Home Page Search Final Report Interim Report Evidence - Transcripts - Witness Statements - Submissions - CCNR Report and associated documents - Statistical Reports and associated documents - Background Papers - Expert Papers Inquiry Seminars About the Inquiry Help		Daily transcripts HEARING SUMMARY 16th September 1999 Hearings continued today with evidence from four expert witnesses: Mr Leslie Hamilton, Consultant Paediatric Cardiac Surgeon, Freeman Hospital, Newcastle Upon Tyne; Dr Duncan Macrae, Consultant in Paediatric Intensive Care, Royal Brompton Hospital, London; Dr Barry Keeton, Consultant Paediatric Cardiologist, Southampton General Hospital; and Mr Andrew Derbyshire, Cardiac Nurse Clinician, Royal Liverpool Children’s Hospital. All witnesses today were members of the Inquiry’s Expert Group and gave evidence about the post-operative treatment and care of babies and children undergoing complex cardiac surgery. Their discussions began with the subject of the transfer of patients from the operating theatre to the Paediatric Intensive Care Unit (PICU), the development of the role of the intensivist during the 1980s and 1990s, the importance of teamwork in delivering quality and continuity of care for patients and the importance of communication between members of the multi-disciplinary team and parents. Each witness gave opinions on features of PICUs including: proximity to adult facilities; access to operating theatres, parents’ accommodation and other hospital services. They all stressed the importance of teamwork and maintaining a good working relationship. The experts then commented on the referral and transfer of patients between hospitals, the developments in portable ventilation equipment and the introduction of retrieval teams who collect patients from other hospitals and bring them back to the PICU. They discussed the issue of informing parents about risk and adverse prognosis and concluded by debating hierarchy within the PICU, all giving their opinions about who has overall responsibility for the treatment and care of patients admitted for paediatric cardiac surgery.

FULL TRANSCRIPT

   1                    Day 51, 16th September 1999
   2   (9.40 am)
   3                SEMINAR:
   4         POST OPERATIVE MEDICAL AND NURSING CARE
   5   THE CHAIRMAN: Good morning, everyone. Good morning,
   6     Mr Langstaff. Our delay in starting I understand is due
   7     to some technical problem which has now been sorted out.
   8   MR LANGSTAFF: I hope so: that is, the sorting out. Today
   9     we have, as I mentioned briefly yesterday, four of our
  10     independent experts from the Independent Expert Panel to
  11     talk to us and discuss intensive care.
  12        Working around the room, from nearest to me at the
  13     table on my right we have Mr Andrew Darbyshire, who is
  14     a nurse; we have Dr Barry Keeton, a cardiologist. Then
  15     moving to the usual witness chair, we have nearer to you
  16     Mr Leslie Hamilton, a paediatric cardiac surgeon, and
  17     nearest to the touchpad screen, we have Dr Duncan
  18     Macrae, who is an intensivist.
  19        I am going to ask each of them to take the oath
  20     and then each of them to tell us a little bit more about
  21     himself.
  22        Could you stand, please, to take the oath?
  23           MR LESLIE HAMILTON (SWORN):
  24           DR DUNCAN MACRAE (SWORN):
  25           DR BARRY KEETON (SWORN):

   1           MR ANDREW DARBYSHIRE (SWORN):
   2   MR LANGSTAFF: If we can go round in the same order,
   3     Mr Darbyshire, would you like to tell us a little bit
   4     more about yourself and your particular expertise?
   5   MR DARBYSHIRE: I am now employed as an advanced nurse
   6     practitioner in paediatric intensive care at the Royal
   7     Liverpool Children's Hospital. I am a Registered
   8     General Nurse --
   9   MR LANGSTAFF: Could you bring the microphone a little
  10     nearer to you? I am sorry you inevitably will have to
  11     share with Dr Keeton.
  12   MR DARBYSHIRE: Shall I continue from where I was?
  13   MR LANGSTAFF: Yes, please.
  14   MR DARBYSHIRE: I am a Registered General Nurse and
  15     Registered Sick Children's Nurse. I have
  16     a post-registration qualifications in general intensive
  17     care, the ENB 100. I also have a Masters degree in
  18     clinical nursing. For the past four years I have been
  19     employed as an advanced nurse practitioner in the
  20     paediatric intensive care unit at the Royal Liverpool
  21     Children's Hospital. Previous to that, I was the ward
  22     manager and clinical nurse specialist on the separate
  23     cardiac intensive care unit before the two units
  24     amalgamated.
  25        My experience extends back in paediatric cardiac

   1     intensive care to 1986. I also did two years in adult
   2     intensive care.
   3   MR LANGSTAFF: Dr Keeton?
   4   DR KEETON: Thank you. I am Barry Keeton, consultant
   5     paediatric cardiologist at the Wessex Cardiothoracic
   6     Centre in Southampton General Hospital. I have held
   7     that post since October 1978.
   8        Apart from my medical qualifications, I have
   9     post-graduate qualifications, a Diploma of the Royal
  10     College of Obstetricians and Gynaecologists and
  11     a Diploma of Child Health. I am a Fellow of The Royal
  12     College of Physicians and a Fellow of the Royal College
  13     of Paediatrics and Child Health.
  14        My background is that I trained in paediatrics and
  15     paediatric cardiology, mostly in London, specifically at
  16     the Brompton Hospital. From there I went to America, to
  17     the Mayo Clinic, where I spent about 13 months, and then
  18     came back to take up the post in Southampton.
  19   MR HAMILTON: I am Leslie Hamilton, a Consultant Cardiac
  20     Surgeon in the Freeman Hospital in Newcastle with
  21     predominant interest in paediatric cardiac surgery.
  22     I trained initially in Belfast in Northern Ireland.
  23     I did my initial surgical training there and cardiac
  24     surgical training, and I was involved in paediatric
  25     cardiac surgery there.

   1        I then was the Senior Registrar in Yorkshire at
   2     the unit in Leeds, where I was able to continue my
   3     paediatric cardiac training. I spent a year of that
   4     time at Great Ormond Street, having been appointed
   5     a Senior Registrar in 1985. I spent a year, 1988/89, at
   6     Great Ormond Street, and I was appointed consultant to
   7     Newcastle in 1991.
   8        I have, as I say, a predominant interest in
   9     paediatric cardiac surgery. I am a Fellow of The Royal
  10     College of Surgeons of England and of Edinburgh and hold
  11     the Cardiothoracic Fellowship.
  12   MR LANGSTAFF: Dr Macrae?
  13   DR MACRAE: I trained in Scotland, where I graduated in
  14     medicine in 1980. I then pursued a career in
  15     anaesthesia and I gained the Diploma of the Fellow of
  16     the Faculty of the Anaesthetists of Royal College of Surgeons.
  17     I then specialised in cardiac anaesthesia, particularly
  18     paediatric cardiac anaesthesia, through appointments at
  19     the Brompton Hospital and continued following a year in
  20     Melbourne, Australia, where I was a Fellow in paediatric
  21     intensive care, to pursue a career in that.
  22        I was appointed as a consultant in paediatric
  23     cardiac intensive care at Great Ormond Street Hospital
  24     in 1989, where I have worked for the past ten years
  25     until, that is, the beginning of this week, when I took

   1     up the post of Director of Paediatric Intensive Care at
   2     the Royal Brompton Hospital in London.
   3        I am also a Fellow of The Royal College of
   4     Paediatrics and Child Health. That is about it.
   5   THE CHAIRMAN: If I may interrupt, Mr Langstaff, before we
   6     go further, first of all to welcome all of you and to
   7     thank you very much for helping us, as I am sure you are
   8     going to during the day, but to remind you all that,
   9     important as we are, one of the most important people in
  10     this room is sitting over there, the person who takes
  11     down whatever we say so that it forms part of the
  12     transcript and is available to those who follow our
  13     proceedings from a distance.
  14        Thus, without in any way seeking to inhibit what
  15     you may say as you get involved in talking to us, may
  16     I remind you that sometimes you are going to be using
  17     highly technical language; and secondly, sometimes you
  18     may, in the sweep of the moment, speak rather quickly.
  19        So keep an eye on our colleague over there to make
  20     sure that we are capturing everything. That is a plea
  21     at the beginning and I will not say anything more about
  22     it hereafter.
  23   MR LANGSTAFF: It is particularly useful for the Panel, and
  24     indeed the wider audience, to understand some of the
  25     nuances which might be lost were just one of you, on his

   1     own, to speak or to give evidence. The purpose of
   2     having the four of you, from your different
   3     perspectives, to look at the question of post-operative
   4     care, is that each of you will not only contribute but
   5     will pick up points made by one of your colleagues and
   6     point out that that may not be entirely right, or it
   7     needs to be taken further, or whatever your view may be,
   8     so that we, in the Inquiry, get as good a picture as we
   9     can before we address the Bristol situation and the
  10     adequacy of surgery there later on this autumn, of what
  11     you, as experts, have to say about the process of
  12     post-operative care, not just today but from 1984
  13     onwards.
  14        May I begin by asking you how important the
  15     handover process is from surgery, the theatre, to the
  16     intensive care? Would one normally expect the operating
  17     surgeon to be present during that handover process?
  18        Perhaps, Mr Hamilton, you would like to start us
  19     off on this.
  20   MR HAMILTON: It is a personal feeling but I guess, from my
  21     point of view, that I feel the surgeon should be there.
  22     That is the way I was brought up, if you like, during my
  23     training. That is what I have always practised.
  24     I think that would vary from place to place. It would
  25     depend on the seniority of the other people involved in

   1     the operation. I think if there is a very experienced
   2     Senior Registrar or Registrar who understands the
   3     physiology and the surgery that has been done, then as
   4     long as there is a surgeon available, I think the
   5     surgeon should be there.
   6        The handover time has been where we have seen some
   7     of the most dramatic changes over the years in intensive
   8     care, in that monitoring has improved, and portable
   9     monitoring in particular. Duncan might comment later as
  10     an anaesthetist, but certainly my memories of earlier
  11     days in cardiac surgery were that the change from
  12     theatre to the intensive care was a bit of a "grab and
  13     run", if you like. The monitoring was not very
  14     sophisticated, and there were often problems that
  15     occurred during that time.
  16        One of the things that affects physiology, if you
  17     like, post-operatively, is the way the patient is
  18     ventilated. In theatre they are on a machine which
  19     regulates it very carefully, in intensive care they are
  20     on a machine, whereas on the transfer back to intensive
  21     care, it was just an anaesthetist with a bag and there
  22     could be a lot of variation in that. That in itself can
  23     upset the physiology.
  24        But it is a very critical time in the early hours
  25     after coronary pulmonary bypass, so that handover time

   1     is vital.
   2   MR LANGSTAFF: Over what period of time did the bag cease
   3     to be used and the portable monitor start to be used?
   4   DR MACRAE: We certainly still use bags to ventilate
   5     children between the operating room and the intensive
   6     care unit now. Although there are portable ventilating
   7     systems, they are not commonly used for the very short
   8     transfers, although they are used when transferring
   9     critically ill children from one hospital, an external
  10     hospital, to another.
  11        Portable monitors probably came in widely
  12     available from the early 1990s onwards. I would say
  13     1991/92 was the sort of time that we routinely used
  14     a portable monitor which was able to measure not just
  15     the electrocardiogram which had been used before and
  16     perhaps the oxygen saturation, but also, most
  17     importantly, the patient's blood pressure.
  18        In the years before that, the units that
  19     I practised in, the only handle we had on a patient's
  20     blood pressure in the few minutes between the operating
  21     room and intensive care unit was either a finger on the
  22     pulse of a patient, a very clinical guide, or perhaps
  23     a little bubble in the end of the arterial monitoring
  24     catheter which would move backwards and forwards:
  25     a relatively crude indication, but nevertheless, it is

   1     a guide.
   2   THE CHAIRMAN: Mrs Howard has a question.
   3   MRS HOWARD: Dr Macrae, you talked about the short transfer
   4     from theatre to ICU, and then you talked about the few
   5     minutes. Do you have a period of time that you would
   6     say was critical in terms of both distance and time
   7     between transfer from operating theatre to ICU?
   8   DR MACRAE: I think that is a good question. The transfer
   9     itself, for instance, using perhaps Great Ormond Street
  10     as a model, might seem to be insignificant in that the
  11     operating room is physically 50 feet from the paediatric
  12     cardiac intensive care unit. However, the process of
  13     transfer actually involves taking to bits all of the
  14     established monitoring that has been there for two or
  15     three hours, and everything gets into a spaghetti-like
  16     mess however hard one tries to avoid that.
  17        So there is a period of time in the operating room
  18     when monitoring is being taken down and it is less
  19     efficient, people are busy doing things and it is
  20     a critical time. So the actual physical transfer may
  21     only take half a minute but the process can probably
  22     take 15 minutes from the time that full monitoring was
  23     taken down to full monitoring being established.
  24        So the physical distance I think is less important
  25     than the recognition of the dangers of that period: the

   1     patient having been stable, hopefully, in the operating
   2     room and suddenly, however good the monitoring is, they
   3     are suddenly moved, they are being observed in
   4     a different way, there are different conditions, the
   5     lighting is different. There are all sorts of factors
   6     which actually make transfer of any patient, not just
   7     a cardiac patient, but any ventilated patient or
   8     critically ill patient, really quite hazardous.
   9   MRS HOWARD: What would be the outside period for safety in
  10     the move?
  11   DR MACRAE: I think transfer anywhere within the same
  12     part of a hospital, including transfers between floors,
  13     provided they are properly conducted, are acceptable
  14     even to this day, certainly now provided there is
  15     adequate monitoring. The extension of the process to go
  16     from 50 feet to 500 yards actually in terms of time is
  17     not all that great. I think the majority of the time is
  18     actually the preparation time at the beginning, and then
  19     the re-setup time at the end. The physical difference
  20     is not all that great.
  21        I would not like to be in a hospital corridor for
  22     more than three or four minutes.
  23   MR LANGSTAFF: You used the expression "even to this day" it
  24     is not necessarily unacceptable to have a difference in
  25     level and a lift, presumably, between the two; but that

   1     suggests that you actually regard a lift between two
   2     floors as being undesirable?
   3   DR MACRAE: I have spent time, fortunately not with
   4     a patient, in a lift that did not function. That is
   5     always a possibility, and whilst, you know, one would
   6     always take precautions and take resuscitation equipment
   7     and so on with us, it would nevertheless be a sticky
   8     time if one were in that situation with a very sick
   9     child. So if it can be avoided, that is great. But
  10     I think one has to be pragmatic. Hospitals are not
  11     necessarily designed in a perfect way with the
  12     paediatric cardiac theatre absolutely next to the
  13     cardiac intensive care unit. That is not always
  14     possible. If I were an architect designing a site from
  15     scratch, that is what I would plan.
  16   MR LANGSTAFF: So the ideal is to have the intensive care
  17     next-door?
  18   DR MACRAE: Yes.
  19   MR LANGSTAFF: The further you get away from that, the
  20     further away you are moving from the ideal?
  21   DR MACRAE: Yes, that is correct.
  22   MR LANGSTAFF: The reason it is ideal, it is ideal
  23     presumably from the point of view of the safety and care
  24     of the child, the patient?
  25   DR MACRAE: It is ideal for a number of reasons. The short

   1     transfer is clearly one of them. The second reason,
   2     I believe, is that it puts the intensive care unit very
   3     close to the surgical team and the anaesthetic team, so
   4     that it facilitates communication between the operating
   5     room and the intensive care unit.
   6   MR LANGSTAFF: And the fact of going in a lift, presumably,
   7     can cause a problem in the sense that you cannot get
   8     that many people necessarily in the lift, so some of the
   9     team stay downstairs, some come upstairs. Is that the
  10     way it works or not?
  11   DR KEETON: We have had experience of this in Southampton,
  12     since we moved into Southampton General. I cannot
  13     remember the actual date but it was in the 1980s. We
  14     looked at this very carefully and were very worried
  15     about it.
  16        When we set up the unit, it was not possible
  17     physically to have the operating theatre and the
  18     intensive care unit adjacent to each other; they were on
  19     separate floors. We commandeered one of the hospital
  20     lifts and made it a dedicated lift for the purpose of
  21     transfer between cardiothoracic ITU and the operating
  22     theatres. That lift was equipped with all the
  23     resuscitation equipment and monitoring equipment
  24     actually within the lift.
  25        We also had to ensure that the power supply,

   1     et cetera, was all as secure as possible, and make
   2     arrangements as to what was to happen if the lift broke
   3     down. I remember the discussions very clearly in the
   4     days when we were moving into the general hospital.
   5     So we made do by making it as safe as we possibly
   6     could. We have, touch wood, not had any problems with
   7     it, so I think it is possible. But I agree, it is not
   8     ideal.
   9   THE CHAIRMAN: May I ask a question? Clearly, what you have
  10     just said is in response to Dr Macrae's observation
  11     that one has to be to a degree pragmatic in terms of
  12     what one is confronting. But was the lift large enough
  13     to accommodate both the staff and all the material or
  14     machines that you would need should anything go wrong?
  15   DR KEETON: It can get rather cosy in there! It is
  16     a standard sized hospital lift. It takes a bed and --
  17     the way we got around this was to hang the equipment on
  18     the walls, on rails, so that less space was taken up by
  19     the equipment. The person accompanying the child would
  20     certainly be the senior anaesthetist, his assistant, the
  21     Operating Department assistant, and usually one of the
  22     junior surgeons or the senior registrar would come down
  23     with the child. So we would hope to have within the
  24     lift the key personnel that may be required should some
  25     problems occur during the transfer.

   1   MR LANGSTAFF: One of the themes that is already beginning
   2     to emerge is the importance of communication between the
   3     operating team and the intensive care team.
   4        Mr Hamilton's practice is to go with the patient
   5     to intensive care. What is your general experience,
   6     Mr Darbyshire, of what happens around the country?
   7   MR DARBYSHIRE: Around the country, it is the usual standard
   8     that you will get someone from the surgical team.
   9   MR LANGSTAFF: Someone?
  10   MR DARBYSHIRE: Yes. In my own experience, quite often it
  11     is the surgeon who has done the surgery or it will be
  12     the surgeon who has assisted him. Invariably, you will
  13     have the anaesthetist who has actually run the child on
  14     bypass coming back with the patient and the nurse from
  15     theatre, usually the scrub nurse who scrubs during the
  16     operation will come back. That is my general
  17     impression, talking to colleagues around the country:
  18     that is the usual practice, and it is definitely the
  19     practice that I have seen.
  20   MR LANGSTAFF: Is there a problem if it is not actually the
  21     surgeon who has done the operation, for instance if he
  22     has left his registrar to do the closure and the
  23     registrar comes down? He obviously does not have the
  24     experience of a consultant. He may not have been as
  25     acutely aware of the pressures and so on and so forth

   1     that the surgeon might have been aware of during the
   2     course of the operation.
   3   MR HAMILTON: It is fair to say, though, that an assistant
   4     in a paediatric case, because of the complexity of the
   5     cases, would tend to be fairly experienced and fairly
   6     senior. The main role, if you like, of the surgeon
   7     would be, if there was a disaster, to open the chest.
   8     That would be, often, our first response, to check if
   9     there was any bleeding or any compression of the heart
  10     or whatever. As long as there was a surgeon of that
  11     sort of experience, that would be the main reason for
  12     having the surgeon there.
  13        I think it is interesting, just talking about the
  14     transfer time, I think we have got slower now. Distance
  15     has become less important with modern portable
  16     monitoring. The main time that I fear is the time of
  17     actually moving the child from the operating table on to
  18     the bed. That is where we spend a lot of time making
  19     sure -- as Duncan says, you get everything tangled up.
  20     Once you have the child on the bed for transfer and you
  21     have your monitoring set up, the actual time and
  22     distance nowadays does not matter. We actually have
  23     become slower in our transfers as time has gone on
  24     because there is not the same need to rush to intensive
  25     care to get the monitoring set up.

   1   DR MACRAE: I think that is true. Certainly, in the
   2     transfer of children from other hospitals, there has
   3     always been this debate about "scoop and run" or "stay
   4     and play". We are now very much towards the "stay and
   5     play", in other words, get everything organised and
   6     double-check that we are quite happy with the transfer
   7     before actually going out into the hospital corridor,
   8     whereas perhaps in the old days, when there was not much
   9     monitoring, it was a question of "get this done quickly
  10     so we can reconnect".
  11   MR DARBYSHIRE: I think another important point is actually
  12     the number of moves the patient makes. If you go from
  13     theatre table to a trolley, then a trolley to a bed in
  14     the unit, you are physically moving the patient more
  15     times. I think it is important to take the bed they are
  16     going to stay on straight into theatre and take them
  17     off, so you can avoid such risks as dislodging the
  18     endotracheal tube, dislodging vascular access.
  19        In the length of time it takes to come back, in my
  20     experience one thing I have seen is that you can
  21     sometimes occlude vascular access. Not all the fluids
  22     given in theatre -- say the maintenance fluid would be
  23     stopped just to stop having another piece of equipment
  24     on the bed. I have seen one or two of those catheters
  25     come back and they have actually occluded; they have

   1     actually clotted off on a few occasions. I think that
   2     might be a process of the length of time it has taken
   3     since you actually stopped giving the maintenance fluid
   4     to actually getting back to the unit.
   5   THE CHAIRMAN: May I just ask a question? Mr Darbyshire,
   6     you have been very helpfully recalling your wide
   7     experience and that there is a surgeon or a surgical
   8     assistant, a nurse and the anaesthetist, who would
   9     accompany the child, and you make this observation about
  10     the same bed. But do I take it that you are talking
  11     about what would be described as good or best practice
  12     now? One of the things we have to bear in mind is to
  13     what extent that would have been standard or good
  14     practice in the period we are particularly concerned
  15     with, 1984 to 1995, what Dr Macrae, because of his
  16     youth, describes as perhaps "the old days".
  17   MR DARBYSHIRE: My personal experience has always been that
  18     the child has come back on a bed that has been prepared
  19     in the ITU. One issue about the actual transfer is that
  20     it just does not happen that the patient comes out of
  21     theatre; there is an awful lot of preparation that has
  22     to be undertaken within the ITU. In my experience,
  23     communication between theatre and the intensive care
  24     unit prior to the patient actually coming back, to
  25     actually have some indication about how has the patient

   1     been since it came off bypass, is quite important. You
   2     can get a lot of pieces of equipment ready and have it
   3     prepared, and I think that is an important part, if we
   4     are talking about communication, about the issues
   5     surrounding the transfer: you must be pre-warned to be
   6     pre-armed, so to speak, to be ready.
   7   DR MACRAE: Can I just make an additional comment on this
   8     issue? I think it is true to say that it certainly is
   9     best practice for cots or beds to be taken into the
  10     operating room, but equally, even now in the modern
  11     age, if you like, I would not criticise a practice of
  12     using a trolley. The question is how it is done; if it
  13     is done in a controlled and expert way, then that is
  14     just as acceptable to me, even now, as what we do, which
  15     is use beds and cots.
  16   MR LANGSTAFF: We had presented to us yesterday, by
  17     Professor Marc de Leval, that when surgery was finished
  18     and the consultant surgeon with 20/30 years experience,
  19     and the anaesthetist with 20/30 years experience
  20     (between them, say, 50 years experience) handed over in
  21     intensive care, they might hand over to much more junior
  22     doctors who, between them, might have no more than 5, 6,
  23     8 years experience. So a sudden drop in experience,
  24     which he was suggesting to us carried with it
  25     a potential for difficulty in the continued management

   1     of the child.
   2        Do you see it that way, or not?
   3   DR MACRAE: I think what he was describing was the need for
   4     an intensivist. Perhaps I should first of all explain
   5     what this rather bizarre term means?
   6   MR LANGSTAFF: You would say that, wouldn't you!
   7   DR MACRAE: It is interesting, but in fact it is true.
   8     I cannot say "in the old days" again, but traditionally,
   9     when cardiac surgery started in children, the key people
  10     involved were a paediatric cardiologist who was largely
  11     responsible for pre-operative and post-operative care,
  12     mainly in the non-surgical sense, and a surgeon and
  13     cardiac anaesthetist who were mainly involved in the
  14     immediate operative and post-operative care. There was
  15     not such a thing as a specialist in intensive care
  16     itself. Most of that fell to a combination of the
  17     skills of the anaesthetist to look after ventilators and
  18     some of the devices, arterial lines and access, that
  19     sort of thing, and the surgeon who broadly speaking
  20     perhaps understood the inside of the heart, and between
  21     them they decided what the best support and treatment
  22     for that child is, with additional support from
  23     cardiology.
  24        But the difficulty of course was that at the end
  25     of an operation, a surgeon and indeed his anaesthetist

   1     would probably have to go back to the operating room, or
   2     perhaps even another hospital, to do some of the
   3     procedure, leaving the patient in the intensive care
   4     unit often being looked after by very skilled nurses,
   5     but a hotchpotch of resident doctors in training who may
   6     or may not have particular skills in intensive care;
   7     they were there to monitor and call people back to help
   8     if possible.
   9        The history of my job at Great Ormond Street was
  10     that there was funding for another surgeon and the
  11     surgeons looked at one another and said "We do not
  12     really want another surgeon; we want someone to look
  13     after the things we now do in the intensive care unit,
  14     so let us put the money towards someone to do that, to
  15     take that load off our shoulders so we do not have to
  16     worry about the intensive care unit while we are back in
  17     the operating room".
  18        I think perhaps that helps to explain the
  19     perception of this skill gap, the sort of vacuum that
  20     was there, and increasingly over the last ten years,
  21     that gap has been filled by people who are called
  22     intensivists, many of whom are anaesthetists who
  23     specialise in intensive care, some physicians or
  24     paediatricians who have done the same.
  25   MR LANGSTAFF: If I can just take some of the things you

   1     have said a little further, you were describing the
   2     importance of those in intensive care having access to
   3     expert help, and the expert help you had in mind was
   4     presumably the surgeon, or was it the surgeon and the
   5     anaesthetist?
   6   DR MACRAE: The surgeon and the anaesthetist, yes.
   7   MR LANGSTAFF: And if necessary a cardiologist, all of which
   8     help may have to be brought in from wherever it happens
   9     to be. The surgeon who has operated in the morning may
  10     have a second operation in the afternoon.
  11   DR MACRAE: Correct.
  12   MR LANGSTAFF: He may have to go pretty well straight from
  13     the first operation to the second, might he?
  14   DR MACRAE: Yes.
  15   MR LANGSTAFF: What is the most critical period in intensive
  16     care? Is it the beginning?
  17   DR MACRAE: Yes, I think if things are going to go wrong,
  18     they often do go wrong within the first 6 to 12 hours,
  19     and that certainly is a very critical period.
  20   MR DARBYSHIRE: I would agree. Again, it is in the first 4,
  21     6, 12 hours we see most of the things that go wrong.
  22     Sometimes you may, within the first 3 hours, actually
  23     need to return the patient to theatre in some instances
  24     as well.
  25   DR MACRAE: I think the things that go wrong commonly are

   1     perhaps bleeding in the first few hours after surgery,
   2     and then in the time from sort of 2 to 6 or 8 hours,
   3     a heart may temporarily contract less well. That is
   4     a time when the cardiac output, the function of the
   5     heart to pump blood around the body is, hopefully
   6     temporarily, impaired. I do not know if Mr Hamilton
   7     agrees with that?
   8   MR HAMILTON: I see the IT phase as being in several
   9     different time periods. The first few hours are
  10     critical and that is when things are going to happen
  11     dramatically and you may have to be sharp to pick up any
  12     sudden change like the heart rhythm may change, the
  13     heart may stop or bleeding may impair the function of
  14     the heart.
  15        After that phase, as Duncan said, we know that
  16     putting anybody on coronary pulmonary bypass, even if
  17     you do not do anything to the heart, the heart will be
  18     impaired for the first 6, 8, 12 hours post-operatively.
  19        After that sort of phase you move into what you
  20     would like to see as a steady progression of getting
  21     better, a constant improvement, if you like, and that,
  22     I always explain to the juniors, is like putting
  23     a jigsaw together. You are looking for all the
  24     different little clues you are getting from the patient
  25     that they are getting better. If they are not, that is

   1     the time to intervene. That is a much more prolonged
   2     phase and, if you like, a constant observation.
   3        So I think there are the different timescales in
   4     intensive care.
   5        Once you get beyond that phase, then you are
   6     looking for the more chronic problems like infection and
   7     so on.
   8   MR LANGSTAFF: In the days before there was, then, an
   9     intensivist, someone dedicated to the charge of
  10     intensive care, an expert, on the days when a surgeon
  11     might very well have one operation and then go on to
  12     another, how was any emergency in the first four hours
  13     or so coped with?
  14   DR KEETON: What we did in Southampton, it was difficult.
  15     I think it has always been a problem, that the surgeon
  16     cannot be standing by the bed the whole time and
  17     anything can happen at any time. It is more likely for
  18     things to go wrong in the early hours. There may be
  19     other surgeons in the building who would always help,
  20     and I think it is important to understand that they
  21     usually work pretty well as a team. If the surgeon was
  22     operating and could not leave to come back and see the
  23     child, he would get his colleague to come along, or one
  24     of the more experienced junior staff could "hold the
  25     fort" for a while.

   1        But undoubtedly, it is a problem area.
   2        The key people, of course, the nurses, become very
   3     experienced at knowing what is going on. Clearly they
   4     cannot re-intervene and re-open the chest, but they are
   5     extremely skilled at spotting when problems are
   6     arising. I know on occasions the surgeon has had to
   7     take his gloves off and come down to the unit and see
   8     the child and leave his assistant with the patient on
   9     the table. I think that has happened on one or two
  10     occasions during my career.
  11   MR HAMILTON: The other point to make, when you are
  12     scheduling your list you will try -- different
  13     operations will have different anticipated problems
  14     afterwards. That is one of the keys to intensive care,
  15     anticipating particular problems after that particular
  16     procedure. You would tend to put the most
  17     straightforward case on first so you would not be in the
  18     situation of going back to theatre worried about the
  19     case you have just done and not being able to
  20     concentrate on your next case. I think most surgeons
  21     would take that approach.
  22   MR LANGSTAFF: Has that been a general pattern?
  23   DR KEETON: Speaking personally, yes, it has.
  24   MR LANGSTAFF: When you say that you may need to bring in
  25     another surgeon if surgeon number 1 who has done the

   1     operation is back in theatre, that presupposes that
   2     there is a number of qualified, in a paediatric case,
   3     paediatric cardiac surgeons on hand. That demands, no
   4     doubt, a certain size of department?
   5   DR KEETON: Yes. We have been a two (for a while a three)
   6     paediatric surgeon department and of course there are
   7     times when only one of them is there. It probably would
   8     be safer if you had a department with more people
   9     around, but it is probably not that practicable.
  10   MR HAMILTON: The sort of emergency situation you are
  11     talking about, you do not need particular skills in
  12     paediatric cardiac surgery. You just need a pair of
  13     scissors to open the chest. Any surgical resident will
  14     be able to do that. That is in terms of surgical input
  15     at that stage.
  16   DR MACRAE: I think that is true. The problem basically in
  17     the early stage, the really urgent problem that has to
  18     be sorted out now is cardiac tamponade from bleeding or
  19     something similar to that, and really, once the chest is
  20     open, even if the bleeding is continuing, the problem
  21     is at least temporarily resolved. I think it is
  22     probably fair to say that the level of skill actually in
  23     stopping bleeding is perhaps less than the level
  24     required to do the complex intracardiac operation
  25     itself.

   1   MR LANGSTAFF: So looking at the development of the
   2     intensivist, you described how the post developed in
   3     Great Ormond Street. Was that the way that it developed
   4     across the country? What was the progress of the
   5     development of the intensivist?
   6   DR MACRAE: It still continues. I believe that my
   7     appointment was the first full-time appointment of
   8     anyone in paediatric intensive care. At that time
   9     intensive care was delivered, as I mentioned earlier,
  10     by either anaesthetists, cardiologists or surgeons who
  11     dedicated some of their time to duties in the intensive
  12     care unit.
  13        In some intensive care units at that time, those
  14     people had dedicated sessions. In other words, they
  15     would have time allocated to intensive care duties when
  16     they were free of other duties. Certainly in my
  17     training in adult intensive care, for instance, there
  18     were four consultant anaesthetists who covered the units
  19     and they did one day each week fully dedicated to the
  20     intensive care unit when they were free of any
  21     anaesthesia commitments. That is the way that certainly
  22     some paediatric cardiac intensive care services worked.
  23        Because of the specialisation of paediatric
  24     cardiac anaesthesia, there are not actually too many
  25     paediatric cardiac anaesthetists either, so in the

   1     children's cardiac intensive care units, the intensive
   2     care was delivered by the anaesthetist or the surgeon
   3     whilst doing their other job as well. In other words,
   4     they would be in their operating room nearby the
   5     intensive care unit, and they would try and supervise
   6     the more junior medical staff in the intensive care unit
   7     from the operating room. That clearly is not as
   8     satisfactory as having a full-time dedicated person who
   9     can be there at a senior level and supervise the care.
  10        So I think over the last ten years we have seen
  11     the development of those dedicated sessions or fully
  12     employed intensivists to supervise intensive care.
  13     But even to this day, I think there are some units where
  14     that is not fully in place yet.
  15   MR LANGSTAFF: I would imagine, because of the job that you
  16     do, what your answer might be to the next question, so
  17     I think I will ask Dr Keeton to comment.
  18        How desirable is it to have intensivists rather
  19     than the surgeon or the anaesthetist who took part in
  20     a particular operation looking after the intensive care
  21     unit?
  22   DR KEETON: I think it is very desirable. We have recently
  23     this last year or so got a paediatric intensivist in
  24     Southampton --
  25   MR LANGSTAFF: Could I ask you to pause there and bring the

   1     microphone towards you? That microphone is a bit quiet
   2     and we cannot do much about it.
   3   DR KEETON: In the last year or so we have had a paediatric
   4     intensivist in Southampton and this has been a growing
   5     development in most units since probably the early
   6     1990s, when paediatric intensivists began to be
   7     appointed.
   8        Prior to that, there had been no training
   9     programme for paediatric intensive care, it was not
  10     recognised as a specialty, so that work inevitably was
  11     being done by anaesthetists and their junior staff.
  12        In the same way as Duncan said, the allocated
  13     sessions were given to the cardiac anaesthetic team to
  14     cover ITU, and it was their responsibility.
  15        Prior to that, going back to the 1980s when we had
  16     only two cardiac anaesthetists, they did the job from
  17     the operating theatre, covering the intensive care and
  18     their juniors. I think it is much more desirable what
  19     we have today, and it continues to develop.
  20   MR HAMILTON: I think that was certainly the pattern around
  21     the country, that the intensive care would be supervised
  22     by the anaesthetist and the surgeon. Duncan made the
  23     point, it does not matter what background they come
  24     from, someone present in intensive care who understands
  25     the physiology and the anatomy of congenital heart

   1     defects, whether they are an anaesthetist or
   2     paediatrician or cardiologist I think is less important;
   3     it is the fact they are there and understand what is
   4     going on.
   5   DR KEETON: I think the paediatric cardiologist has a role
   6     to play as well. I was involved a lot in intensive
   7     care. If the chaps were busy in theatre they would call
   8     me and I would go along and make a diagnosis and advise
   9     appropriate treatment, and if necessary put my head
  10     around the theatre door and call the surgeon and say,
  11     "You have to come".
  12   MRS HOWARD: Could I ask Mr Darbyshire: from his experience
  13     I assume he has worked in both situations where there
  14     has been a surgeon lead or an intensivist lead. From
  15     a nursing perspective, what are the differences and can
  16     you take it further in terms of comment?
  17   MR DARBYSHIRE: I think in terms of the management of
  18     problems within ICUs, my opinion has always been it is
  19     part of the nurse's role. Allusions have been made to
  20     having highly skilled experienced nurses within the
  21     environment. You try to get the right people in the
  22     right place at the right time. I think in the era
  23     pre-intensivist it would have been difficult to fulfil
  24     all three criteria at any one point. I think
  25     post-intensivist -- at Liverpool, I think it was 1991/92

   1     when we had an intensivist appointed -- that became less
   2     of an issue because you had somebody who was probably
   3     the right person allocated there and you knew whom to
   4     contact. Part of the nursing role within the ICU is
   5     looking at that jigsaw which Mr Hamilton referred to,
   6     and it is spotting where things are going wrong, where
   7     intervention is needed. Within the nursing role, it is
   8     very difficult -- it is impossible -- to deliver that
   9     intervention yourself, but as I say, just getting the
  10     right person into the arena and telling them what you
  11     have seen was always difficult, before the intensivist.
  12        My own experience has been that it was a mixture
  13     of consultant anaesthetists, cardiologists, surgeons and
  14     I think from a nursing point of view, your first point
  15     of contact was usually a senior registrar in
  16     anaesthetics or a senior registrar in cardiology. They
  17     were always the first point of contact if you had
  18     a problem. The senior registrar in anaesthetics might
  19     be involved in theatre, the SR in cardiology might be
  20     down in a clinic, and there was always a problem about
  21     actually drawing them into the unit if you actually had
  22     a problem.
  23   THE CHAIRMAN: May I follow that question up? I found that
  24     response very interesting. At the time we are talking
  25     about, or now, would there be any sort of protocol or

   1     sense of who is the better person to approach for this
   2     or that problem, so that the nurse having, as it were,
   3     noticed there is a piece of jigsaw out of place, knows
   4     to whom to take that?
   5   MR DARBYSHIRE: I would not say there was any formalised
   6     protocol, but as a nurse, if you were basically faced
   7     with what you considered to be a ventilatory problem,
   8     you called the anaesthetist. If you were faced with
   9     a cardiovascular problem like the patient was starting
  10     to have arrhythmias, then you were more likely to call
  11     a cardiologist.
  12        At times it almost appeared, if you were faced
  13     with very big problems, that it was a question of whom
  14     you could get to be there.
  15   THE CHAIRMAN: That would be because of your training in
  16     being able to identify the nature of the problem. Does
  17     that, as it were, suggest that paediatric training was
  18     important, if not essential, so as to be able to play
  19     that role and identify whom to call in?
  20   MR DARBYSHIRE: I think so. I have experience of working in
  21     adult intensive care as well, and there are very big
  22     similarities between, if you like, the physiological
  23     care of a child in ICU, looking at the physiological
  24     factors of their condition. There are great
  25     similarities. If you are an experienced adult nurse,

   1     I think you can probably cope with the physiology of
   2     children as long as you can adapt it to children, but
   3     they do not have straightforward anatomy. As long as
   4     you can understand that, you can be trained in that.
   5        I think the paediatric nursing part comes in that
   6     it is like treating the whole patient as a child,
   7     delivering the "family-centred care", one of the buzz
   8     phrases that has been around for a while, in
   9     understanding the interaction between the parents and
  10     the child. But in terms of delivering that
  11     physiological care, I think experienced adult nurses,
  12     provided they have made the adjustments into paediatrics
  13     and the anatomical and physiological problems of the
  14     child, could deliver that.
  15   MR LANGSTAFF: Mr Hamilton was talking, in respect of his
  16     jigsaw, the second phase of intensive care, of the need
  17     to pick up the subtle signals which may show that
  18     something is not quite right or may be on a downward
  19     slope and care is not progressing as it might.
  20        Is there, do you think, a difficulty -- this is
  21     what we have heard from others -- in picking up the
  22     subtle signals from a child if one is not particularly
  23     child-centred or child-trained?
  24   MR HAMILTON: Personally, I think the key is that they are
  25     used to dealing with patients who have the abnormal

   1     physiology that we see after coronary pulmonary bypass,
   2     or after repair, closed surgery. I think that is very
   3     specific to cardiac patients. As Andrew said, if you
   4     are an adult nurse, as long as you are in
   5     that paediatric environment, your skill will be in
   6     picking up those subtle signs.
   7        I think, again, the background of the person is
   8     less important than how they are integrated into the
   9     unit. To me, paediatric intensive care is very much
  10     a team thing and everyone has their own input. The role
  11     of the intensivist is to bring all that together. The
  12     nurses are the key at the beside; they are the ones who
  13     pick up, usually first of all, that something is not
  14     quite right. It may be a surgical problem, it may be
  15     something else, but I think it is very much an
  16     integrated thing.
  17        One potential problem in intensive care is if the
  18     nurses get different vibes, different instructions even,
  19     from different people. One of the things we have
  20     discussed and faced is that it is important that all
  21     decisions are channelled through an individual. That
  22     would usually be the intensivist, if there is one, as
  23     long as there is an identified individual through whom
  24     all decisions are channelled. There is nothing worse
  25     for the nurse at the bedside, I am told, from talking to

   1     them, than that they do not know whom to believe or go
   2     by. Hopefully that will not arise, but it is
   3     a potential problem.
   4   DR MACRAE: I certainly would second that. I agree that
   5     intensive care is teamwork. In some ways, getting back
   6     to the period that the Inquiry are looking at, I would
   7     like to slightly get away from the concept of the
   8     intensivist and more back to the concept of intensive
   9     care as a team. Clearly, the resident on the intensive
  10     care unit or a consultant with sessions in the intensive
  11     care unit was an intensivist by another name. I think
  12     where we have developed now, however, is where people
  13     have a much longitudinal view, in other words, you can
  14     deliver point of care, crisis manage effectively
  15     individual patients, but where paediatric intensive care
  16     has gone now by appointing numbers of full-time
  17     intensivists, it has allowed us to develop training
  18     strategies and protocols and have a much better
  19     continuity of care and policies of care within units.
  20        I think that is how paediatric intensive care has
  21     developed, but I think the day-to-day management was
  22     often of a very good standard, even if the people doing
  23     it were doing it from -- or could potentially be very
  24     good, even if they were doing it from the cardiac
  25     operating theatre or on a sessional basis where there

   1     was a different consultant each day of the week. It
   2     could still be care of a high standard, but perhaps what
   3     was lacking in that situation was the opportunity to
   4     train and develop protocols and to fine-tune the care of
   5     children.
   6   MR LANGSTAFF: Two particular points I think emerge from
   7     your contributions. One is the issue of who is in
   8     charge of the patient in intensive care. The second,
   9     which I will explore in a moment, is the question of
  10     adult trained nurses nursing paediatric cases. I want
  11     to explore that a little bit further.
  12        Dealing with the first, was there any general
  13     pattern, as you understand it, as to who was in charge
  14     of the patient once the patient got into intensive
  15     care?
  16   DR KEETON: Certainly in Southampton, the surgeon maintained
  17     responsibility for the case. He had done the operation
  18     and knew what was going on, but he was very much
  19     supported by the rest of the team.
  20        I think the point that the nurses could get
  21     confused about who was actually giving the orders was
  22     a very valid one. If different people came at different
  23     times and made different suggestions, I think nurses did
  24     get confused, but we did try and define any system where
  25     the surgeon had overall control; the paediatric

   1     cardiologist or anaesthetist had major input and
   2     channelled everything through the resident who was
   3     a paediatric Senior House Officer or a paediatric
   4     registrar, so patients were being looked after by
   5     paediatrically trained junior staff.
   6        On the nursing side, clearly it is very desirable
   7     that the nurses have had paediatric training, but we
   8     must not ignore the very experienced nurses who became
   9     very adept at looking after both adults and children
  10     within the intensive care environment. Although they
  11     may not have had paper qualifications, they have looked
  12     after children, and families, for many years and done it
  13     very well. Clearly things have changed in more recent
  14     years, where they now go off on courses and get their
  15     paediatric qualifications, but our senior nursing staff
  16     were very expert with the children. It was not an ideal
  17     environment, we had to make do, but I think they did
  18     quite a good job.
  19   THE CHAIRMAN: May I ask a question which other colleagues
  20     may wish to respond to as well? You say in Southampton
  21     the surgeon was in charge. Did the others know that the
  22     surgeon was in charge? Was this, in other words,
  23     formalised, or was it a matter of perception, perhaps,
  24     offering the possibility of a different perception.
  25   DR KEETON: I think we all knew that the surgeon had a final

   1     say on things. Southampton was a small unit and we were
   2     able to communicate very readily. If a child was not
   3     doing well, everybody was at their bedside, the surgeon,
   4     the anaesthetist, the paediatric cardiologist, trying to
   5     sort out what was going on. There was a small group of
   6     us in the those early days, but I think the surgeon was
   7     the boss and I was happy to allow him to have that
   8     responsibility. But I would hope he would take notice
   9     of what I was saying!
  10   MR HAMILTON: I think I have to comment, as a surgeon.
  11     I agree, I feel I still carry overall responsibility.
  12     I think, having said that, it should not actually be an
  13     issue and it should not arise because if you are working
  14     as a team and discuss everything and everybody is fully
  15     informed, hopefully you are all moving in the same
  16     direction. There may be slight differences in how best
  17     to manage things but those should be resolved by
  18     discussion. At the end of the day, the surgeon's name
  19     is at the end of the bed and he carries the overall
  20     responsibility. But it should not be an issue.
  21        It is interesting that you ask, because at the
  22     next meeting of the British Paediatric Cardiac
  23     Association, that is a topic for debate. There is
  24     actually a formal debate on who actually is in charge of
  25     intensive care.

   1   MR LANGSTAFF: Who is, or who should be?
   2   MR HAMILTON: Both.
   3   MR LANGSTAFF: Who is must depend upon a mixture of
   4     factors. Leaving aside the theory of responsibility,
   5     the actual person who is taking the decisions may not
   6     necessarily be the responsible surgeon if the
   7     responsible surgeon is elsewhere or has a weekend at
   8     home and something needs to be done urgently; somebody
   9     else is going to make the decisions.
  10   MR HAMILTON: I said earlier that all decisions need to be
  11     channelled through one person. If you want to view that
  12     in terms of the person being in charge, that is
  13     correct. I would see that as an important thing. That
  14     is often not, usually not, the surgeon.
  15        But at the end of the day, if there are major
  16     overall decisions to be made -- I am talking in terms of
  17     planning overall care -- then I think the surgeon
  18     carries the final responsibility.
  19   MR LANGSTAFF: Again, examining the idea of final
  20     responsibility, suppose that there is an anaesthetic
  21     problem, a problem of ventilation or intubation: the
  22     surgeon may be ultimately responsible, but is he
  23     actually in charge of that problem or does he defer to
  24     the anaesthetist?
  25   MR HAMILTON: No. Of course if you are working as a team

   1     then you respect each others skills and contribution.
   2     As I say, it is not really an issue -- it should not be
   3     an issue.
   4   DR MACRAE: It is certainly true that the consultant
   5     anaesthetists would be responsible for their own skills
   6     in that area and if there was a problem that clearly
   7     related to anaesthesia, whilst the surgeon and the
   8     anaesthetist together might go to a family to explain
   9     the problem, given that it was the surgeon, if you like,
  10     who got the child into the operating room or put the
  11     child in that situation, suggested that was an
  12     appropriate thing to do, nevertheless the anaesthetist
  13     would be 95 per cent responsible for the anaesthetic
  14     problem. That would be my view, wearing my anaesthetic
  15     hat.
  16   MR DARBYSHIRE: I think one comment I would like to make as
  17     a nurse having experience of this, quite often you have
  18     to maintain a narrative at the bedside because the
  19     surgeon would arrive but would not see the
  20     anaesthetist. You would basically have to convey the
  21     information that the surgeon had given to you to the
  22     anaesthetist. At times they would not actually meet for
  23     a length of time and you would have to maintain this
  24     narrative at the bedside about who had been, what had
  25     been decided and whether that had actually changed; then

   1     revamp the narrative, if you like, for the next one on.
   2   MR LANGSTAFF: Teamwork is all very well if you can reach
   3     a consensus, a team view. What if you cannot?
   4   DR MACRAE: Clearly someone has to be in charge, and
   5     usually, if it is in terms of strategy and major
   6     decisions about to re-operate or reinvestigate, then in
   7     a post-operative patient I would say that the surgeon
   8     would have the final decision.
   9        Getting back to who is in charge on a minute by
  10     minute basis, there clearly has to be one common pathway
  11     and that is usually the senior of the ICU residents.
  12     They need to know what is happening to every patient in
  13     the unit that they are responsible for, and everything
  14     decision, large and small, they need to be aware of
  15     those suggestions and decisions and changes. But when
  16     it comes to major strategy, a child who is not doing
  17     well and needs to be reinvestigated, then the more
  18     senior members of the broad team -- intensive care is
  19     very much teamwork; it is not down to one individual.
  20     It may be that an intensivist is supervising the
  21     minute-by-minute management, but when it comes to
  22     a crisis point, the intensivist is not going to be
  23     a cardiologist, not the surgeon who does the operation,
  24     very often. They need to consult with their senior
  25     colleagues. So in many ways I think I could describe an

   1     intensivist as being, if you like, the general
   2     practitioner who then observes that there is a problem
   3     and then refers to the expert to deal with that specific
   4     problem.
   5   THE CHAIRMAN: I am following this, and of course it is
   6     a statement of the obvious that at any given moment
   7     someone must be in charge. The thing I am interested in
   8     in my question to Dr Keeton is whether everybody always
   9     knows who is in charge and whether everyone always has
  10     agreed as to who is in charge. I get a sense from
  11     Mr Darbyshire's contribution that the nurse who, in
  12     periods of 8 hours or whatever, longer, is always there,
  13     is from time to time perhaps presented with conflicting
  14     strategies, let us say, and although he would accept as
  15     a matter of reality someone is in charge, he may not be
  16     entirely clear who that candidate is or whether there is
  17     any agreement as to that.
  18        So do you not need some kind of -- it is
  19     a question I am asking for your expertise -- do you not
  20     need some kind of greater formalisation of the system,
  21     rather than saying, well, it is all the team, because
  22     all the team may define themselves, if I may use
  23     a soccer analogy as strikers or goalkeepers, and then
  24     there may be some degree of problem.
  25   MR DARBYSHIRE: I always viewed it as more a cricket

   1     analogy, actually. Pre-intensivist, like the English
   2     cricket team at the moment, it seems to change its
   3     captain all the time. With intensivists, it is more
   4     like having WG Grace who is going to be there for the
   5     next 30 years: you can identify with that person as the
   6     leader of the team within the PIC unit.
   7   MR HAMILTON: If there is a problem in that area, then the
   8     senior nurse in the unit, if they are running the unit
   9     well, will bang some heads together and find out exactly
  10     who the nurses are meant to take final decisions from.
  11   THE CHAIRMAN: That then becomes, does it not -- again, the
  12     benefit of having you four with your huge experience --
  13     a question or so of wider management. That itself needs
  14     to be engaged, does it not?
  15   DR KEETON: I think if a team cannot work together then it
  16     is a dysfunctional team. I think you are making
  17     a problem that probably does not exist that often.
  18     I accept that occasionally there will be disagreements
  19     on the way things should be managed, but it is an
  20     infrequent occurrence, in my experience. I think that
  21     most members of the team are experienced and reasonable
  22     and they will discuss it and come to a consensus view as
  23     to what the best management should be at a particular
  24     time.
  25   MR HAMILTON: I think one of the changes we have seen in

   1     intensive care, as Andrew quite rightly points out, is
   2     that in the past messages might have been passed from
   3     one member to another through the nurse, and that system
   4     can work. I think the trend has been, over the last few
   5     years, I guess, to have formal joint ward rounds on
   6     a regular basis. Certainly in the past it was
   7     a question of the surgeon might be on an early morning
   8     ward round and then the anaesthetist would come later to
   9     manage the unit for a day and they might pass a message
  10     through the nurse.
  11   THE CHAIRMAN: Mrs Maclean?
  12   MRS MACLEAN: I am very interested in what you are saying,
  13     the difference between now and the past. When exactly
  14     would the "past" be, roughly speaking?
  15   MR HAMILTON: It is hard to be specific. There are
  16     different arrangements around the country in different
  17     intensive cares, so it has been a gradual process rather
  18     than a cataclysmic event. I do not think one can be
  19     specific.
  20   DR KEETON: I think a formal ward round is a very desirable
  21     aim, but it is often not that practical when many
  22     members of the team have very busy programmes. Speaking
  23     personally from a paediatric cardiology point of view,
  24     my day is very committed most days. Often I am doing
  25     clinics hundreds of miles away from Southampton and

   1     could not possibly be on a formal ward round unless it
   2     was before 5.30 or 6.00 in the morning, which is not
   3     terribly practical.
   4        So I think it is an aim we would like to achieve,
   5     but with our current personnel and numbers, I do not
   6     think we can commit ourselves to a formal daily ward
   7     round; it just is not possible.
   8   DR MACRAE: If I can comment on the situation at Great
   9     Ormond Street, we always said that we wanted to have
  10     surgical representation on the main intensive care ward
  11     round of the day. In theory, that was always going to
  12     be possible, but surgeons being surgeons always drift
  13     off to the operating room to watch some interesting
  14     thing happening and leave the poor old intensive care
  15     unit behind. We eventually solved that, I have to say
  16     at the expense of my breakfast, by walking around with
  17     the surgeons at 7.30 in the morning. That clearly was
  18     so they could go off and do their operations at 8.30.
  19        That is a fairly drastic step to take, if you
  20     like, but it did work extremely well. Whilst I perhaps
  21     moaned and groaned at the start of this, I soon realised
  22     that actually that dramatically improved communication,
  23     because we would have a situation where there were two
  24     or three consultant surgeons and two or three
  25     anaesthetists or intensivists on that round, plus some

   1     junior staff, and that took our quality of care several
   2     steps forward, by making that joint round.
   3   MR LANGSTAFF: So in order to have the collectivism of the
   4     team operating in the patient's best interests, the need
   5     is for communication. You are saying that is best when
   6     it is co-ordinated by some system or other.
   7   DR MACRAE: The more senior level the communication occurs
   8     the better, but it is very important that the person who
   9     is at the bedside all the time, the nurse and the
  10     resident, the trainee in charge of the unit on
  11     a minute-by-minute basis, are also involved in the
  12     discussions and are certainly informed of any collective
  13     decisions which are arrived at, the strategies or
  14     policies arrived at for a particular patient.
  15   MR LANGSTAFF: Can we take it as a given that throughout the
  16     period the Inquiry is interested in, the need for
  17     communication and the co-ordination of it would have
  18     been appreciated by anyone involved in intensive care?
  19   DR MACRAE: I can only speak personally, but I have always
  20     been very aware that there are lots of interfaces in
  21     this type of team and that almost inevitably when
  22     problems occur, they occur because of failure to make
  23     a particular person in the team aware of the situation;
  24     failures of communication, yes.
  25   MR HAMILTON: I think in the past it might have been more

   1     a picture that one person would be there and they would
   2     call in the "fire-fighting", if you like. They would
   3     call in the particular expert they wanted to deal with
   4     the particular problem. That trend has been more
   5     towards the more formalising of communications, as
   6     Duncan says.
   7   THE CHAIRMAN: I wonder what you four experts would say to
   8     a slightly provocative observation, that in many other
   9     sectors of activity, in industry, for example, it would
  10     be deemed quite surprising, even in the early 1980s, for
  11     activities of the sort we are talking about, which are
  12     high risk activities, not to have been subjected to very
  13     careful management and organised control, if you will,
  14     whereas here Dr Keeton says that if they do not work
  15     together they are a dysfunctional team but that does not
  16     happen very often; and you all say, "Well, we all more
  17     or less know who is in charge at any given moment".
  18        I am saying this provocatively; these are not
  19     necessarily the views of anyone but they need to be
  20     tested. That is what we are here for, drawing on your
  21     experience for. Is that an observation you would like
  22     to comment on?
  23   DR KEETON: I think I accept your comment and the
  24     criticism --
  25   THE CHAIRMAN: It is not a criticism; I put no value on what

   1     I am saying, I merely seek your advice, as do we all.
   2   DR KEETON: I think that the members of the team have
   3     different skills and the problems that the children have
   4     would need principal advice from one of those members of
   5     the team, whether it is surgical or anaesthetic,
   6     paediatric cardiological, or maybe renal or whatever.
   7     The hierarchy that we have, it is not a firm structure
   8     like that. I am not sure that this field lends itself
   9     to autocratic boss and everybody having to take what he
  10     says. There is much more interplay in the care of
  11     a child.
  12   DR MACRAE: I think that is right, certainly now, but
  13     I think at the start of this period, that was the end of
  14     the Sir Lancelot Sprat autocratic surgical approach
  15     where the surgeon was very definitely the boss and
  16     everybody else did what the surgeon said. You did not
  17     change his prescription for X, Y or Z without very good
  18     reason, unless you wanted to be scored off the Christmas
  19     card list.
  20        Things have evolved from that during the period
  21     the Inquiry is looking at. I suppose from a management
  22     point of view, the attitude then was, there was nothing
  23     for these children unless they had an attempt to do
  24     something. If this man thinks he can do it, that is the
  25     way we should allow it to happen. That has now evolved,

   1     I think. There is much more discussion and people are
   2     more realistic about what their role in the team is and
   3     the surgeon is no longer -- I am sitting next to one,
   4     I have to be very careful -- in places I am aware of,
   5     the autocrat. They may be in overall charge of the
   6     case in the nicest sense, but they are not dictating
   7     every single thing and sitting on top of people who have
   8     perhaps better skills in decision-making in those
   9     sub-areas.
  10   MR HAMILTON: I would agree entirely, and I will still send
  11     you a Christmas card! We should not lose sight of the
  12     fact that the majority of patients actually go through
  13     intensive care remarkably smoothly, with skilled
  14     nursing. When you are adjusting the parameters of the
  15     cardiovascular system there are unlimited number of
  16     things to do and watch for, and the majority of patients
  17     do not require great intervention by the team. There is
  18     a process and the nurses are very skilled in that, and
  19     they know in most situations how to progress the
  20     patient. It is the patients who are not progressing
  21     that need the intervention of the team. That is
  22     relatively uncommon.
  23   MR DARBYSHIRE: It is a question of the differentiation
  24     between the ones that will get better and the ones that
  25     will not. I think it is part of the issue. It is like

   1     actually trying to identify early enough these are
   2     patients who are not quite going to get through, and
   3     what can we do about that.
   4   DR MACRAE: I do not think we should give the impression
   5     that there were no processes in the early era of
   6     paediatric cardiac surgery. The common post-operative
   7     protocols, the things that doctors -- you go from unit
   8     to unit and what is written down for the post-operative
   9     orders for a particular procedure are very similar
  10     between units. That is the distillation of skill, put
  11     down on paper, so it may not have been presented as sort
  12     of managed care, but that is actually what did come out
  13     of it.
  14   MR LANGSTAFF: I think the point you were perhaps addressing
  15     was the change in approach to management. I noticed
  16     that Mr Hamilton used the word "responsibility" which he
  17     feels he has as a surgeon, whereas the Lancelot Sprat
  18     days would be the day when the surgeon was not so much
  19     responsible as in charge. Perhaps the difference
  20     between those two words: does that perhaps give us an
  21     idea of the flavour of how attitudes have changed, or
  22     not?
  23   MR HAMILTON: Yes. Looking back from my own personal
  24     experience, I was appointed a senior registrar in 1985,
  25     roughly the beginning of the time period the Inquiry is

   1     looking at. Because of my interest in paediatric
   2     cardiac surgery I was appointed as the senior registrar
   3     responsible for intensive care. I would do a morning
   4     ward round and layout plans for the day, the nurses
   5     would take those forward, the anaesthetists would come
   6     in later in the morning and have a look round, check
   7     that what I had decided was okay, and if there was any
   8     particular intervention to be done, then fine. The
   9     other senior registrar, my colleague, would deal with
  10     any ventilatory things, but we worked very much as
  11     a team. I think that gradual change has been away from
  12     an individual senior registrar running the unit towards
  13     a full-time intensivist who would be there all the
  14     time. That has been, I think, the trend in most units
  15     over these years around the country.
  16   THE CHAIRMAN: I just wanted to have one more bite at this
  17     particular cherry.
  18        What Mr Hamilton has just described is a system
  19     functioning and Dr Macrae referred to the existence of
  20     protocols, understood as being such, but of course in
  21     management terms, is it not the case, would you not
  22     think, that one needs always to have a plan B if there
  23     is a dysfunctional team or if some disagreement does
  24     arise, and therefore one must have structures in place
  25     for dealing with that.

   1        Is it your experience that they existed, or exist,
   2     or that the need never arises for it?
   3   MR HAMILTON: Again, from the personal experience I have
   4     just recounted, I would go round and make the decisions
   5     in the morning. If the child is getting better, I have
   6     done the right thing. If the child is not making
   7     progress, then either my boss would have words or the
   8     anaesthetist would come along later on. So it was
   9     a team, it was not all there at the same time, but I do
  10     not think that was dysfunctional.
  11   DR MACRAE: I think what you are getting at is the sort of
  12     anecdotal situation where Dr X does not talk to Dr Y
  13     because he bought a car that was bigger than his, or
  14     some professional disagreement -- perhaps I should not
  15     be too flippant about it. I think I probably have seen
  16     examples where that can impact on the way a unit feels
  17     or indeed the way a unit functions, and certainly, in
  18     today's climate, it is absolutely essential to have
  19     mechanisms in place to nip things in the bud and have
  20     a professional way of dealing with disputes, and, if
  21     necessary I suppose, a disciplinary route as well, if it
  22     is a non-clinical matter.
  23   DR KEETON: The structures are now in place within the wider
  24     hospital, in the Trust. I do not think such structures
  25     were in place within the department, although the senior

   1     members of the department would probably have a view on
   2     it and may well have a quiet word on the side. If there
   3     was some issue going on of the sort we have mentioned
   4     with Dr X not speaking to Dr Y and if that was
   5     inflicting on patient care, I would see it as
   6     a responsibility of some senior member of the department
   7     to take that in hand.
   8        We now of course have directorate structures.
   9     Those did not exist in the days we are talking about.
  10     I am not sure when the first director came in, but it
  11     would now be the responsible of the director to address
  12     those sort of problems.
  13   MR HAMILTON: I think it is important to remember that every
  14     child is different and every child will respond
  15     differently to even the same operation, so it is not
  16     like a production line. You cannot set out rigid
  17     protocols; there has to be flexibility in the system.
  18   DR KEETON: There were some protocols in some centres, were
  19     there not? I remember that the Alabama unit, I think,
  20     was legendary for having a very strict protocol-driven
  21     management. In the event this happens, you do X; if
  22     that does not work you do Y. It was all very clearly
  23     written down. We did not have such structures.
  24   THE CHAIRMAN: Mrs Maclean?
  25   MRS MACLEAN: May I ask Dr Macrae: while we are looking at

   1     the position of the intensivist, there seem to be two
   2     intermingled aspects to it. One is the clarity of the
   3     first point of contact, who is the responsible person,
   4     but the other issue, am I right in thinking, is to do
   5     with accessibility? Is it the case that where you have
   6     a single identified intensivist, that that person would
   7     be more accessible than under the previously changing
   8     shared responsibilities?
   9   DR MACRAE: It is not necessarily true to say that
  10     surgeons, even if they are involved in a second
  11     operation in the operating room, is not accessible.
  12     They are probably accessible to a verbal communication
  13     and in a crisis could make themselves physically
  14     available, but it is clearly much easier for a resident
  15     or a nurse to discuss a minor or potential problem with
  16     an intensivist who is only on call, available for the
  17     intensive care unit, where they might hold back and say
  18     "I will speak to Mr Hamilton when he has finished his
  19     operation", by which time a problem may have developed
  20     from something that was insignificant and could have
  21     been corrected at an early stage into something which
  22     was much more serious.
  23        I think that is an important difference between
  24     the way that we practise now and perhaps practised 10 or
  25     more years ago.

   1   MR HAMILTON: Again, changes that have happened over the
   2     years, many of the key things that need to be adjusted
   3     post-operatively are the ventilation parameters, which
   4     would obviously fall to the anaesthetist. I know in
   5     Newcastle, before I started, they did not actually have
   6     a resident anaesthetist at night; the consultant would
   7     be phoned up at home. That obviously changed and then
   8     I was a resident anaesthetist, and I think that is
   9     compulsory.
  10   MRS MACLEAN: What dates are you thinking of there?
  11   MR HAMILTON: That would be the late 1980s. I started in
  12     1991, so ...
  13   DR KEETON: Do you mean another resident anaesthetist at any
  14     level, or at consultant level?
  15   MR HAMILTON: The consultants were very involved in joint
  16     adult and paediatric intensive care. Again in Newcastle
  17     there was a paediatric section of the adult intensive
  18     care and that was one of the other changes that
  19     happened -- again, it would be about 1989/1990, as it
  20     was in many units around the country. In Leeds again it
  21     happened in about 1985, I think, that they separated.
  22   MR LANGSTAFF: I think what Dr Keeton was asking was: was
  23     there no resident anaesthetist at any level?
  24   MR HAMILTON: As far as I am aware, no.
  25   MR LANGSTAFF: You obviously asked that because you were

   1     surprised by it?
   2   DR KEETON: I am surprised. I would have thought you could
   3     not do this without having at least a fairly senior
   4     registrar within the building.
   5   MR HAMILTON: There was someone who was probably -- we are
   6     all unique as human beings, but this particular
   7     character was very involved. He lived a short distance
   8     from the hospital and was in instantly if there was any
   9     problem, so I think that was how they managed. But he
  10     obviously recognised that was a problem and they then
  11     instigated a resident anaesthetist. That is just to
  12     illustrate the changes that have happened.
  13   MR LANGSTAFF: Sir, may we call time on the first session
  14     this morning? It has overrun because of the interesting
  15     interchange that there has been. Perhaps if we start
  16     again at a quarter past 11?
  17   THE CHAIRMAN: Yes, it is very important that we hear these
  18     exchanges. This is how we learn. We are here to
  19     learn. Let us take a break now for 15 minutes and then
  20     reconvene at 11.15.
  21   (11.00 am)
  22               (A short break)
  23   (11.15 am)
  24   MR LANGSTAFF: Can we come back to the topic of the need or
  25     not for there to be paediatrically trained nurses in

   1     intensive care and tie that in with whether it is, in
   2     your view, desirable, important, essential, not at all
   3     important, not at all essential, or whatever, to have a
   4     dedicated paediatric intensive care unit, whoever starts
   5     it, as opposed to a mixed paediatric and adult unit?
   6   DR MACRAE: I think on the question of first of all nursing
   7     skills, some of the best paediatric cardiac intensive
   8     care nurses I have come across have actually been adult
   9     nurses who have come to paediatric intensive care
  10     nursing, adult nurses with intensive care training, who
  11     have been absorbed and trained within the unit by the
  12     paediatrically trained people there who really have been
  13     excellent nurses.
  14        Having said that, the overall feel of the
  15     paediatric nursing needs to come from nurses with
  16     paediatric training, so it is possible for units to
  17     function with a proportion of intensive care trained
  18     nurses who are not specifically paediatric nurses but
  19     there very definitely needs to be a balance, or indeed
  20     a majority, of paediatrically skilled people to set the
  21     overall tone and policy of the unit.
  22        In terms of whether a paediatric intensive care
  23     unit should be separate for cardiac surgical patients,
  24     that depends, I think, more on local circumstances.
  25     There are certainly benefits in a large programme in

   1     having a completely separate unit that is independent,
   2     has its own staffing structures. In a unit that is
   3     perhaps less busy, whilst the physical environment for
   4     the care of paediatric patients should, I think, be
   5     separate from the environment where adult patients are
   6     cared for, that does not mean they have to be in a
   7     completely separate unit. There can be a common
   8     resource and even common management, and paediatric
   9     skills allocated within that geographical unit. I am
  10     thinking of perhaps a four-bedded paediatric room which
  11     is next to a slightly larger adult intensive care area,
  12     but the skills that are deployed to that area and the
  13     way that that particular subunit functions must very
  14     definitely reflect the needs of children rather than the
  15     needs of adults, and certainly not treat children as
  16     small adults.
  17   MR DARBYSHIRE: I think in terms of the need for paediatric
  18     nurses, obviously as I am a paediatric nurse myself I am
  19     not going to speak against the role of paediatric nurses
  20     in intensive care nursing.
  21        I take on board the point that Duncan made, that
  22     an adult ICU nurse may well be able to offer very good
  23     physiological care for children within the ICU, and
  24     maybe from a medical perspective that is how you would
  25     judge a good nurse; what information you get to enable

   1     you to do your job. I think from a paediatric nursing
   2     perspective there is a little bit more to it and I think
   3     paediatricising a unit is something that paediatric
   4     nurses are qualified and trained to do.
   5        I think the support of the family, again, is
   6     something specific to paediatrics, and the involvement
   7     and the relationship between the patient and their
   8     parents is very important and is an important facet, so
   9     if you like, paediatric training.
  10        I think there is a bottom line underneath all the
  11     statements I have made that is what is really important
  12     is that you have a skilled, experienced paediatric
  13     intensive care nurse, and they can come from an adult
  14     background. They can come from a paediatric
  15     background. It is the experience that they have within
  16     the PICU that I think is of fundamental importance.
  17        There are all sorts of arguments about what sort
  18     of ratio do you need of paediatric trained staff to
  19     non-paediatric trained staff; I do not know the answers
  20     to those questions. I know recent guidelines have been
  21     published that state that a very large percentage should
  22     be paediatrically trained.
  23        I think the other issue surrounding paediatric
  24     nurses in PICU in a mixed unit is how you actually
  25     allocate those staff to the patients. Do you have an

   1     individual nurse who one day is allocated to adult
   2     patients and the next day to paediatrics? No matter how
   3     good an adult nurse is, on the first day she looks after
   4     a paediatric patient she will not be as good
   5     a paediatric nurse as she was an adult nurse and it is
   6     how you actually structurally organise that situation in
   7     a mixed unit that I think would be of great importance
   8     in the delivering of skilled nursing intervention
   9     really.
  10   MR HAMILTON: Essentially I would agree with both the
  11     previous speakers. As a surgeon, I want a nurse at the
  12     bedside who is going to pick up the subtle changes that
  13     we see after cardiac surgery, so I want an intensive
  14     care nurse who is experienced in and knows about
  15     cardiopulmonary bypass and post-operative cardiac
  16     patients. I think it is very important to have the
  17     paediatric environment. Whether it is physically
  18     separate has to be clearly identified, and I think the
  19     senior nurses in the unit need to be paediatrically
  20     trained to bring that paediatric component and the care
  21     of the whole family into it, so I think those need to be
  22     wedded together.
  23   MR DARBYSHIRE: I think I just want both. In my position as
  24     a ward manager, what I would want is actually both
  25     together.

   1   MR HAMILTON: I do not think, as you say, that it matters
   2     really what background they come from. Whether
   3     they have intensive care experience is the key thing.
   4   DR KEETON: I would agree with the previous comments that
   5     have been made. I obviously have personal experience of
   6     evolving from working within a specific cardiothoracic
   7     intensive care unit which housed both adults and
   8     children to now the much better situation that we have
   9     of having a separate paediatric ITU.
  10        I think the paediatric bits of nursing -- the
  11     paediatric nurses do not have a monopoly of it. There
  12     were some very good adult-trained intensive care nurses
  13     who were extremely good at looking after children and
  14     within our unit we had a group of nurses within the
  15     intensive care unit staff who liked looking after
  16     children and who did it quite well, and in fact they are
  17     the nurses now who have gone off and got their
  18     paediatric qualifications and now some of them are
  19     running the paediatric intensive care unit or the
  20     cardiac bit of the new paediatric intensive care unit
  21     which we have.
  22        As for the physical environment, clearly it was
  23     highly undesirable to have children and adults in
  24     adjacent beds. Neither patients really were properly
  25     housed. Resources were such that it took a long time

   1     for us to be able to get a separate paediatric intensive
   2     care area, and even now we are still developing it and a
   3     new one will open next year.
   4        I think the nursing staff did their best to try to
   5     make the environment for the child as pleasant as
   6     possible in terms of putting them in a separate room
   7     where it was appropriate and putting out toys and
   8     suchlike, but there is more to paediatric nursing,
   9     I know, than just creating a pretty-looking environment
  10     with pretty teddy bears and things. There is more to
  11     paediatric nursing than that.
  12        So I think the ideal, and we have now come to it
  13     in most units, is to have a separate paediatric ITU
  14     staffed by very good paediatric intensive care nurses
  15     who are experienced in cardiology.
  16   MR LANGSTAFF: The way that you put it, this has been a
  17     gradual development throughout the period of this
  18     Inquiry. That is what we have heard from other sources,
  19     from the Royal Colleges. At what stage in the
  20     chronology from 1984 to 1995 did it cease to become
  21     something which one would aspire to and become one which
  22     really you ought to have?
  23   DR KEETON: I think the pressure really came most recently
  24     from the Government's document, I think it was in 1997,
  25     when the pressure was really put on for the Trust to

   1     develop paediatric intensive care unit facilities.
   2     I think there were two reports: "Bridge to the Future"
   3     and "Framework for the Future" I think they were
   4     called.
   5        It was from that time that we were able to push to
   6     get separate facilities. Prior to that there was a BPA
   7     report, I think, in about 1993, advising that paediatric
   8     intensive care facilities were provided. At that time
   9     our nurses -- I think it was the late 1980s, early 1990s
  10     that they started going off and getting their paediatric
  11     qualifications. In fact our senior nurse came to
  12     Bristol to do her paediatric intensive care training
  13     here, although she had been a very experienced ITU nurse
  14     looking after children within our mixed unit.
  15   DR MACRAE: Could I make a comment that there is, I think,
  16     a distinction between the development of paediatric
  17     intensive care units generally and the care of children
  18     following cardiac surgery because there is a trade-off.
  19     Yes, you can develop a regional paediatric intensive
  20     care unit that will take all children who require
  21     intensive care, and that may be children who have burns,
  22     children with head injuries, children following cardiac
  23     surgery, children with respiratory ailments, renal
  24     problems, children following cancer treatment, and,
  25     fine, they will be in a completely paediatric

   1     environment, cared for by nurses who are all trained in
   2     paediatric intensive care, but the cardiac part of that
   3     may only be 15 or 20 per cent of the caseload. So the
   4     trade-off is: do you have the child in the end of the
   5     cardiac intensive care unit, where they are perhaps 30
   6     or 40 per cent of that unit's intensive care workload in
   7     a room that is decorated as a children's sub-ICU, do you
   8     have them there with a little bit of interplay between
   9     the adult and paediatric service, or do you put them in
  10     the specialist paediatric ICU where perhaps the level of
  11     pure cardiac skill and expertise in purely cardiac
  12     matters is actually less than it would be if they were
  13     back in the mixed unit?
  14        So there is a trade-off and I do not think that
  15     we have answered that yet.
  16   MR LANGSTAFF: I was going to say, you have posed the
  17     question; what is your answer?
  18   DR MACRAE: It is difficult for me to answer in the sense
  19     that both in my present position and in my position at
  20     Great Ormond Street I have worked in units that have a
  21     high throughput and therefore are able to sustain a
  22     sufficient volume to have separate adult and paediatric
  23     units. The units would simply be too large to manage if
  24     adults and children were thrown together so that, in a
  25     sense, is difficult for me to come to terms with, but

   1     I certainly can see that in some circumstances where the
   2     volume of activity through a unit is smaller, there may
   3     still be an argument for, yes, protecting the paediatric
   4     side of things but nevertheless sharing some of the
   5     common skills and resources. The availability of
   6     resident anaesthetists, for instance, might be very
   7     difficult to double up in a small unit.
   8        If there are only one or two patients typically in
   9     a unit at a weekend, it is difficult to justify a
  10     completely separate on-call system for those two
  11     patients, and then it may be possible to bring the two
  12     together.
  13        There are good examples worldwide of very
  14     successful intensive care units -- in Melbourne for
  15     instance, and in Toronto -- where there are both cardiac
  16     and general intensive care patients together. Equally,
  17     there are examples of, say, Boston Children's Hospital
  18     where there is a very definite distinction between
  19     cardiac and non-cardiac patients, even within a
  20     children's hospital.
  21   MR LANGSTAFF: Do I take it that your ideal, because of your
  22     experience, is to have a sufficient size and throughput
  23     to have a dedicated paediatric cardiac intensive care?
  24   DR MACRAE: Yes, I think that is ideal.
  25   MR LANGSTAFF: That really is a function of size, so a unit

   1     has to be large enough to have the throughput to justify
   2     that or to operate that.
   3   DR MACRAE: Yes, absolutely.
   4   DR KEETON: I think throughput is a problem. We are a
   5     relatively small unit in Southampton doing 250 cases a
   6     year, roughly. When we were a combined unit, the eight
   7     intensive care beds which were physically together in
   8     cardiothoracic ITU could be housed very flexibly to
   9     house either children or adults or a mixture. We did
  10     not have a firm, physical demarcation that those beds
  11     were paediatric and those beds were adult, so on
  12     occasions when we had sudden rushes of babies, as
  13     occasionally occurs, we might have seven -- or I think
  14     on one occasion all eight beds were filled with
  15     children.
  16        Then, when the units were separated and we
  17     eventually grew to 12 beds and the four paediatric beds
  18     were put the other side of the wall into paediatric
  19     intensive care, and some of the other paediatrically
  20     intensively cared for patients were put together with
  21     them, we lost some of that flexibility in that, when we
  22     did have the need for six, seven, eight children to be
  23     ventilated at any one time, we only had four beds.
  24     We were in a situation of then having to sometimes turn
  25     children away.

   1        More recently the unit has increased. We now have
   2     seven dedicated paediatric beds, so we are able to cope
   3     with the increases in numbers; but it did have resource
   4     implications for the whole unit, both for adults because
   5     they had a diminution in their numbers of beds and for
   6     paediatrics where we were not able to expand, so there
   7     was a down side to it.
   8   MR LANGSTAFF: Can I change the focus for a moment and ask
   9     you this. Is it the case that a good intensive care
  10     unit will make a significant difference to a child's
  11     survival -- either free of morbidity or survival?
  12   DR KEETON: Shall I start? I think that the answer is yes,
  13     it will make a difference. I think the most important
  14     thing about paediatric cardiac surgery is actually what
  15     happens in the operating room, and Mr Hamilton will
  16     comment on that, but it has always been my feeling that
  17     if you have a good operation you get a good result, but
  18     of course we do not always have the best substrate to
  19     work on. Some of these children have very complicated
  20     heart abnormalities which cannot be totally corrected
  21     and at best you are patching them up, doing some sort of
  22     palliative procedure.
  23        I think it is undoubtedly true that children can
  24     be rescued from being very sick post-operatively and can
  25     come through successfully with high quality intensive

   1     care, and if the intensive care was not of that quality
   2     then those children may not come through.
   3   MR HAMILTON: Yes, I would obviously agree with that. One
   4     of the changes we have seen over the last few years has
   5     been the availability in the operating theatre of
   6     echocardiography, either what we call epicardial or
   7     trans-oesophageal, which gives us a lot of information
   8     that what we have done is correct or is sufficient.
   9        Often, in situations where, for instance, in a
  10     relatively common condition like tetralogy of Fallot,
  11     where you are cutting muscle out of the heart to enlarge
  12     the outlet, then you want to cut the minimum muscle but
  13     you want to relieve the obstruction, so it is getting
  14     that balance. Having information in the operating
  15     theatre that you have resected enough, or not enough, is
  16     very valuable because then you can go and correct it
  17     there and hopefully that child will have a much shorter
  18     post-operative course, whereas if you leave a residual
  19     problem then inevitably they will struggle in intensive
  20     care.
  21        I think that will be one of the changes that
  22     we will see over the next few years as that becomes more
  23     widely available.
  24   DR KEETON: I think it has been available for some years.
  25     We have been offering epicardial echo initially, I think

   1     since certainly the middle 1980s. I suspect probably as
   2     early as 1983 we were going in with the plastic bag and
   3     the jelly to do on-table echos for the surgeons if they
   4     had doubts about the adequacy of the repair. Now
   5     we have trans-oesophageal of course. It is not quite
   6     routine, but certainly if the surgeon has any anxiety
   7     about the adequacy of the repair we would offer that
   8     service to the surgeon.
   9   MR HAMILTON: Absolutely, I agree, but being practical it is
  10     not always possible to have the consultant paediatric
  11     cardiologist in the operating theatre all the time.
  12   DR KEETON: No, that is right, but with appropriate junior
  13     staffing you can get somebody who has -- our resident
  14     has become quite experienced at echo and can certainly
  15     give a reasonable opinion. We do now try to have one of
  16     the paediatric cardiologists in the hospital at all
  17     times so that if there is doubt about something we can
  18     be called to go and advise.
  19   MR LANGSTAFF: Just taking this forward, for how many
  20     operations do you use trans-oesophageal?
  21   DR KEETON: I think it is the minority, I would say. We
  22     particularly use it for certain conditions like the
  23     repair of the atrioventricular septal defect, where one
  24     is left with some degree of atrioventricular valve
  25     regurgitation, so if the valve is likely to have some

   1     degree of leaking afterwards the surgeon may well want
   2     some quantification of that -- it is not totally
   3     quantitative, it is semi-quantitative -- to see how the
   4     repair has gone before finally closing the chest, and
   5     certain other procedures where we would be called in
   6     more regularly. I think overall it is probably no more
   7     than, as a guess, 20 per cent, say, 25 per cent.
   8     20 per cent.
   9   MR LANGSTAFF: For how long have you done that?
  10   DR KEETON: Only this last few years, probably the last four
  11     or five years, have we offered a sort of stats service,
  12     but for many years we have been available to be called
  13     if there is doubt for the epicardial echo.
  14   MR LANGSTAFF: Can you give us an idea of how many
  15     "many years" is?
  16   DR KEETON: As I said, I think we started offering it --
  17     when my colleague, George Sutherland, arrived to work
  18     with us in 1983, I think it was, we then got some decent
  19     echo equipment, and certainly from about 1983, 1984,
  20     onwards we were offering epicardial -- that is on the
  21     surface of the heart, the echo probe put on the surface
  22     of the heart in a sterile plastic bag at the end of the
  23     operation to see what was going on.
  24        The surgeons did not call for it that often but
  25     it was available. Similarly, in the post-operative

   1     intensive care unit I think there has been over this
   2     period a big growth in the frequency of echo assessment
   3     post-operatively. It is now, in our unit, routine that
   4     the patient gets a transthoracic echo on return from the
   5     operating theatre to the unit within the first few hours
   6     to assess cardiac function and then as and when required
   7     thereafter. Certainly every few days we are echoing in
   8     the post-operative ITU to assess the child's
   9     haemodynamics.
  10   MR LANGSTAFF: Pursuing the question of interoperative echo,
  11     how long has that been a feature of your own practice?
  12   MR HAMILTON: I think that has been quite a luxury in
  13     Southampton. I think the general picture around the
  14     country would be much later than that.
  15     Trans-oesophageal echo has only recently come in,
  16     particularly in the small babies where it is only with
  17     recent technology that probes have been small enough to
  18     get down the baby's throat. That is only really in the
  19     last few years.
  20        Certainly my own practice, if I am undertaking
  21     a procedure where there is specific information I want
  22     at the end, then I will arrange for that. It is much
  23     easier to put the trans-oesophageal probe down the
  24     throat before all the towels are placed for the
  25     operation, so if you can predict that in advance it is

   1     much easier.
   2   DR KEETON: I would agree with that and that is the way we
   3     do it as well. We are usually warned. The surgeon will
   4     say, "I am doing such and such a case today and I would
   5     like a TOE at the end, or an epicardial echo at the
   6     end".
   7   MR HAMILTON: If you go to these international meetings, the
   8     enthusiasts will stand up and say they do it in every
   9     case, but that is not the real world.
  10   DR KEETON: No, it is not.
  11   MR LANGSTAFF: Post-operative echo: how commonly has that
  12     been done over the years since 1984?
  13   MR HAMILTON: Again, I think the trend has been increasing.
  14     The equipment has got better. It is actually quite
  15     difficult, I think Barry would agree, to get really
  16     clear pictures in the first few hours after the
  17     operation, but obviously the earlier you can get
  18     information to tell you that you perhaps need to do
  19     something further surgically, the better the child is
  20     going to cope with that and the quicker recovery
  21     they will make. So, certainly we would have the same
  22     policy, but that has been relatively recent, the past
  23     four or five years.
  24   DR KEETON: Yes, I agree with you that the adequacy of the
  25     examination -- it may not be complete because of the

   1     difficulty with echo windows. The problem is that once
   2     you have opened the chest and you have a big plaster
   3     down the front of the chest, you cannot put the probes
   4     where you want to get the images. Also, the fact that
   5     you have separated the tissue layers means that the echo
   6     beam does not go through as well as pre-operatively, but
   7     we can usually get pretty good information.
   8        I think we also use it to guide us with how well
   9     filled the child is, what the ventricular function is
  10     like, even if we cannot actually get the Doppler
  11     gradients as precisely as we might like, but we can
  12     usually get good information from the post-operative
  13     echoes.
  14   MR LANGSTAFF: Again, how long have post-operative echoes
  15     been used, either at all or more routinely?
  16   DR KEETON: In Southampton it has been more or less routine
  17     since --
  18   MR LANGSTAFF: For how long?
  19   DR KEETON: Well, since we got a decent echo machine. I am
  20     going on memory here. I think we had a reasonably good
  21     echo in 1983 for imaging and we had colour, I think, in
  22     1989 or maybe 1990, so that sort of era. I think
  23     it would be true to say that either myself or my juniors
  24     would be wheeling the echo machine regularly into the
  25     intensive care unit to assess the children on the unit.

   1   MR LANGSTAFF: Is that a general picture would you say?
   2   DR MACRAE: Yes. I certainly have not practised intensive
   3     care at consultant level in a unit where echo has not
   4     been freely available. If I have had a concern about a
   5     patient, I have always been able to obtain a
   6     two-dimensional echo, and certainly from the early 1990s
   7     onwards colour flow Doppler echos in addition to that.
   8   DR KEETON: I think we got colour just a little bit before
   9     you did. We were quite pleased about that.
  10   MR LANGSTAFF: If then intensive care can make the
  11     difference in the way that you have described, what are
  12     the characteristics that distinguish a good intensive
  13     care unit from a not so good one?
  14   DR MACRAE: I think I can perhaps say something on this
  15     point. I think the first thing to say is that I agree
  16     with what has already been said, that most of what
  17     happens to children has already occurred in the decision
  18     to do a particular operation and the conduct of that
  19     procedure. It is perfectly possible for badly conducted
  20     intensive care to damage what might have been a good
  21     outcome if an incident had not occurred, but equally
  22     it is possible for good quality intensive care to
  23     nurture a borderline case through to a good outcome,
  24     either by preventing death or perhaps more importantly
  25     preventing morbidity, illness in survivors.

   1        I think adequate intensive care perhaps is dealing
   2     with problems when they arrive, but good intensive care
   3     is actually anticipating the problem and preventing it
   4     happening. That may be both at a patient-based level,
   5     clinical level, but also at a clinical management level
   6     by putting in place protocols for common intensive care
   7     procedures, for things like sedation and analgesia so
   8     that the unit's sedation policy is there for everyone to
   9     know and to use so that children do not suddenly wake up
  10     and pull out an essential piece of equipment that they
  11     are attached to, things like that.
  12        Okay, the adequate unit might notice that
  13     something has been pulled out and replace it and the
  14     child may come to no harm, but the good unit would
  15     actually prevent the incident occurring in the first
  16     place.
  17   MR HAMILTON: The other thing obviously in a good unit, in a
  18     paediatric unit, is involving the parents. I am sure
  19     Andrew will have something to say on this. I think that
  20     is one thing we have learned over the years, that
  21     parents are much more involved now in the post-operative
  22     period in intensive care and they are actually
  23     encouraged, I think, in most units to be involved in the
  24     care. That is something that has changed over
  25     the years. It was much more, I guess back in the 1980s,

   1     "You can come and visit your child at such and such
   2     time"; now the parents are there constantly, they are
   3     involved in the care, and that has been a big change
   4     over the years.
   5   MR DARBYSHIRE: What makes a good intensive care unit?
   6     I take on board all the things that have been said
   7     before by Duncan and Leslie. I think there is one issue
   8     and that is the teamwork that occurs within the
   9     intensive care unit. The better the team works, I think
  10     the more effective it can actually be. The better the
  11     interpersonal communication that goes on between the
  12     members of the team, the better the intensive care can
  13     be.
  14        In terms of outcome, I very much agree that to a
  15     large extent what happens in theatre dictates an awful
  16     lot of what happens in the intensive care unit. I think
  17     in intensive care you can support a patient through a
  18     return to function that may not have been there when
  19     they came out of theatre, and that may well allow the
  20     actual anatomical thing that has happened in theatre to
  21     work a little bit better. I think you can get them
  22     through that. But I also think there are certain
  23     patients that, no matter how good the intensive care,
  24     you cannot actually change what may well be an
  25     inevitable outcome. I think paediatric intensive care

   1     in itself is maybe better equipped to actually deal with
   2     that eventuality.
   3   DR MACRAE: I think you have touched on a good point there
   4     because I think good intensive care is doing what is
   5     appropriate in the best interests of the child towards a
   6     good outcome, but also knowing when to stop, when the
   7     point is reached where, no matter what is done and what
   8     invasive and painful and uncomfortable procedures are
   9     undertaken, the outcome is not going to be successful.
  10     That is clearly terribly difficult for all involved, but
  11     there are small numbers of patients where that occurs,
  12     even in the best units in the world.
  13   MR HAMILTON: On a slightly different tack, just to take it
  14     back a stage further, obviously what happens in theatre
  15     is important but so is the decision-making beforehand.
  16     If the team, and again it would usually be made as a
  17     team, decide to do an inappropriate operation or the
  18     wrong operation, or the child is not suitable for that
  19     operation, no amount of good surgery or good intensive
  20     care will change the outcome. I think the classic
  21     example of that is what we call the Fontan operation
  22     where a lot of the decisions are based on the
  23     pre-operative investigations. If your prediction that
  24     the physiology will work afterwards is wrong, then no
  25     amount of good surgery and intensive care will change

   1     that.
   2   DR KEETON: Yes, I agree. I think the point about involving
   3     the parents is a very important one and I think that is
   4     the mark of a good intensive care unit, where the
   5     parents feel well-informed.
   6        I think occasionally things can get a bit out of
   7     control down there and I do not want to make a big point
   8     out of this but you will get the occasional parent who
   9     is looking so much at the monitors and the figures and
  10     the fluid balance, and almost trying to dictate the
  11     treatment, and I find this quite a difficult area.
  12     I occasionally have to say to my parents, "Look, this is
  13     for the nurse and the doctors to do this. You have to
  14     look at the baby, hold his hand and be a parent and
  15     leave us to worry about the figures", because they can
  16     get really obsessed with the figures and it can make for
  17     very difficult management.
  18        I think it does need experienced nurses to give
  19     the parents enough information but not try to put the
  20     burden of decisions on to them. You may also want to
  21     comment on that.
  22   MR DARBYSHIRE: I think it is not just so much the giving of
  23     information, it is actually communicating with the
  24     parents. I think, in my experience, a lot of those
  25     issues where -- if you say the parents are obsessed with

   1     the monitors, obsessed with the heart rate, usually you
   2     find at some point there has been a breakdown in
   3     communication and that communication needs to be
   4     re-established. I think, again, you have to be
   5     sensitive towards the relationship between the parent
   6     and the child or the paediatric aspects of ITU.
   7   DR MACRAE: Certainly I recognise the situations that
   8     you are describing, and particularly that situation
   9     tends to arise in the more complex children who have
  10     been there for quite long periods of time. Very often
  11     conflicting messages are given, very often
  12     unintentionally.
  13        In a 24-hour period, a parent who is at the
  14     bedside for a substantial part of the time may meet 10
  15     or 15 people and they will all want to give good news
  16     and be supportive, but they all may say slightly
  17     different things. You have stressed the importance of
  18     communication and in that situation I find it
  19     particularly helpful to say to families, "I will talk to
  20     you each day and give you the definitive update and
  21     I would like you to come to me if you feel you need
  22     information in between those periods of time".
  23     Otherwise, the inevitable happens and something is said
  24     out of context, or misunderstood, and I think it is
  25     important that parents in that situation do have

   1     confidence in the ability of the nursing and medical
   2     teams to deal with things like the monitors and the
   3     fluid balance and therefore not feel that they have to
   4     worry about them themselves.
   5   MR DARBYSHIRE: I think there is an important issue as well
   6     in that, as you point out, it tends to be with the more
   7     long-term patient within the PICU environment that these
   8     communication breakdowns happen. The longer they are
   9     in, usually the more problems you have encountered along
  10     the way, and it is the dealing with those problems as
  11     they arise. As I say, if personnel change, slightly
  12     different emphasis is given in explanation and it can
  13     just raise the anxiety of the parents where they do
  14     start to worry an awful lot about what is going on with
  15     the child.
  16        I think one of the things I have seen from the
  17     development of an intensivist is that if you have the
  18     intensivists there -- in Liverpool we have three
  19     intensivists and usually for the long-term patients one
  20     of the intensivists says, "I will be the person who
  21     communicates with that particular family".
  22        It comes from just one person. Parents very much
  23     look towards the medical staff, the most senior doctor
  24     they can talk to, as the person that they are really
  25     going to listen to. In studies I have read that the

   1     nurses come second but it is the medical staff they
   2     really do seek reassurance, information and support from
   3     about the condition of their child.
   4   MR HAMILTON: I would agree entirely. I think this is
   5     something we have learned over the last few years in
   6     intensive care, that parents do often get what they see
   7     as conflicting information. It is the old example of
   8     whether a cup is half full or half empty. It is exactly
   9     the same thing but the parents will interpret it
  10     differently, and obviously the parents want to hear the
  11     good news. I think that identifying a person to be the
  12     communicator is the key.
  13        The other very controversial issue is whether
  14     parents should be there during the ward rounds, and this
  15     is something I have not resolved. The two issues --
  16     obviously the parents should be involved and you should
  17     not be discussing anything that you do not want to say
  18     to the parents, yet sometimes there are very difficult
  19     decisions to be made. You need to get a team view
  20     before you put that to the parents.
  21        The other issue, of course, is confidentiality for
  22     the other children who are around. It may be that one
  23     set of parents are there and the other are not, and they
  24     hear you talking about the other child and then they
  25     communicate with the parents, so you get into a real

   1     vicious circle.
   2   DR KEETON: I accept that point as well and for that reason
   3     we tend to hold our business ward rounds away from the
   4     bed and discuss strategy and management with the
   5     intensivists and anaesthetists, et cetera, away from the
   6     bed. Then someone will go and talk to the parents,
   7     usually someone fairly senior in the team, about what
   8     decisions have been made. The nurse will also know then
   9     precisely what to say to them.
  10        They look to the surgeon as well, I think, to keep
  11     them informed of the child's progress and also to the
  12     paediatric cardiologists to keep them informed of the
  13     child's progress, and I would certainly make a point of
  14     seeing a child's parents on a fairly regular basis,
  15     every few days at least if it is a long, protracted ITU
  16     stay.
  17   MR LANGSTAFF: You have not mentioned the involvement of any
  18     liaison nurse or anyone occupying that sort of role.
  19   DR KEETON: We have two specialist nurses who fulfil that
  20     role, both of whom were previous sisters on the
  21     paediatric intensive care unit and they now job-share
  22     the liaison nurse role. They play a very major part in
  23     communication with the parents, and also when the child
  24     goes home in maintaining that communication.
  25   MR LANGSTAFF: So the communication with the parents has to

   1     involve also communication between the team and the
   2     liaison nurse so that the liaison nurse is in a position
   3     to convey the information?
   4   DR KEETON: Yes, so one of them is always around and knows
   5     what is going on and will talk to the surgeon, the
   6     paediatric cardiologist, the intensivist, so that we try
   7     as far as possible to avoid any conflicting
   8     information. There needs to be consistency in what the
   9     parents are being told.
  10   MR HAMILTON: I could not agree more. I think this is a key
  11     role. We appointed our senior ward sister, I think