Again, for the purpose of identification,

   1     this is a draft agreement between the Bristol & Weston
   2     Health Authority and the Bristol Provider Unit, so it
   3     comes from 1990 or early 1991. If we can go down to
   4     paragraph 11.7, it is dealing here with neonatal care
   5     rather than cardiac care, but 11.7:
   6        "There should be sensitive arrangements for
   7     helping parents cope with handicap or bereavement and
   8     access to counselling for both parents and unit staff."
   9        To what extent do you feel there were sensitive
  10     arrangements for helping you cope with your bereavement?
  11   A. I do not think there were any sensitive arrangements.
  12     I think, as I said before, we were hurried out of the
  13     BRI. I think we should have had access to counselling
  14     there, and also on our return to Devon, perhaps followed
  15     up with some counselling, but I do not think we were
  16     dealt with in a sensitive way at all, once we had
  17     learned that we had lost Thomas. I felt very much like
  18     it was "Quick, pack up and go home. We are finished
  19     with you" and that was that, really. Our feelings and
  20     views were not taken into account.
  21   MR LANGSTAFF: I do not know whether Valerie Mandelson would
  22     like any information which may assist her so she can
  23     help the Inquiry. If so, I would now invite you to ask
  24     what you would wish.
  25   MRS MANDELSON: I was just wondering whether you were given

   1     any details whatsoever -- you said about wanting some
   2     support when you got home: were you given any
   3     information about local services that may be of help, or
   4     assistance that you could contact?
   5   A. When I got home, my midwife I had had previously came up
   6     to see me, because she had obviously got to know me
   7     quite well. Although she was not a qualified
   8     counsellor, she came to see me and gave me a leaflet for
   9     some organisation that escapes me at the moment, to
  10     contact. But at that point, my husband was very
  11     supportive, and also my parents, so I did not feel the
  12     need to actually see somebody at that point in time, or
  13     to actually ring. But in retrospect, I think that
  14     I should have had somebody who was independent of my
  15     family, to have actually come and seen me and discussed
  16     how I felt. I did return to work quite quickly, because
  17     on coming back from the BRI, it was two months later and
  18     I found I was pregnant again, and rather than be
  19     distressed during this pregnancy, the second pregnancy,
  20     I felt that it was best to go back to work full-time and
  21     try and concentrate on the next baby.
  22        Looking back, I do not think I was ready to return
  23     to work, and also, I had needed help in that time.
  24   MR LANGSTAFF: I have asked you a number of questions.
  25     I have nothing more that I want to ask you, but is there

   1     anything that you would wish to add, either to emphasise
   2     what you have already said, or because you think we
   3     ought to know, anyway?
   4   A. No, I think you have brought out the point, that we feel
   5     very strongly we should have been sent to a hospital
   6     where there was greater expertise. We should never have
   7     been referred to Bristol in the first instance.
   8   MR LANGSTAFF: There may be some questions from the Panel.
   9   THE CHAIRMAN: Professor Jarman?
  10             EXAMINED BY THE PANEL
  11   PROFESSOR JARMAN: I just wondered if you got any support
  12     from your general practitioner at all?
  13   A. Yes, my GP had seen him quite often and come around to
  14     see me, but he did not actually refer me to
  15     a counsellor. There is now a counsellor that is
  16     attached to the practice, but that has been quite a new
  17     thing. I was actually offered the service about 12
  18     months ago, when I had taken my other children for
  19     a check-up. They broached the subject and offered
  20     counselling.
  21   THE CHAIRMAN: Mrs Pottage, we have no more questions.
  22     Mr Lissack?
  23   MR LISSACK: No, thank you very much.
  24   THE CHAIRMAN: I am grateful. If I may put words into
  25     Mr Langstaff's mouth, there may be other things that

   1     come to your mind that you would like to tell us about,
   2     even though you say you have brought to our attention
   3     all the things currently on your mind. If there is
   4     anything else, please know you can let us know, either
   5     by writing or through your advisers, whatever, we will
   6     hear and we are anxious to hear anything you may have to
   7     say. For the moment, on behalf of Mr Langstaff, and
   8     certainly on behalf of the Panel, thank you for coming
   9     to tell us Thomas's story. We are very grateful to
  10     you. We are much obliged to you.
  11   MRS POTTAGE: Thank you.
  12   MR LANGSTAFF: Thank you very much.
  13             (The witness withdrew)
  14   MR LANGSTAFF: Sir, our next witness, Mrs Johnson, is
  15     scheduled for this afternoon. May I be bold enough to
  16     suggest that we have a break until 2 o'clock, or just
  17     after?
  18   THE CHAIRMAN: I think that will be right. Shall we adjourn
  19     now and reconvene at 2 o'clock.
  20   (1.15 pm)
  21            (Adjourned until 2.00 pm)
  22   (2.15 pm)
  23   MR LANGSTAFF: Could we have Julie Johnson, please?
  24        Mrs Johnson, I think you have followed our
  25     proceedings from time to time. You know that at the

   1     beginning we take an oath. Will you please stand for
   2     the oath?
   3           MRS JULIE JOHNSON (AFFIRMED):
   4            Examined by MR LANGSTAFF:
   5   Q. You are Julie Johnson?
   6   A. Yes.
   7   Q. Can we have a look at your statement on the screen:
   8     178/1 is the covering sheet. Page 2 is where the text
   9     begins. If we turn to page 22, that is your signature
  10     at the end, is it?
  11   A. That is right, yes.
  12   Q. And the contents of that statement are true?
  13   A. Yes.
  14   Q. You know, because I think you were here for part of this
  15     morning, that the focus of today and much of this week
  16     is on counselling, information and support.
  17   A. That is right.
  18   Q. And you are going to tell us about your son Max, who was
  19     born on 29th November 1993, and what happened to him.
  20     Although you give us a lot of detail in your statement,
  21     for which I thank you, you will appreciate that we will
  22     not go into every detail, and no disrespect is
  23     intended.
  24   A. I understand.
  25   Q. When did you first become aware that something might not

   1     be all right with Max?
   2   A. It was the day that he was born. He was born just after
   3     midday in St Michael's Hospital. I was put on to a ward
   4     and he was not drinking a lot of milk and he seemed to
   5     be making a grunting sound so I rang the bell and got
   6     the midwife to have a look. By the time the midwife had
   7     come in he had stopped grunting, so she just left and
   8     went again. So it must have been about half 4 in the
   9     afternoon by then, just hours after his birth.
  10   Q. Max was not your first child?
  11   A. He is my second.
  12   Q. When did you first understand what was wrong with Max?
  13   A. It was a couple of days later. He was taken to SCBU
  14     that evening, and it was the Wednesday I think it became
  15     definite that there was something wrong with his heart.
  16     I think it was when we were introduced to Dr Alison
  17     Hayes from the Children's Hospital.
  18   Q. That is Wednesday 1st December, is it?
  19   A. That is right.
  20   Q. What did Dr Hayes say to you about the nature of Max's
  21     problem?
  22   A. She took Max to the Bristol Children's Hospital to
  23     perform a cardiac catheterisation and have an echo to
  24     look to see what the problems were. When she returned
  25     that day she said he needed to go back the following

   1     day, the Thursday, for a balloon atrial septostomy.
   2   Q. Did he?
   3   A. Yes.
   4   Q. What did you understand to be the results of the
   5     septostomy?
   6   A. Max had transposition of the main arteries, but it was
   7     slightly complicated because I was told that both
   8     outlets came from the right ventricle. He also had
   9     a hole in the bottom of the two chambers.
  10   Q. Did anyone describe it to you as a "double outlet right
  11     ventricle"?
  12   A. On occasions. Transposition of the main arteries with
  13     complications, but very rarely was it referred to as an
  14     actual switch.
  15   Q. At what stage did you understand what was likely to
  16     happen?
  17   A. I think it was the same day or the following morning
  18     after the balloon atrial septostomy. She said they had
  19     a clearer picture of Max's heart. He needed to have
  20     open-heart surgery as soon as possible, but because of
  21     the size of the child, it would be better to wait until
  22     he was a year older, so they were going to patch him up
  23     temporarily until he got older and stronger, and then he
  24     would have a second operation and that would be it for
  25     life. So he was going to be patched up temporarily with

   1     closed-heart surgery, and then, about a year later, he
   2     would have the actual transposition.
   3   Q. So that was what would happen in December of 1993?
   4   A. That is right.
   5   Q. It was later in 1994, was it, that he came back for
   6     a second operation? He had a first operation in 1993,
   7     a second operation in 1994?
   8   A. Yes, that is correct.
   9   Q. So far as the first operation was concerned, where was
  10     that performed?
  11   A. It was in the Children's Hospital. Bristol Children's
  12     Hospital.
  13   Q. The second was at the BRI, was it?
  14   A. That is right.
  15   Q. So you had experience of the special care baby unit in
  16     St Michael's?
  17   A. Yes.
  18   Q. Experience of the Children's Hospital?
  19   A. Yes.
  20   Q. And you had experience of the Royal Infirmary?
  21   A. Yes.
  22   Q. From your perspective, how did they compare?
  23   A. The special care baby unit, the staff were very good.
  24     I had obviously just given birth to the child and within
  25     hours he was in SCBU and they gave me a room there

   1     within the hospital and said I could stay as long as
   2     I liked.
   3        When I met Dr Hayes she said the surgery, the
   4     closed-heart surgery would be in the Children's
   5     Hospital, which was completely opposite, the building
   6     opposite, but the SCBU staff said I could stay there if
   7     I wanted to in one of their rooms rather than move to
   8     the other.
   9        In SCBU they had a key nurse system which worked
  10     very well. In the first days when Max was being
  11     diagnosed it was difficult to take in all the
  12     information. I had a nurse stay with me who was Max's
  13     key nurse. When the consultant left she would say "Did
  14     you understand all this?" and if there was something
  15     I was not sure about she would go through it all with
  16     me. I found that very helpful.
  17   Q. The key nurse was the same person all the time, was it?
  18   A. Yes. There were a group of nurses that did the same
  19     care for the same patients, but one particular nurse,
  20     because the one that always came and explained things
  21     and if there was a problem, I would go back to her.
  22        When I got to the children's ITU, they had
  23     a similar type system, but probably because there were
  24     a lot more babies there you did not necessarily see the
  25     same nurses very often. There was a key group of

   1     nurses, all the nurses came under "green", and then
   2     somebody else would have a different set of nurses under
   3     "blue" or things like that, so there would be someone
   4     within that group you could actually talk to if there
   5     was a problem.
   6   Q. Did you find communication easy, or difficult?
   7   A. Relatively easy, yes. I did not have too many concerns
   8     when he was in -- to me the actual closed-heart surgery
   9     itself was the problem, and I thought the time after,
  10     once he had got over the surgery, I was not too
  11     concerned about him, he seemed to be progressing quite
  12     well, so there was not very often I needed to ask
  13     anything during that time.
  14   Q. So you have now covered SCBU and you have covered the
  15     Children's Hospital. What about the BRI?
  16   A. The BRI was very different. When I arrived we met
  17     a nurse, Kathy Warren, I think it was, on the first
  18     day. I did not necessarily see her for a little while
  19     after. I did not know many of the nurses at all.
  20     Before Max went for surgery, we were on a little ward
  21     which was just a couple of children, either going to
  22     surgery or recovering from surgery. We were all put in
  23     the same room. I did not really know any of the nurses
  24     in particular. There was a play specialist there, but
  25     then they went home at weekends, so we were there in the

   1     evening.
   2   Q. You have mentioned a name: Kathy Warren?
   3   A. Yes.
   4   Q. So obviously you knew a nurse well enough to not only
   5     know her name but remember it?
   6   A. Yes.
   7   Q. Why her in particular? What about her makes you
   8     remember her?
   9   A. Because she was there just after Max's surgery, when he
  10     came up from surgery. She was there for a little
  11     while. She was not actually looking after him that
  12     evening, but she was there when he first came up, and
  13     I had a few concerns about the surgery that I expressed
  14     to her as well. Like all the nurses there she did not
  15     have an answer to most things, but I remember her in
  16     particular. She also came to my house afterwards,
  17     actually.
  18   Q. So you developed a relationship with her?
  19   A. Yes.
  20   Q. Despite your, if we put them in rank order --
  21   A. That was one. There was not a combination. There were
  22     two or three more, I am not saying all the nurses were
  23     the same.
  24   Q. Is what you are saying that there was a variety of
  25     nursing approaches at the Royal Infirmary?

   1   A. Yes.
   2   Q. Some of which you found more helpful than others?
   3   A. Yes, exactly.
   4   Q. Whereas at the Children's Hospital there was a team
   5     approach which you found generally helpful, but what you
   6     found most helpful, speaking personally, was the key
   7     nurse with whom you related well from the Maternity
   8     Hospital?
   9   A. Yes, that is right.
  10   Q. Do you remember her name?
  11   A. Julie. Only the first name. We did go back to see her,
  12     actually.
  13   Q. Following the operation in 1993, the closed-heart
  14     surgery at the Children's Hospital, how long, roughly,
  15     did Max stay at the hospital?
  16   A. Three weeks. We came home a week before Christmas. The
  17     surgery was on 16th December.
  18   Q. During that time, did you meet anyone who was there to
  19     offer you counselling, or some?
  20   A. I met Helen Vegoda a couple of times. She would ask me
  21     and my husband if we wanted to go back to her office for
  22     a cup of tea or something.
  23   Q. Did you take her up on it?
  24   A. A couple of times, yes.
  25   Q. Did you find the contact helpful or not?

   1   A. I was not particularly bothered at the time. I did not
   2     particularly need that sort of help at the time.
   3   Q. Because things were okay and progressing well?
   4   A. Exactly, yes.
   5   Q. If you had needed her, would she have been there for
   6     you?
   7   A. Yes, I think so, yes.
   8   Q. So he was back at home just before Christmas 1993?
   9   A. Yes.
  10   Q. And does not come in again for surgery until the middle
  11     of the following year?
  12   A. That is right.
  13   Q. Tell me how it came about that it was realised that he
  14     needed surgery then.
  15   A. Well, when I came home the week before Christmas, I had
  16     an outpatients appointment in the January, one of the
  17     first clinics after Christmas, where I had to see the
  18     cardiologist, and two weeks after that, I had to see
  19     what should have been Mr Dhasmana, in fact it was his
  20     Sister I saw, just to see how Max had got on after he
  21     got home, really. I went to outpatients every two
  22     weeks, because we lived in Bristol it was convenient,
  23     just to keep an eye on what was happening, and also Max
  24     went in for a catheter in March 1994.
  25   Q. In April, did you see Dr Hayes and then Mr Dhasmana?

   1   A. That is right, yes. As a result of the catheter in
   2     March, they decided I should see both Mr Dhasmana and
   3     Dr Hayes.
   4   Q. What did you discuss?
   5   A. Further surgery. I knew he was going to have further
   6     surgery, but the catheter said that the first, the
   7     closed-heart surgery would not last him a year. He was
   8     basically patched up and Dr Hayes felt that it would not
   9     last that long and he needed to go in more urgently than
  10     they had anticipated. So I had to speak to Mr Dhasmana
  11     about this.
  12   Q. Do you recall meeting Mr Dhasmana for that first
  13     consultation?
  14   A. Yes, I do.
  15   Q. What was said?
  16   A. He just said that he had hoped that Max's surgery would
  17     have lasted a year, because he would be older and
  18     stronger, but Dr Hayes had said, after the catheter,
  19     that Max was suitable for the switch.
  20        There was some talk that the part of the artery
  21     that was on -- because both arteries were coming from
  22     the left, there was some talk it might be more committed
  23     to the right by March, so it was more of a switch, but
  24     it was never very clear whether that was the case or
  25     not. Mr Dhasmana said he needed open-heart surgery

   1     quite soon.
   2   Q. What questions did you ask and have answered about the
   3     nature of that surgery?
   4   A. Dr Hayes had already told us in outpatients there was
   5     a risk to Max's life, because of the fact that he had
   6     never used the left side of his heart correctly, and she
   7     said it was turning to muscle and she was a bit
   8     concerned about that. Mr Dhasmana did not seem to be
   9     too concerned about that particular aspect; he just said
  10     that he would do the surgery quicker than he had hoped
  11     for.
  12   Q. Were you worried by the risks to Max?
  13   A. I never tried to think about it too much, because I did
  14     not feel -- we were never given any alternative. He was
  15     to have this surgery. After the surgery, we were told
  16     he would have a near normal life, so that was that,
  17     really.
  18   Q. Can I break off there for a moment and ask you to pull
  19     the microphone a little nearer to you? You have
  20     naturally quite a soft voice, and speaking fairly
  21     quickly as you do, it is sometimes difficult for some
  22     people to pick up what you are saying.
  23        Let us start again. You were going to tell us,
  24     you were telling us, about the risks which you
  25     understood there were in the surgery; you did not really

   1     want to know, I think, is what you are saying?
   2   A. Yes.
   3   Q. Were you told anything specific about any particular
   4     risk?
   5   A. Well, Dr Hayes said that there would be a risk up to
   6     14 days following surgery, because Max would have to
   7     learn how to use the left side of his heart, because he
   8     had never used it. Mr Dhasmana said that basically, he
   9     would live or die in the operating theatre. He was more
  10     concerned with the