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Daily transcripts
Hearing summary
21st September 1999
Hearings this week focus on evidence from parents and hospital staff commenting on the
subject of tissue retention.
Today the Inquiry heard from three parents of children who died following surgery to
correct congenital hearts defects at the Bristol Royal Infirmary (BRI): Paul Bradley from
Cardiff; Sharon Tarantino from Gloucestershire; and Brenda Rex from Bristol.
Mr Bradley told the Inquiry about the life and death of his daughter Bethan who died at
the age of five following an operation performed by Mr James Wisheart at the BRI in August
1993. Mr Bradley was particularly concerned by the lack of support and counselling and
information given to parents. He suggested that discussions about post-mortems and
retention of tissue could take place well in advance of an operation (12-18 months where
possible) to give parents the opportunity to prepare themselves for a negative outcome to
surgery. Mr Bradley concluded by stressing the importance for parents and families of
remembering a child in a positive way and ended his evidence by reading a tribute from his
family to his daughter Bethan.
Mrs Tarantino told the Inquiry about her daughter Corinna who was born in July 1993 and
died following corrective heart surgery performed by Mr Dhasmana in May 1994. She said
that following Corinna’s death she and her husband were told that a post mortem would
have to take place and she stated that she asked that only Corinna’s heart be looked
at by the Pathologist. Mrs Tarantino said that she has subsequently learned that other
organs were investigated and removed.
Mrs Rex explained that her second son, Steven, was born in May 1986 with a very rare
congenital heart defect, Truncus Arteriosus. She told the Inquiry that Steven died in
August 1986 at the BRI following complex cardiac surgery performed by Mr Dhasmana. Mrs Rex
described her reaction to the confirmation earlier this year that Steven’s heart and
other tissues had been retained at the hospital following a post mortem.
|
FULL TRANSCRIPT
1 Day 53, 21st September 1999
2 (9.00 am)
3 THE CHAIRMAN: Good morning, everyone. Good morning,
4 Miss Grey.
5 MISS GREY: Good morning, sir. Sir, this morning we have
6 evidence first from Mr Paul Bradley, who is the father
7 of Bethan Amanda Bradley. It is about the circumstances
8 surrounding Bethan's life and death that we will be
9 hearing.
10 Mr Bradley, we take evidence on oath or
11 affirmation in the Inquiry. Could I ask you to stand
12 whilst you take the oath, please?
13 MR PAUL BRADLEY (SWORN):
14 Examined by MISS GREY:
15 Q. If we could have on the screen, please, WIT 229/1, that
16 is the first page of a statement which you have given to
17 this Inquiry; is that right?
18 A. Yes, that is correct.
19 Q. If we go, please, to page 28, we should see there,
20 I hope, the last page and your signature at the bottom.
21 A. Yes, that is correct.
22 Q. Are the contents of that statement true to the best of
23 your knowledge and belief?
24 A. Yes, they are.
25 Q. Mr Bradley, you are here to tell us today about the life
0001
1 of Bethan and her death, and also the events that
2 happened after her death; is that right?
3 A. Yes.
4 Q. If we look at paragraph 3 of your statement, going back
5 to page 1 we see there that Bethan was born on
6 19th September at St David's Hospital in Cardiff;
7 is that right?
8 A. Yes, that is right, yes.
9 Q. Was it shortly after her birth that you realised or
10 medical staff realised that there might be a problem?
11 A. When Bethan was born, everything at first seemed fine.
12 It was only first thing Sunday morning I had a phone
13 call at home from the medical staff at St David's to
14 advise me that Bethan was being transferred to the
15 Bristol Children's Hospital, which was quite a shock.
16 They asked me to go down to St David's Hospital,
17 Cardiff, and so Bethan went quite early on Sunday and we
18 followed on afterwards in an ambulance over to Bristol.
19 Q. How was Bethan transferred?
20 A. We understood by ambulance, by separate ambulance.
21 Q. But your wife and yourself also travelled by ambulance?
22 A. Later on, yes.
23 Q. Because Mrs Bradley was presumably admitted to the
24 Maternity Hospital; is that right?
25 A. Yes, that is right, yes.
0002
1 Q. When you got to the Children's Hospital, is it right
2 that Bethan was admitted to the ITU?
3 A. Yes, that is correct.
4 Q. Who did you meet there when you got to the hospital?
5 A. When we arrived, we were met by Dr Joffe and he took us
6 aside into a quiet room, which was designed for parents
7 and there he confirmed at that point that Bethan was
8 suffering with complex congenital heart disease and he
9 said it was very complex. He did explain some aspects
10 as to what was wrong, but he did indicate that it was
11 life-threatening.
12 Q. And all of this took place in a quiet room, you say?
13 A. Yes, that is right, yes.
14 Q. At the Children's Hospital?
15 A. Yes.
16 Q. If we look at paragraph 5 of your statement, which is
17 page 2, we see there that you were told that Bethan
18 would require immediate surgery; is that right?
19 A. Yes. That is right.
20 Q. And an internal catheter examination was performed which
21 led to further details of her condition --
22 A. Yes, that is right.
23 Q. -- being understood?
24 A. Yes, that is right, yes.
25 Q. But at that stage you say in your statement you were too
0003
1 bewildered and numb to understand things?
2 A. Yes. I mean, at that particular point it was such
3 a shock, it was a new world for us. We never imagined
4 that following the birth we would be faced with such
5 a traumatic occasion, a point in our lives when our
6 new-born baby would be on the brink of death.
7 The way he spoke to us, he was very sympathetic
8 and softly spoken, and he did endeavour to explain to
9 us, but to be fair to him, it was quite difficult for us
10 in the state that we were in to really digest it
11 properly.
12 Q. All of this was happening very quickly, was it not?
13 A. Yes, that is right.
14 Q. Because in fact Bethan needed an operation, a shunt
15 operation?
16 A. That is right, yes.
17 Q. Which took place on 23rd September?
18 A. Yes, on the Wednesday, yes.
19 Q. And that operation was performed by Mr Wisheart,
20 I think?
21 A. Yes, that is right, yes.
22 Q. Did he explain what he was doing to you before the
23 operation?
24 A. Yes. I think we saw him the night before Bethan's
25 operation and he explained that he was going to perform
0004
1 this right Blalock shunt operation. I think at the time
2 we were not really sure what that was, but that was what
3 he explained to us at that particular point in time.
4 Q. And it was explained to you, was it, that that was the
5 way in which Bethan's life could be saved at this stage?
6 A. Yes, although he did say it was not certain and so we
7 were preparing ourselves for the worst outcome, really,
8 at that point.
9 Q. If you were preparing yourself for that outcome at that
10 stage, was there anybody else in the hospital apart from
11 Mr Jordan and Mr Wisheart whom you have mentioned who
12 would help you to discuss the situation?
13 A. There were some nurses on the intensive care unit and
14 they were very sensitive to us. They were very good.
15 They knew we were going through a traumatic time and
16 that was reflected in the way that they spoke to us.
17 They said it was a very serious operation, a very
18 serious condition, but we felt that -- they did
19 communicate that they were on our side. They did
20 communicate to us the sense of distress that we were
21 going through.
22 I do remember the Chaplain of the Bristol
23 Children's Hospital coming to see us while we were on
24 the ward at the Maternity Hospital. He came briefly to
25 offer his help and support, but that, to my knowledge,
0005
1 was the only support. I think one of the senior nurses,
2 I recall, she did offer for Bethan to be baptised, for
3 a baptismal type service before the operation as
4 a matter of comfort just in case the worst outcome
5 prevailed.
6 Q. Did you take up that offer or did you decide to wait?
7 A. No, we did not take up that offer. It was very
8 difficult for us to give our daughter even at that
9 stage, even though we knew it was a serious situation.
10 Q. Did you have any contact with Helen Vegoda at that
11 stage?
12 A. No, we did not. I am not sure whether she was there at
13 that time, in 1987.
14 Q. You are quite right, I am reminding myself that was
15 before her appointment, thank you. So the right Blalock
16 shunt was performed and the outcome was successful, was
17 it not?
18 A. Yes, it was, yes.
19 Q. I think you were able to take Bethan home on
20 3rd October?
21 A. Yes.
22 Q. What was your overall experience, then, of the
23 Children's Hospital?
24 A. Initially it was distressing, but as I say, the nursing
25 staff, they were very good. Before Bethan had the
0006
1 operation, they took a photograph, even though Bethan
2 was covered with tubes and connections, but they took
3 a photograph and they presented that to us before the
4 operation, and that was our one token as far as we knew
5 of evidence that she had actually been born. That was
6 very precious to us. So they were really sensitive to
7 us, and we were very impressed by the way that they
8 continued to be sensitive every time we came in the
9 ward, they never told us to go away, they were very
10 welcoming and they were happy to explain to us exactly
11 what they were doing with Bethan, even though we could
12 not understand it.
13 Q. If we look at page 4 of your statement, you set out
14 there some further details of some contact you had with
15 the Chairperson of the local Heart Circle, Jean Pratten?
16 A. Yes.
17 Q. She visited you on the ward and gave you a booklet about
18 children with congenital heart disease?
19 A. Yes. That was a very useful booklet, because we were
20 not familiar with the terminology, complex congenital
21 heart disease, and it was very useful, that booklet.
22 Q. You pick that point up a little bit at paragraph 13 of
23 your statement, if we just drop down the page a little,
24 when you say that at this stage, that is the stage when
25 Bethan was discharged, a written diagnosis of Bethan's
0007
1 condition would have been helpful for you?
2 A. Yes, that is correct. We say this with hindsight now.
3 At that time we did not think to ask for a written
4 diagnosis, but with hindsight, we realise it would have
5 been helpful because obviously they explained to us and
6 with diagrams as well, but it was verbal so we were
7 trying to think in our minds exactly what was said and
8 so invariably, at subsequent appointments, we seemed to
9 be always in the process of clarifying exactly what was
10 said the time before. So it would have been useful to
11 have had in our minds earlier and quicker exactly what
12 Bethan's condition was.
13 Q. And something written would have been useful because you
14 could have gone away --
15 A. Yes, as a point of reference.
16 Q. -- studied it and presumably found out anything about
17 aspects you did not understand?
18 A. Yes, that is right, yes.
19 Q. Then you go on, at paragraph 14, to register thanks and
20 appreciation to the nursing team, to Dr Joffe and in
21 particular Mr Wisheart?
22 A. Yes.
23 Q. For restoring to you Bethan at that stage?
24 A. Yes, because it was a wonderful moment when we went home
25 with a baby that to all intents and purposes would have
0008
1 died and so we realised we were so fortunate and having
2 been told that a few years ago an operation of the kind
3 performed would not have been possible. So we did
4 appreciate we were very fortunate to be going home with
5 our baby, Bethan.
6 Q. So you took her home and then in the interim years
7 before the second major operation, she continued to be
8 overseen, to be seen regularly by Dr Joffe?
9 A. Yes.
10 Q. If we turn over the page, please, page 5 of your
11 statement, paragraph 17, you give there details of the
12 professionals and social workers in particular who were
13 involved in the care of Bethan prior to the second
14 operation?
15 A. Yes, that is right, yes.
16 Q. Turning to the bottom of the page, paragraph 19, it
17 seems that there was regular contact between the
18 agencies in Cardiff and the Bristol hospitals?
19 A. Yes.
20 Q. And by the "Bristol hospitals", do you mean the
21 Children's Hospital or the BRI?
22 A. The Children's Hospital. We were not aware of the
23 co-ordination taking place, but when we came in to see
24 Bethan's medical notes early this year, it was clear to
25 us that that co-ordination was taking place.
0009
1 Q. It is right, is it, that on 9th February 1992, Bethan
2 had to be readmitted to the Children's Hospital to have
3 a catheter investigation?
4 A. Yes, that is right, yes.
5 Q. What was the purpose of that?
6 A. Firstly, when Bethan was born they did say to us that
7 they were not sure whether there was a corrective
8 measure that could be taken for Bethan's condition, and
9 it all depended upon further investigation, so the
10 purpose of the catheter investigation was first and
11 foremost to clarify and to confirm Bethan's diagnosis,
12 and then to identify some means of correction. The
13 consequence of that was that Dr Joffe saw us in the
14 hospital after the catheter operation and he also
15 confirmed and clarified Bethan's condition, and also
16 they felt there was some corrective measure that they
17 could propose.
18 Q. If we turn on to paragraph 25, page 7, we see a little
19 bit more detail about the options that were available
20 for Bethan's future surgery at that stage.
21 A. Yes.
22 Q. Can you remember what Dr Joffe was telling you about the
23 options that were available?
24 A. I seem to think that after the catheter operation, at
25 our next meeting with him on 25th February, he did an
0010
1 echocardiography for Bethan and at that time he just
2 shared with us confirmation of Bethan's condition and
3 then began to explain what the proposal was. He
4 explained that it could be in one or two stages that the
5 operation could be performed. He drew diagrams. A lot
6 of it went over our heads because we are not medically
7 minded but he did take the trouble to explain it to us.
8 What we did after that was that when we went home,
9 we wrote down what we thought he said and we sent that
10 back to him for him to confirm whether our understanding
11 was correct.
12 Q. At that stage was the option of a two-stage operation
13 still being left open or was a one-stage operation being
14 presented as the preferred option?
15 A. At that particular stage, in February, and I seem to
16 think a little while afterwards, an optional stage
17 approach was under consideration, and I think it was
18 only really prior to meeting Mr Wisheart that it was
19 confirmed that they were going to opt for the one
20 operation.
21 Q. If we look briefly at a page from the medical records,
22 this is MR 2232/92, and there will be an address that
23 requires to be blanked, please, Chairman. Mr Bradley,
24 you should have on your screen now a letter to you from
25 Dr Joffe which I think is the letter replying to your
0011
1 letter in which you had set out your understanding of
2 what Dr Joffe had been telling you?
3 A. Yes.
4 Q. If we look at the second line of this letter, we see
5 firstly he has confirmed that you have understood what
6 was being suggested?
7 A. Yes.
8 Q. And that he adds that:
9 "I would simply add that the proposed operation
10 could be achieved in one operation or in two stages and
11 this aspect will be discussed with you by Mr Wisheart at
12 your appointment with him."
13 A. Yes.
14 Q. Does that confirm the impression you have just told us
15 in evidence, which is that at this stage the two options
16 were being left open?
17 A. Yes.
18 Q. It could be either one-stage or two-stage?
19 A. Yes.
20 Q. If we look at the same medical record at page 90,
21 please, this is a letter -- do have that on your screen?
22 A. Not yet, no.
23 Q. You should have on your screen now a letter which
24 I think you would not have seen at the time; is that
25 right?
0012
1 A. Yes.
2 Q. It is a letter from Professor Anderson to Dr Peter
3 Wilde, the consultant cardiac radiologist at the BCH?
4 A. Yes.
5 Q. That is not something you were aware of -- the fact that
6 Professor Anderson was in communication with Dr Wilde is
7 not something you knew at the time?
8 A. No, it is not, no.
9 Q. If we go on and scroll through the letter, we see he is
10 setting out a diagnosis of Bethan's condition and over
11 the page, please, he sets out in the first paragraph the
12 suggested proposed surgery, in other words, he says,
13 a total cavopulmonary connection?
14 A. Yes, that is right.
15 Q. So it seems, does it, from the medical records that
16 Bristol was in communication with the Brompton on the
17 proposed course of management for Bethan's condition?
18 A. Yes.
19 Q. When you saw Mr Wisheart, then, on your meeting of
20 8th April, did he propose a particular course of
21 treatment for Bethan?
22 A. At that point he indicated to us that they would go
23 forward with a one-stage operation in April.
24 Q. Was it explained to you why a one-stage operation would
25 seem to be, in Mr Wisheart's opinion, the better course
0013
1 of operation?
2 A. I seem to recall that whether at that meeting with
3 Mr Wisheart or in a subsequent meeting with Dr Joffe, we
4 did ask as to whether it was best for the operation to
5 be one-stage and why not the two-stage, and the way that
6 they answered that was that they said that it was risky
7 performing an operation either way, whether a two-stage
8 approach or a one-stage; they were equally as risky, and
9 in fact, it did seem to infer that to have a two-stage
10 approach entailed greater risk because it meant opening
11 Bethan's chest twice. So that was the reason that they
12 put it to us, which we accepted at that time.
13 Q. We have received comments from Dr Wisheart on these
14 aspects of your statement. What he suggests is that the
15 reason for advising a one-stage operation, except in
16 certain circumstances which were considered to increase
17 the risk for that particular patient, was that "we
18 believed" -- I think he is referring not merely to
19 himself but to the team or other cardiac
20 centres -- "that the sum of the risks of the two
21 operations would be greater than the risks of a single
22 operation".
23 A. Yes. I think that was the impression we had when he
24 spoke to us at the time.
25 Q. At that stage, was there any discussion with Mr Wisheart
0014
1 of the risks to Bethan of performing the operation?
2 A. The only risk that was mentioned was in terms of
3 mortality, and he explained that there was a 1 in 4
4 chance of Bethan not coming through the operation, but
5 that was the only aspect of risk that was mentioned to
6 us.
7 Q. Did you get an impression as to whether or not he was
8 quoting figures that were based on his own experience or
9 the experience of other centres in the UK, or on any
10 particular considerations?
11 A. We interpreted his figures for being the average,
12 nationally. We just took it that that was a general
13 average figure.
14 Q. Did you ask him any questions about his experience in
15 performing this operation?
16 A. No, we did not. We did not ask him in terms of whether
17 he had done the operation before, no.
18 Q. Did you get any impression from either Dr Wisheart on
19 this occasion or other occasions as to the rarity of
20 Bethan's condition?
21 A. To be fair, they did emphasise to us that Bethan's
22 condition was rare; it was unique. So we were aware
23 that she had a very rare abnormality and that they were
24 confronted, themselves, with this very distinct
25 condition that Bethan had, which was rare.
0015
1 Q. Because the consequence of that might mean that any
2 surgeon would have difficulty in presenting his own
3 figures for a particular operation?
4 A. Yes.
5 Q. And might have to give you figures based on the national
6 experience?
7 A. Yes, that is right, yes.
8 Q. So what was your general impression, then, of the
9 process by which the operation was explained to you and
10 which culminated in you signing the consent form for the
11 operation?
12 A. Our impression was very much coloured by our first
13 experience when Bethan had her life-saving operation in
14 Bristol Children's Hospital, and so we felt indebted to
15 the team at the Bristol Children's Hospital, to
16 Mr Wisheart and Dr Joffe, and that inspired in us the
17 confidence that they were able to perform this
18 particular procedure for Bethan. So we did not have any
19 qualms that they were not up to it. They did have our
20 confidence for Bethan at that time.
21 Q. If we look again at paragraph 32 of your statement,
22 page 9 of WIT 229, please, you discussed this
23 paragraph a little. What you say at the beginning of
24 that paragraph was:
25 "What was not impressed upon us was the risk of
0016
1 the undiagnosed aspects of Bethan's condition and the
2 consequences that such clarifying might have on the
3 operation itself, and hence upon the eventual outcome."
4 I think it is right to say in other parts of your
5 statement -- we can go back to the paragraphs if it
6 helps, you mention that Mr Wisheart did explain to you
7 the possibility that there might be unexpected findings
8 at the operation itself?
9 A. My recollection is that the night before Bethan had the
10 operation, he came to see us on the ward and he
11 explained at that particular point that there might be
12 some clarifying required to be done when they actually
13 performed the operation the following day. That is my
14 only recollection of him and any occasion of that being
15 said to us, that there might be further clarification to
16 be done.
17 Q. Because what Mr Wisheart says in response to that
18 particular sentence, after making the point that that
19 was a matter that was generally discussed with you, is
20 to add this:
21 "Mr Bradley may be right to say that the details
22 of the many possible unexpected findings and their
23 implications were not discussed. It would be extremely
24 difficult to do so other than in the most general way
25 as, by definition, the possibilities of unexpected
0017
1 findings are virtually unlimited."
2 A. Yes.
3 Q. Do you have any comment to make on that?
4 A. My comment I would like to make -- we have given a lot
5 of thought to this -- about the aspect of informed
6 consent is that we appreciate that prior to Bethan's
7 operation they were explaining as best they could about
8 the proposed operation, what they hoped to do. It was
9 difficult for us to absorb all the information and so to
10 be fair to them, for us to make an informed decision it
11 was difficult for us because we had no medical
12 expertise.
13 So the ability of ourselves as parents to make an
14 informed decision about an operation we accept is very
15 difficult, but in the light of what we now know, and
16 what we have thought about since, we would have wished
17 that there was perhaps just an outside -- outside of the
18 hospital -- an outside team, panel of experts, to which
19 Bethan's case, because of the complexity, could have
20 been referred to. They could have decided, perhaps
21 overrided, rather, with regard to Bethan, the decision
22 for Bethan's operation to take place in Bristol, but
23 perhaps to take place somewhere else where there was
24 more experience to maximise the possible chance of
25 survival.
0018
1 Q. I think you have said already that one of the factors
2 that influenced you at that stage was a positive
3 experience of the Children's Hospital?
4 A. Yes.
5 Q. And considerable trust in the team --
6 A. That is right, yes.
7 Q. -- as a result?
8 A. Yes.
9 Q. So was there any discussion of whether or not Bristol
10 would be the best centre to perform this operation?
11 A. No, there was not, and again, to be fair to them, we did
12 not think it worth discussing because of our first
13 experience. We were so impressed with the way that they
14 saved Bethan's life at first, that we did not think to
15 discuss or even to raise any doubts, so we were happy
16 for Bethan to be operated upon at Bristol, such was the
17 confidence we had in them.
18 Q. Since that date you have become aware of the letter that
19 we saw a few minutes ago, the discussion between
20 Dr Wilde and Professor Anderson as to the best way that
21 this operation should be performed?
22 A. Yes.
23 Q. I think it is fair to say that that letter does not
24 contain any suggestion that the operation should have
25 been carried out at a place other than Bristol?
0019
1 A. My understanding -- this was conveyed to me in some
2 correspondence by Professor Anderson -- is that they did
3 not regard themselves as being empowered to make such
4 a suggestion as that, that it was within the limits of
5 Bristol for such a decision to be made and hence we
6 wished that there had been that empowerment, to an
7 outside body, for that to be made.
8 Q. So that is where your suggestion of, as it were,
9 a "clearing house" for complex cases arises?
10 A. Yes.
11 Q. The feeling, is this right, if I can summarise, that
12 there should be an outside body which would be able to
13 decide if difficult cases should be managed at one
14 centre?
15 A. Yes.
16 Q. Or whether they should be referred to another?
17 A. Yes, that is right, yes, and I say this with all due
18 respect to the medical team in Bristol, because I know
19 it is very easy to make -- I speak from personal
20 experience -- a wrong judgment with all the best will in
21 the world, and I think in the interests of medical staff
22 as well as most important of all for the child and for
23 parents, it would have been helpful if there had been
24 such a facility, to help form the right judgment or the
25 best judgment as could possibly be made.
0020
1 Q. I think it is right, Mr Bradley, that you would accept
2 that you yourself would not be able to make the judgment
3 on whether Bethan in fact would have fared better at
4 another hospital, or could properly have been managed at
5 Bristol, that that is a matter that other people have
6 expressed opinions to you, but is not within your own
7 expertise?
8 A. I accept that we are not experts medically; we can only
9 go on what we are informed, and what we have been
10 informed since, this year, with correspondence, is that
11 the mortality rates that Mr Wisheart quoted, it was not
12 a national average. It has been indicated to us that it
13 was for the very best centres in the country.
14 Q. We have in your statement the account of the opinion
15 from others on this point?
16 A. Yes.
17 Q. It is on that, obviously, that you now base those
18 judgments?
19 A. Yes. I accept that it is matters based on opinion and
20 judgment, but then you do take credence when that
21 opinion and judgment comes from somebody qualified
22 medically. So we gave that serious credence.
23 Q. Of course, and it is on that of course, that you then
24 base some of the criticisms you make of the process
25 whereby you were informed of the risks; is that right?
0021
1 A. Yes, that is right, yes.
2 Q. If we could just finish on that aspect of the matter,
3 you tell us that immediately before the operation,
4 Mr Wisheart came on to the ward -- this is paragraph 41
5 of your statement, page 11 -- and you say that
6 immediately before the operation he was encouraging you
7 by saying that Bethan's prospects had improved from
8 a 3 in 4 success rate to 9 in 10?
9 A. Yes, that is right.
10 Q. First of all, Mr Bradley, I think it appears from what
11 you have said up to now that you understood that this
12 was a serious operation and that there was a real risk
13 of death?
14 A. Yes.
15 Q. Mr Wisheart again has commented on that part of your
16 statement. Can I ask you first, are you sure in your
17 recollection of that conversation?
18 A. Yes, I am sure. He came on the ward. I am sure he said
19 other things as well, but you can imagine that as
20 parents, we were clutching at straws for any positive
21 signs that Bethan was going to come through, so for him
22 to increase the success rate in the form of 3 in 4 to
23 a 9 in 10 was something we were not likely to forget; it
24 was exactly the sort of communication we were looking
25 for and wanting to pin our hopes on. I do recall that
0022
1 after Bethan's demise, when we went to see Mr Wisheart
2 five minutes afterwards, he did confirm, because we
3 asked him, he did agree that he did express that rating
4 at that particular time.
5 Q. Can you remember particular figures, or is it possible
6 that he was merely indicating in a more general sense
7 that the risks had improved?
8 A. For ourselves, we took it personally for Bethan, Bethan
9 going down into the operating theatre the following day,
10 and we took it personally that he was inspiring us with
11 confidence that the prospects were better for Bethan,
12 that it had improved considerably from 3 out of 4 to
13 9 out of 10. That inspired our confidence further to
14 what we were hoping the following day and for the
15 following week.
16 Q. Mr Wisheart's comment was that:
17 "My experience in the immediately preceding years
18 suggested that the results for this operation were
19 improving but that the risks had not fallen to 10 per
20 cent. I may have indicated an improvement but basically
21 it is highly unlikely that I would have said that the
22 risk was as low as 10 per cent."
23 Do you think it is possible he might just have
24 indicated to you that things were better than he had
25 said before, but did not put a precise figure on it?
0023
1 A. My wife was with me and, as I say, it was communicated,
2 what is said to parents is important and for parents at
3 that stage, we were going through the stress of this
4 operation being performed. We would not have
5 misconstrued a figure like that and so, with due respect
6 to Mr Wisheart's comments, he did say 9 out of 10, and
7 he did agree, he did say in a subsequent appointment
8 that we had with him, that that was something that he
9 had said.
10 Q. He might not have said something like, "They are moving
11 nearer to 9 out of 10"?
12 A. We immediately hinged on the "9 out of 10". That is
13 what we took hold of for Bethan's operation. We are
14 sure that that is what was said.
15 Q. In any event, consent was given for the operation which
16 was planned to be the one-stage operation?
17 A. Yes.
18 Q. And you had to prepare Bethan for the operation?
19 A. Yes.
20 Q. How did you do that?
21 A. The way that we did it was, we did it two-fold. First
22 of all, we equipped ourselves to understand what was
23 going to be happening to Bethan so we asked Helen Vegoda
24 for some material and she provided us with the Heart
25 Children's booklet. We also got hold of a GCSE biology
0024
1 book and looked at some pictures. Then, for Bethan, we
2 just tried to explain to her in very simple terms what
3 was going to be happening, why she was going to
4 hospital. We had a calendar and we explained to her
5 that on such-and-such a day, that down the line she was
6 going into hospital. We explained her heart was broken
7 and that Mr Wisheart, the people in Bristol, they were
8 going to mend her heart, and we explained to her that
9 she was going to be so much better -- I mean, this was
10 the way we felt we had to say it to her. I do not think
11 we could say to her there was a risk that she might not
12 live, so we explained it to her in optimistic terms,
13 that she would be able to ride a bike and do all the
14 things that other children of her age could do. So that
15 is how we prepared her.
16 Then we explained to her what we expected from
17 her, that when she went on to the ward, to do everything
18 that she was told by the nurses and the staff, and to
19 try not to cry because it would make it easier for the
20 staff to do their tests, it would be quicker and there
21 would be less discomfort and pain. So in that sense,
22 that was how we were preparing her beforehand.
23 Q. Do you think that you found your own way to prepare
24 Bethan, or were you given help, if you needed it, to do
25 that?
0025
1 A. I do recall that we did have conversations with Helen
2 Vegoda, and we just verbally shared some ideas. I do
3 seem to remember this idea of explaining about her heart
4 being broken in the sense that Bethan could understand
5 and that it was going to be mended and that that was
6 something that we shared, but we asked Helen how we
7 could do this, and it was upon request that then she
8 responded. We did not have any material or any
9 guidelines or information on how to do that for Bethan.
10 Q. So things did not come to you automatically and you had
11 to ask for help?
12 A. No.
13 Q. When you asked, it was helpful?
14 A. Oh, yes, it was, yes.
15 Q. Bethan was then admitted for the operation on
16 17th August 1993?
17 A. Yes.
18 Q. You mention at paragraph 40 of your statement, page 11,
19 that she was introduced to Helen Passfield, the play
20 nurse?
21 A. Yes, that is right, yes.
22 Q. And generally, she was in good spirits before the
23 operation?
24 A. Yes, she was, yes.
25 Q. She went down for the operation on Thursday,
0026
1 19th August?
2 A. Yes.
3 Q. And it was a long operation. She was in the operating
4 theatre for 10 hours?
5 A. That is right, yes.
6 Q. After the operation, when Bethan returned, I think
7 Mr Wisheart came to see you and told you about the
8 progress of the operation?
9 A. Yes.
10 Q. But it was not an uncomplicated period after Bethan had
11 returned from the operating theatre, and it must have
12 been a very difficult period for you?
13 A. Yes. It was traumatic. It was traumatic on the day of
14 the operation. We had been advised that the operation
15 would be about six hours but it was much longer,
16 10 hours, so the hours of waiting, it was very traumatic
17 for us. Then when Bethan came on the ward, in the Royal
18 Infirmary, she looked poorly and her response of
19 recovery was not the same. It was so distressing to see
20 her as she was back in the intensive care unit in the
21 adult ward.
22 Q. I think you make the point in your statement,
23 paragraph 47, page 13, that Bethan at that time was the
24 only child in the adult ITU?
25 A. Yes. That is right, yes.
0027
1 Q. There were a number of days during which your hopes were
2 raised a little, but it was obviously a very difficult
3 time?
4 A. Yes.
5 Q. Then sadly, Bethan died on 26th August.
6 A. Yes, that is right, yes.
7 Q. I think your wife was there at the time?
8 A. Yes, because I was home with our son, Timothy, in
9 Cardiff. Bethan did seem to be responding and so we
10 were equipping ourselves for her recovery. We saw that
11 we needed to be ready, so we began taking turns to go
12 home and have a proper rest, so we could cope with her
13 when she came round. That was the purpose of me going
14 back to Cardiff that particular night.
15 But then, on that particular night I think at
16 2 o'clock in the morning Valmai phoned me to say to come
17 back over to Bristol and thankfully, my brother-in-law,
18 he drove us back over to Bristol. By the time I got
19 back, Bethan had already passed away and Mr Wisheart had
20 already arrived and gone. So I was just there with my
21 wife, Valmai.
22 Q. So Mr Wisheart had come, had spoken to your wife?
23 A. My wife, yes.
24 Q. But had gone by the time you arrived?
25 A. Yes.
0028
1 Q. Was your wife able to stay with Bethan then?
2 A. Yes. The nursing staff, they offered to Valmai to hold
3 Bethan for the last time. At that point they
4 disconnected Bethan and handed her over to Valmai to
5 hold, and then -- but by the time I came, Bethan was
6 back on the bed. So Valmai had stayed with Bethan.
7 Q. Were you able to see Bethan, to stay with her for as
8 long as you liked?
9 A. We stayed with Bethan for a while. The nurse had pulled
10 the curtain around the bed and there were some flowers
11 on the side table, and we stayed with Bethan for
12 a while. In our own way we gave a prayer of thanks.
13 For ourselves, we did not want to stay. We have been
14 quite private; we wanted to leave. So we decided to
15 pick up our luggage and to go home and in our own way,
16 when we got home, we just closed the curtains of the
17 house and that was where we collapsed into tears.
18 Q. You mentioned in your statement it was perhaps your
19 brother-in-law who organised the details of the funeral?
20 A. Yes, that is right, because it was very difficult for me
21 to cope with the fact that Bethan had died before I had,
22 and I found that very, very difficult to cope with the
23 funeral, although we did, but it was very difficult, and
24 almost we did not want to do it, it did not seem right
25 to do it. And of course, Bethan was still in the
0029
1 Bristol Royal Infirmary, so the arrangements for the
2 funeral and conveying Bethan's body back to Cardiff were
3 largely done by my brother-in-law.
4 Q. So did you have any conversations with the staff at the
5 Royal Infirmary about how those things had to be handled
6 and in particular, about whether or not a postmortem
7 would be needed?
8 A. No. They were done by my brother-in-law. He lives in
9 Bath so he was closer to Bristol, so it was easier for
10 him to come in and make those arrangements but he did
11 tell us that Bethan's body could not be conveyed to
12 Cardiff until the postmortem was carried out and that
13 was how we were informed and how we realised that
14 a postmortem would have to be carried out.
15 Q. Did he explain to you, or did he pass on to you any
16 explanation of why a postmortem would be required?
17 A. My brother-in-law, but we had an understanding that it
18 was through the postmortem that we would have the
19 explanation for the causes of Bethan's death and that is
20 how we interpreted the purpose of the postmortem.
21 Q. Did anyone explain to you, or ask you, explain to you,
22 that because it was to be a Coroner's postmortem, your
23 consent would not be sought for it?
24 A. No, no, that was not explained to us at all, no.
25 Q. Was there any explanation passed on to you by your
0030
1 brother-in-law of what the postmortem would actually
2 entail, what would happen to Bethan?
3 A. No. I was of the impression that it was not explained
4 to him and so he did not convey that to us, as a matter
5 of instruction, that he was asked to do that. So he did
6 not pass that on to us, no.
7 Q. So the arrangements for the funeral were co-ordinated by
8 your brother-in-law?
9 A. Yes.
10 Q. It led then to a funeral for Bethan in Cardiff?
11 A. Yes, that is right, yes.
12 Q. I think that after that, you had some further contact
13 with the Royal Infirmary in that you went back initially
14 to see Dr Joffe, and also to see Mr Wisheart about the
15 course of Bethan's treatment?
16 A. Yes.
17 Q. If we look at the period before that, Mr Bradley, and
18 look at paragraph 75 of your statement, page 20, you say
19 firstly there that you did not find that Helen Stratton
20 was particularly helpful to you at that stage, but that
21 maybe with the benefit of hindsight it is possible that
22 that was because she herself was troubled by the
23 difficulties at the Royal Infirmary.
24 A. Yes, that is right. The former statement was written
25 before she gave her evidence here to the Inquiry, and
0031
1 reading the transcript of what she said, we have become
2 aware that I think she expressed that by 1993 she
3 herself was under stress with her job.
4 Q. But that appears to have come through to you in your
5 dealings with her, is that right?
6 A. Yes, as if she found it very difficult herself to come
7 to us, which was something we found very difficult to
8 understand, because we thought that was what she was
9 there for, to be proactive in that role, to be available
10 to us, to help us through our situation, but that did
11 not happen.
12 Q. At paragraph 76 of your statement you say that you did
13 not receive the option of any bereavement counselling?
14 A. Yes.
15 Q. Can I ask you first, was there any contact from your
16 GP when you got back to Cardiff?
17 A. Yes, there was. Within a few days our GP, Dr Hayes,
18 came along to see us at the house, and at that time we
19 just wanted to be left alone; we just wanted to be on
20 our own. But we did appreciate his call to us. He just
21 wanted to make known his sympathy. I think at that
22 particular point, if he offered help, counselling, I am
23 not sure if we were in the right frame of mind to take
24 in what he said. But we do acknowledge his sympathy
25 coming to us.
0032
1 Q. So it might have been more helpful if somebody had
2 called back perhaps a few weeks later to see whether or
3 not at that stage further help might have been
4 appreciated, or you would have been in a position to
5 want to respond?
6 A. Yes. I think we were of an expectation that something
7 would come to us in a written form, and -- we say this
8 with hindsight, but we feel that if it had been done
9 even before Bethan's operation, and I think we are
10 thinking about the counselling role, that if there had
11 been some sort of liaison with us as to what the
12 facilities were that were available, even before the
13 operation had taken place, because at that particular
14 point, after Bethan died, it was so difficult for us to
15 be of sober thinking and of a proper mind, and to have
16 had as a reference point in the house something which
17 had been sent to us, even well before the operation,
18 I think that that might have helped us. That is what we
19 feel. And also, it would have impressed upon us the
20 risky nature of the operation more.
21 Q. I know that the nature of the liaison and counselling
22 with the hospital is something that you have thought
23 about a great deal?
24 A. Yes.
25 Q. In particular, I think, you do comment on whether or
0033
1 not, firstly, the persons that you were dealing with at
2 the hospital had adequate skills to cope with the roles
3 that they were put into?
4 A. Yes, that is right, and we say that with kindness,
5 because a lot of our dealings were with Helen Vegoda,
6 and she was very good with us, she was very helpful in
7 as much as if we went to her and asked her anything, she
8 would always turn round and respond; she was not
9 unresponsive, she was always responsive, and she was
10 very friendly and helpful to us.
11 But, I mean, it is easy to say these things with
12 hindsight, but we go back and we wonder what she saw the
13 expectations of her job to be. We wonder if that was
14 made clear to her, as to what her expectation was in her
15 job. We have our doubts that she fully understood, but
16 we think back and we think back as to how we would have
17 liked it now, which is easy to say.
18 Q. Perhaps we can try and deal with the things you would
19 have liked more help with. I think if we look first at
20 the period before the operation, what sort of tensions
21 were you trying to deal with at that time, and do you
22 think you could have been better helped to know how to
23 manage them?
24 A. For ourselves, it was traumatic all the way through
25 prior to Bethan's operation. We had this big operation
0034
1 on the horizon somewhere down the line. It was
2 traumatic having this in front of us. It was difficult
3 to cope with that. The tension of being realistic about
4 the risk and then having your child before you and
5 knowing how to help your child, what to say, so the
6 tension of being realistic, but then being optimistic
7 for the sake of your child and for our own self-survival
8 and to be optimistic to help to get us through. There
9 was that tension. It was a problem.
10 So from our point of view, we would have liked it
11 if even perhaps a year or so, but certainly a few months
12 before, if there had been what I describe as just
13 a routine appointment with a liaison counsellor and that
14 particular person, as a matter of routine, if they had
15 just said to us, "It is my job, my job description to go
16 through this with you, Mr Bradley, it is not because of
17 Bethan's particular case, I have to do this with every
18 patient". If they had that expectation to deliver
19 certain information such as what bereavement facilities
20 were available in the unfortunate event of death, what
21 was entailed with postmortem, what that exactly was, so
22 that we were clear about that --
23 Q. I think you say that you would have welcomed more
24 information about the possible negative outcome and how
25 to cope if things did go wrong, as well as how best to
0035
1 prepare -- let me stop there. Is that right?
2 A. Yes, that is right. Yes, because our impression was
3 that for the staff at the BRI it was almost as if they
4 found it difficult to contemplate failure as well, and
5 as if it was a management problem for them. When
6 Mr Wisheart conveyed to us the problem of there being
7 a 1 in 4 chance of failure, this was earlier on, the
8 nursing staff would turn around and say, "But you must
9 look at it the other way, Mr Bradley, a 3 in 4 chance".
10 So the emphasis was put on the other side. We can
11 understand both sides of the line, but then again, we
12 would have wished that as a consistency there had been
13 a tempering of both sides, of the optimistic side and of
14 the what I would call, not the negative, but the
15 realistic side.
16 I wonder about the communication, that there
17 seemed to be a problem with communication, what should
18 be said, what was said to us, what should have been
19 said, perhaps what should not have been said.
20 Q. Is that what you mean when you talk about "consistency"?
21 A. Yes.
22 Q. That there needed to be a consistent and realistic
23 portrayal of the possibility of failure and tragic
24 outcome?
25 A. Yes, that is right.
0036
1 Q. As well as the up-beat and the optimistic?
2 A. Yes. That they would be in touch with our feelings for
3 Bethan, who was still alive then, that we were having to
4 cope with this and be optimistic for her sake, but
5 counselling for us to help us manage that.
6 Q. And also possibly to help you on the preparation of
7 Bethan for the operation?
8 A. Yes, that is right.
9 Q. What about the role of the counsellor in assisting you
10 to understand what is happening? Do they have an
11 important role there as well?
12 A. We interpret it that a counsellor is there to help
13 a parent, to make sure that the parent understands what
14 is being told by the medical team, that their role is to
15 make sure that parents understand and to clarify any
16 misunderstanding in what is said perhaps in the
17 diagnosis or in what treatment is being proposed, and as
18 to what the parents' understanding is concerning the
19 risk. We perceive that that is within the role of
20 a counsellor and not so much in the role of the medical
21 team. That is how we interpret it.
22 Q. So that it might have been useful, for instance, to have
23 had the counsellor sit in with you during outpatient
24 appointments and then assist in clarifying what was
25 being said to you afterwards?
0037
1 A. Yes, because we have always seen the role of counsellor
2 as a befriending role, helping us to get through this
3 awful situation, and being there to help us. I think
4 that would have been greatly valued, if right down the
5 line they were there, not just as a friendly face but
6 also as a person who would help us to make sure we
7 understood what the different aspects of Bethan's
8 condition was and the treatment proposed and the risks
9 and so forth.
10 Q. What about after death? Do you think there could have
11 been more done to have smoothed over as best as
12 possible, if that can be done, at least the practical or
13 administrative sides of the consequences in giving you
14 information about matters such as postmortems,
15 certificates, registration of death?
16 A. I mean, the way that we would have liked it in our
17 circumstances is if it had been conveyed before death,
18 and I say "before death" because if it had been done in
19 a routine manner what was the procedure for complaints,
20 what the line of communication was, to whom we should
21 go, what the facilities were as regards bereavement,
22 what postmortem meant, but also, especially about the
23 retention of organs. I think we would have perceived it
24 better if it had been a few months or even a year or so
25 before the operation; not just before the operation, but
0038
1 a few months before.
2 Q. Is it not likely that you would have seen it as
3 unnecessary and upsetting, distressing detail about
4 something that you hoped very much would never come to
5 pass?
6 A. Obviously it is something that we would have hoped never
7 to have come to pass, but we see that it would have been
8 as it were an aspect of the tempering of the things that
9 we were looking for, the optimistic, the mortality rate
10 like the 3 in 4 success, that that would have been an
11 aspect of the tempering, and we would have accepted it,
12 that it was not being negative to Bethan's case, but
13 just as a matter of protocol, a matter of routine, that
14 that was part of their job to do well beforehand,
15 I think well before the operation, not the day before,
16 but well before, when we were in a spirit receptive to
17 receive that information.
18 Q. In any event, you yourself tried to fill the gaps
19 as you perceived them by producing a booklet called
20 "Remembering your Child"?
21 A. Yes, that is right, yes.
22 Q. If we look at page 32 of the witness statement, please,
23 that just gives us the title page of the book.
24 If we go over the page, please, we see there that
25 it is sponsored from the Bethan Amanda Bradley fund,
0039
1 because you set up a fund in your daughter's name as
2 well, did you not?
3 A. That is right, yes, we have, yes.
4 Q. The booklet we have seen already in previous sessions,
5 but it was written together with Helen Vegoda, in that
6 she provided you with some of the factual information
7 contained in it?
8 A. That is right, yes.
9 Q. And presumably you did this because you felt that it
10 would have been helpful to have had such a booklet
11 available after Bethan's death, to assist in the process
12 particularly of knowing how to remember, how to grieve
13 for your child?
14 A. Yes, that is right, because had Bethan passed away, we
15 were very distressed, very upset. We wanted to be alone
16 for a while, but then we were of an expectancy to be
17 receiving something from the hospital, to have a letter
18 of empathy, of an expression of concern over Bethan's
19 operation; we were expecting to have an appointment
20 confirmed to us to go back and to discuss Bethan's
21 operation, neither of which happened. It did not happen
22 as an automatic course of events. We did not receive
23 any letter, no appointment was offered to us in writing
24 to go back to the hospital, and we had a terrible ordeal
25 with a series of events, when it seemed as if Bethan had
0040
1 just been forgotten.
2 Bethan before the operation, the day before, she
3 had done some drawings. We asked for these drawings to
4 be returned to us. We were informed they had been
5 thrown away and we were shocked by that. We were very
6 upset by that.
7 We had no meeting with Mr Wisheart until we asked
8 for one and then we had no meeting with Dr Joffe until,
9 again, we asked for one. That was 18 months after the
10 operation. When we asked for the meeting with Dr Joffe,
11 we did that through Helen Vegoda. We expressed our
12 grief that he had not met with us.
13 When Helen Vegoda responded, this was 18 months
14 after the operation, she said she did not know that
15 Bethan had died. We just could not believe this.
16 We could not comprehend how she did not know. We were
17 confident that Dr Joffe did know, but we could not
18 understand why they had not come back and therefore this
19 awful feeling that Bethan had been forgotten, as if she
20 had not existed. We could not understand -- it did not
21 make sense with our experience before, when they did
22 seem to be so caring and they did seem to be so
23 concerned.
24 Bethan had had a very good relationship with
25 Dr Joffe. I can recall Dr Joffe giving Bethan a cuddle
0041
1 in an outpatients appointment and Bethan giving him
2 a Christmas card and in some ways, we feel that it is
3 not true that he did not care. We are quite convinced
4 he did care, but somehow there seemed to be this
5 inability to express it. We cannot understand why.
6 Q. You have mentioned that Mr Wisheart did not have any
7 further contact with you until you asked to see him.
8 Just again, I should show you what Mr Wisheart has now
9 said about your statement there. It is page 52,
10 please.
11 He is commenting on the fact that you said that
12 no formal letter of regret or sympathy was sent, and he
13 agrees that he did not write to you after Bethan's
14 death, but he does go on to say that it was his usual
15 practice when a child died to say that the Coroner would
16 be involved and that a postmortem would be likely, and
17 that he would also "invite the parents to come back to
18 see me if that was their wish in due course". He thinks
19 that he would have been surprised if he did not mention
20 those matters to you and your wife after Bethan's death.
21 Is it possible that he mentioned them to you but
22 that in the circumstances immediately after the death,
23 they might have slipped perhaps from you and your wife's
24 minds?
25 A. To be fair to Mr Wisheart, at the time of Bethan's
0042
1 death, he came in to see me and he said that he was
2 sorry for us. It may have been that he might have said
3 verbally to me or my wife "Please come back and
4 discuss", but we had nothing in writing. I think the
5 point at that time, if you can just imagine, we were so
6 traumatised and minds not thinking at that time.
7 Q. So the point is that really you need that sort of
8 information, invitation in writing, so that you can come
9 back to it and consider it?
10 A. Yes, as a point of reference, and I wonder whether, if
11 it is made known in writing beforehand, well beforehand
12 as part of the counselling procedures, that there is
13 this facility open. But we had nothing in writing to
14 that effect.
15 Q. You have mentioned the fact that of course you did
16 arrange a funeral for Bethan, it was very difficult but
17 that it took place.
18 When did you discover that after the postmortem
19 Bethan's body had not in fact been returned to you
20 whole?
21 A. Only this year. We were first made aware when we saw
22 the item highlighted on the news with regard to Helen
23 Rickard's experience, and that was our first occasion
24 when we became aware that this might be a possibility in
25 Bethan's case, and that was when we began seriously to
0043
1 consider that this might also be the case with Bethan.
2 Q. I think you say that it was in March of this year that
3 a letter from Ian Barrington at the Children's Hospital
4 did confirm that that had been the case?
5 A. That is right, yes.
6 Q. That is paragraph 69 of your statement, page 18. What
7 was your response to that information, Mr Bradley?
8 A. Our response, and even now, when I think about it, we
9 are so terribly upset about it, and so terribly
10 distressed, and there are no words to describe the
11 feeling. We were just so upset when we -- when it was
12 confirmed to us, and I think what distressed us was the
13 extent of the retention, that it was not just limited to
14 the heart but also her lungs, as we understand, a part
15 of her brain, a part of her kidney and the extent of it
16 extenuated the stress, and I just cannot explain,
17 I mean, the reactions we have felt. It might be
18 considered over the top, but we cannot help how we feel:
19 but we felt it was criminal, what was done. It is how
20 we felt, that it was very contemptuous, what was done,
21 to the dignity of our child that her body had been, as
22 we see it, invaded and body parts stolen, and that is
23 how we see it and how we have received it.
24 The worst aspect, I mean, it is an awful trauma
25 having Bethan being operated on. The one thing as
0044
1 a father one enjoys is having the sense of control over
2 your child's life, but then with the operation, you lose
3 that control, but then to further lose that control
4 after death in this way, it is so upsetting.
5 Q. You mention at paragraph 70 of your statement that after
6 Bethan's death the only controls returned to you were
7 the arrangement of her funeral and subsequent burial?
8 A. Yes.
9 Q. You place the reaction that you had to hearing this news
10 in that context?
11 A. Yes. That is right, yes, because it was the one thing
12 that we felt, arranging the funeral, the Minister --
13 several people come round in relation to the service for
14 Bethan, and it was our opportunity to share with them
15 the things we would just like to be said as thanksgiving
16 for her life at the funeral service. That was an
17 element of control returned to us, the way that we
18 wanted to express Bethan's life at that particular
19 point.
20 Q. If it had been explained to you -- it is a difficult
21 question, I know -- and Mrs Bradley that the hospital
22 wanted to retain parts of Bethan's body so as to be able
23 to better understand what had happened, and possibly
24 also to learn lessons that might benefit other children
25 in the future, how do you think you would have reacted
0045
1 to that?
2 A. I know how I would have reacted. If they had asked us
3 the night before Bethan's operation, and also after her
4 death, I would have said -- well, first of all, before
5 operation, I would have been affronted that they would
6 have been seemingly dismissive, even before the
7 operation, that she was going to die, so I would not
8 have liked that. That is why I feel that well before
9 the operation, when one is in sober mind, it is far
10 better to approach that. But then after the operation,
11 I would have found that difficult and I would have said
12 no, but I do consider that well before we would have
13 been in such a mind, in such a sensible mind, to have
14 thought, yes, it would be a good thing if, in the
15 enforced event of death, for some good to be achieved,
16 for Bethan's organs to be donated.
17 Q. It might be said that if one took the case of a parent,
18 say, whose child had been given a 10 per cent chance of
19 death, that firstly it was unnecessary to tell them in
20 detail about what a postmortem might entail?
21 A. Yes.
22 Q. And secondly, even if they were told that and they said,
23 "All right, if it does happen we consent to various
24 parts of the body being taken away", that they might
25 come to regret that and think about it differently when
0046
1 the 10 per cent chance had sadly come to bear, so it
2 would be safer and better for the parents, for the
3 hospital to consult them after the death when something
4 they had hoped would never happen had sadly become
5 a reality?
6 A. My feeling is that well before the operation, a low key
7 appointment, an interview, would help to put the seeds
8 in the person's mind and even if it was not a case of
9 deciding then, it would have helped to put the seeds in
10 the mind of the parent so that contemplation to decide
11 that would have been easier to reconcile as
12 a preparation in the event of that outcome having
13 occurred.
14 So that is how we perceived it. That is why we
15 feel that in our case if we had been told well before
16 the operation, we would have had a better judgment to
17 have perhaps come and say "Yes, okay, they can have the
18 heart --
19 Q. It has been very much a theme of your evidence about the
20 need for preparation for sad outcomes as well as happy
21 ones?
22 A. Yes.
23 Q. Before operations take place. Is that partly why,
24 Mr Bradley, you have made the suggestion I think that
25 there should be some sort of memorial for children who
0047
1 have died, even at the Children's Hospital. Can you
2 tell the Panel a little about that suggestion?
3 A. Firstly, the preparation side, we feel terribly sad and
4 distressed for Bethan. We feel terribly sad for medical
5 staff because we do not forget the medical team,
6 Mr Joffe and Mr Wisheart, who saved Bethan at birth.
7 We are so thankful for that.
8 We feel terribly sad with what has been happening,
9 so we feel preparation might have averted a lot of all
10 of this, but then we do feel remembering the child, it
11 is so important. I think that as parents it matters so
12 much to have that recognised when your child dies, that
13 there is a bit of fuss made about the child, not so much
14 in our case about the parents grieving, but the child,
15 because we do accept that parents do respond
16 differently, but to encourage a positive remembrance of
17 the child, as a tribute to them. They deserve this, to
18 be remembered positively. And hopefully, that that
19 memory will do some good in the parents' life after the
20 death so that that will be the memorial, first of all in
21 the parents' life, but I think in the hospital.
22 I know Helen Vegoda, we did this booklet and she
23 was very enthusiastic, to be fair to her, and also
24 Dr Joffe, we shared it with him, and he was very
25 enthusiastic as if he recognised -- that is why I say
0048
1 that it does not add up, his seeming not to care after
2 Bethan's death. With the booklet, he was very
3 enthusiastic about it.
4 Q. Can I just separate those things out? Firstly you have
5 talked about the need to ensure that parents are helped
6 to remember their child and to grieve for their child in
7 a positive way?
8 A. Yes.
9 Q. That is a matter of counselling, of support and also of
10 assistance from booklets such as the one that you and
11 your wife produced; is that right?
12 A. Yes, that is right, yes.
13 Q. Is there anything else just more tangible and physical
14 that you wanted to suggest, or is the memorial that you
15 want in that sort of work?
16 A. For what we feel, we know that it is something open,
17 perhaps to be discussed by a Parent Support Group, but
18 one thing which we liked, which Dr Joffe suggested to
19 us, because I was a member for a while of a Parents
20 Support Group for the new Children's Hospital, and he
21 came up with a suggestion which I liked, of a "tree of
22 life" in the new hospital, where on each leaf of the
23 tree will be the name of a child, and I quite like
24 that. But that is just what we felt; how parents would
25 feel as a whole, they may come up with some different
0049
1 ideas.
2 MISS GREY: Mr Bradley, I have been asking you questions for
3 quite a long time. Is there anything else that you
4 would like to tell the Inquiry at this stage?
5 A. I have asked if I could make a tribute and I wonder
6 whether that would be all right?
7 MISS GREY: Yes. Is this the tribute that you prepared
8 earlier, Mr Bradley?
9 A. Yes, that is right.
10 Q. Would it assist if it was on screen?
11 A. Yes, please. Thank you.
12 Q. If we could look, please, at page 29?
13 A. I am sorry, I did mean to say, I have changed some of
14 the wording from what you have.
15 Q. If you would just like to tell the Inquiry what you want
16 to say, Mr Bradley?
17 MR BRADLEY: Thank you, okay.
18 This is a tribute that we would like to give,
19 Valmai, Timothy and myself, to our daughter Bethan.
20 Bethan Amanda was born on Saturday, 19th September
21 1987. When she was born she was suffering with complex
22 congenital heart disease. She was already in the
23 process of dying when she was born, so we were preparing
24 ourselves for the worst, her death.
25 But then on the following Wednesday, Bethan's life
0050
1 was miraculously saved. Nothing can describe the
2 euphoric feeling we had when we went home with a baby
3 that nature had intended should die but, through the
4 dedication and skill of the surgeon, James Wisheart,
5 God determined should live.
6 Due to her life-saving operation, we had the
7 wonderful privilege of enjoying Bethan for almost
8 6 years, through which she gave so much pleasure and
9 happiness.
10 We appreciated the specialness of our child and
11 the gift of life that she was and we felt so grateful to
12 those who saved her life, namely Mr Wisheart and
13 Dr Joffe, and all the medical team involved. We shall
14 always be thankful to God for people like these who
15 aspire to save lives.
16 There are just three things we would like to say
17 about Bethan.
18 Firstly, Bethan gave us such an awful lot of
19 love. She loved our cuddles and affections and she
20 respond with the same. We can remember Bethan going
21 around the house wearing Mummy's shoes and perhaps
22 trying on Mummy's makeup, powdering her nose, using
23 lipstick, dabbing on herself a little perfume. At the
24 end of every working day, Bethan herself, when I came
25 home, she would often give me, her Dad, a "welcome
0051
1 home" hug. Such was the love she gave.
2 She loved her younger brother Timothy. She cared
3 for him like a second mother and she would be concerned
4 if Timothy fell and hurt himself, so when Timothy began
5 going to nursery school, Bethan was there to help him
6 settle in, and Timothy reciprocated Bethan's love.
7 The second thing about Bethan is that she was
8 a great achiever. Despite her disability, she wanted to
9 be as good as other children, and despite many
10 reservations, we, in contact with Dr Joffe, were
11 encouraged to send Bethan to a normal school, which is
12 what we did, and not to a special school.
13 When Bethan began going to her local primary
14 school, she surprised everybody, even ourselves. She
15 was slow at first in development, but by the end of the
16 year her school report confirmed that she was achieving
17 as well as other children of her age.
18 Just a few weeks before her operation, Bethan also
19 took part in the sponsored run at her school, and this
20 sponsored run was to raise money of all things for heart
21 research. She ran to help the school raise money. This
22 made her a little celebrity, because when she ran, the
23 Welsh TV broadcast her achievements. This sense of
24 achievement on Bethan's part spoke so much to us of the
25 untapped potential and contribution which she had and
0052
1 which we would not have witnessed had her life not been
2 saved at birth.
3 So we are so thankful.
4 The third quality that she had was also she
5 trusted. She trusted her Mum and Dad and she trusted in
6 the hospital. She knew why she was going into hospital;
7 she was going to have her heart mended. She knew what
8 was expected of her. She knew that she was expected to
9 do what the doctors or nurses asked from her. She
10 trusted in her Mum and Dad. She trusted in the doctors
11 that they knew what was best for her. The result of her
12 preparation was that she was so great, she did
13 everything that she was told because she was determined
14 to be made well, and we are so very proud of her.
15 Being the people we are, we encouraged Bethan to
16 trust in God also, and she did. She trusted in God, in
17 God's care and this helped her to face the operation in
18 August 1993. She trusted God, but we did not anticipate
19 that her trust would have to be so absolute. She went
20 into the operating theatre on 19th August, a Thursday.
21 She died a week later in the early hours of Thursday,
22 26th. God rewarded our daughter's trust so completely
23 when he caught our lovely daughter when she fell through
24 the net of man's life-saving design.
25 Through her death, and because of Bethan's simple
0053
1 trust in nature, we have learned to trust in God also,
2 and to this day, we believe that God holds Bethan close
3 in his arms and that he will not let her go because his
4 love is so strong. It is our personal conviction that
5 the same is true for all the children who have died
6 under such similar circumstances.
7 Thank you very much.
8 MISS GREY: Thank you, Mr Bradley. The Panel may have some
9 questions.
10 THE CHAIRMAN: We have no questions. Mr Trusted?
11 MR TRUSTED: There is no re-examination, thank you.
12 THE CHAIRMAN: Thank you very much for coming and telling us
13 Bethan's story. I am pleased also your wife and I take
14 it Timothy is here also to hear you. Thank you.
15 MISS GREY: Sir, this might perhaps be an appropriate moment
16 for perhaps a 15 minute break?
17 THE CHAIRMAN: I suggest 10 minutes and therefore reconvene
18 at 10.50.
19 (10.40 am)
20 (A short break)
21 (10.55 am)
22 MR LANGSTAFF: Sir, our next witness is Mrs Sharon
23 Tarantino, if she would like to come forward, please.
24 Mrs Tarantino, if you would stand once you have been
25 "miked" to take the oath, please.
0054
1 MRS SHARON TARANTINO (SWORN):
2 Examined by MR LANGSTAFF:
3 Q. Mrs Tarantino, your full name is Sharon Elizabeth
4 Tarantino?
5 A. Yes.
6 Q. You would like to be called Sharon?
7 A. Yes.
8 Q. We are losing your voice a little. It may be the
9 microphone's fault, but if you speak up just a shade, it
10 may help.
11 You are going to tell us about the birth and the
12 life of your daughter Corinna, who was born on 6th July
13 1993, and who died a little less than the age of 1 year
14 in May 1994?
15 A. Yes.
16 Q. You are going to tell us how it was revealed that she
17 suffered from an AVSD and from totally anomalous
18 pulmonary venous connection, words which I am sure you
19 have come to know and dread?
20 A. Yes.
21 Q. You appreciate, I think, that the particular reference
22 of your evidence today is going to be on the question of
23 the consent for postmortem, the retention of tissue and
24 how that affected you?
25 A. Yes.
0055
1 Q. And can I apologise in advance to you and to anyone
2 listening if it may seem that I do not pay sufficient
3 respect to Corinna in asking you only a little about her
4 life and death and concentrating on the discussions you
5 had afterwards.
6 Can we have on the screen WIT 223/2? Is that the
7 start of the statement which you made to the Inquiry?
8 A. Yes.
9 Q. And if we go through to page 15: that is your signature
10 at the end?
11 A. Yes.
12 Q. Going back to the first page, we will take your
13 statement as read and so if I do not deal with any
14 particular part of it, it is not because it has been
15 overlooked; the Panel have already read your statement
16 and it will be on the Internet with the other
17 statements.
18 You tell us Corinna was born on 6th July 1993, and
19 when she was about three weeks old, you first saw on her
20 notes the letters ASD and VSD?
21 A. Yes.
22 Q. She was born in Gloucester?
23 A. No, Bristol, St Michael's.
24 Q. You had no idea what ASD and VSD meant, so you asked?
25 A. Yes.
0056
1 Q. What were you told?
2 A. I was told it was a hole in the heart.
3 Q. Was that distressing news?
4 A. Yes.
5 Q. Was any reassurance given to you?
6 A. Not at that moment, no.
7 Q. So what were you told about the likely future at that
8 stage?
9 A. At that stage, that was the first we knew she had any
10 heart defect and I just happened to mention to my
11 husband about it being on notes and a nurse overheard us
12 talking and she said that she would get somebody to come
13 and see us, a cardiologist.
14 Q. That was Dr Martin, was it?
15 A. Yes.
16 Q. Briefly, what was it that he said to you, and you
17 understood from him?
18 A. He told us that it was a hole in the heart and
19 I believed it to be small. I did not really understand,
20 you know, what a small hole meant. And that she might
21 need surgery.
22 Q. She might need surgery, but she might not?
23 A. She might not.
24 Q. So you went back home to Gloucester and Corinna went on
25 with the occasional visits I think into hospital until
0057
1 September 1993 --
2 A. No, she had not been home at all.
3 Q. She had not been home at all?
4 A. No.
5 Q. So she had a catheterisation in September 1993, did she?
6 A. Yes.
7 Q. And after that, did Dr Martin speak to you again?
8 A. Yes, because she had the catheterisation because she
9 became very ill. She went to Gloucester hospital from
10 Bristol until she was well enough to come home, and
11 because she became very ill there, she went back to
12 Bristol, had the catheterisation and then Dr Martin came
13 to see us and told us that she would probably need
14 surgery sooner than what he thought.
15 Q. Did he explain to you what the nature of the problem
16 was?
17 A. At that time I do not think they realised that she had
18 more than a hole in the heart. They had not realised at
19 that time how serious her problems were. So they did
20 the catheterisation and then they could see more what
21 was wrong, and said she would need some surgery but it
22 would not be corrective surgery; it would just give her
23 some more time.
24 Q. You were told and understood that Corinna might have
25 a short life?
0058
1 A. Yes.
2 Q. You describe on page 7, paragraph 25, how at about that
3 time you first met Mr Dhasmana, and how he told you what
4 he was going to do.
5 In paragraph 26 you say how he explained that by
6 putting a band on the pulmonary artery, the blood
7 pressure in the lungs would be reduced. That would give
8 Corinna a chance to get stronger so she could have
9 a more serious and difficult operation?
10 A. Yes.
11 Q. You can remember him drawing a diagram. You say you
12 cannot remember any discussion on risks?
13 A. No.
14 Q. Let us have on the screen for a moment, please,
15 MR 1722/97. This is a note, the end of a note from
16 9th September 1993. What Mr Dhasmana is writing is that
17 he "discussed the nature and risks of the proposed
18 operation with parents. Agreed would operate on
19 Wednesday", I think it is the 15th.
20 So he has made a note of actually having discussed
21 the nature and risks of the operation. Certainly he
22 discussed the nature of the operation?
23 A. Yes.
24 Q. And you simply cannot remember, can you, whether he said
25 anything about the risks; is that the position?
0059
1 A. I can remember them not being too sure of the outcome
2 because when she had the catheter operation, she did not
3 do very well after that, so I think they felt that
4 because she did so poorly during the catheter, she might
5 not do so good during the operation.
6 Q. So something was said to you about the chances of the
7 operation being successful?
8 A. I cannot remember them giving me any figures, but it was
9 because of the catheterisation that they were a bit
10 concerned about the operation.
11 Q. In any event, she had the operation on 15th September
12 and after that she came through that operation?
13 A. Yes.
14 Q. I want to take it fairly quickly. She came back in, or
15 came back to the Bristol Infirmary for an operation in
16 May 1994. I want to take you through the seven months
17 from September 1994. We can read that for ourselves.
18 She had the operation; she came back to the ward
19 and she appeared to you to be stable?
20 A. Yes.
21 Q. And you were there with your husband?
22 A. Yes.
23 Q. And you noticed, I think, there had been quite a change
24 in her colour?
25 A. Yes.
0060
1 Q. But two days later she was in intensive care and there
2 was a crisis, was there?
3 A. Are we still on the September operation?
4 Q. No, we have moved forward to May. This is the final
5 operation. She went through the operation, came out and
6 two days later I think she is there and things start to
7 go wrong?
8 A. Yes. I think it was probably the next day, actually,
9 there was a big problem with her blood pressure. It was
10 very low.
11 Q. And you described to us in your statement -- let us look
12 at it, it is page 12. You deal with, in paragraph 44,
13 we can read it for ourselves, how Corinna's condition
14 caused concern and she had a cardiac arrest?
15 A. Yes.
16 Q. You telephoned your husband so he could come back?
17 A. Yes.
18 Q. Mr Dhasmana was called and you were sent away -- the
19 bottom of the page -- you were asked to go into another
20 room while the doctors and nurses did what they could?
21 A. Yes.
22 Q. Did you mind being asked to go into another room or not?
23 A. Yes, I did.
24 Q. Because?
25 A. I wanted to see what was happening, how she was doing.
0061
1 I felt I should have been there with her.
2 Q. Just after that I think a nurse came to see you, did
3 she?
4 A. Yes, a nurse would pop in and out and tell us what was
5 going on.
6 Q. When did you find out that things were very bad?
7 A. I think a doctor came in to see us. She kept
8 arresting. It was taking longer between each one to get
9 her heart pumping again. It all seemed to happen quite
10 quickly, but a doctor came in and we just knew by the
11 look on his face that things were not well at all. The
12 next time he came back in he told us that she had died.
13 Q. The nurses spoke to you, did they, as well?
14 A. There was a nurse with us most of the time. She would
15 go in and out and let us know what was happening.
16 Q. So you obviously were there at the hospital and very
17 upset?
18 A. Yes.
19 Q. Did they try to help you through your upset in any way?
20 A. You mean at the time she died?
21 Q. Yes.
22 A. No, not really. No.
23 Q. The nurses said, did they, that they would wash and
24 dress her?
25 A. Yes.
0062
1 Q. But you wanted to do that yourself?
2 A. Yes.
3 Q. And you did, did you?
4 A. I did, yes.
5 Q. They took a foot print and a photograph?
6 A. Yes.
7 Q. Being able to dress Corinna yourself and to have the
8 foot print and photograph, did that help at all?
9 A. It did, the dressing part, but not the photograph part.
10 Q. You and your husband -- we have heard that some parents,
11 after a death, were hurried out of the hospital, felt
12 they were hurried out of the hospital. Were you, or
13 not?
14 A. No, we actually took Corinna down to the Chapel of Rest
15 ourselves with a nurse. I carried her down. We were
16 able to stay down there as long as we wanted. Once they
17 settled us in, a nurse left us there and called our
18 family and they came down. They said just to let them
19 know when we wanted to leave her.
20 Q. So there was no pressure put on you at all?
21 A. No.
22 Q. Were you able to stay with Corinna for as long as you
23 wanted?
24 A. Yes. We stayed at the hospital overnight as well, until
25 the next morning.
0063
1 Q. Did either you or your husband speak to Mr Dhasmana
2 about what had happened following the operation?
3 A. I do not recall speaking to him, no.
4 Q. Did your husband?
5 A. I do not recall him speaking to him.
6 Q. When did you first understand that there might be
7 a postmortem?
8 A. A day or two after she died.
9 Q. Were you still at the hospital?
10 A. No, but whilst she was still at the hospital, we were
11 coming back every day and we were seeing her in the
12 Chapel of Rest.
13 Q. Where were you living?
14 A. Gloucester.
15 Q. So you came up from Gloucester to Bristol?
16 A. Yes, every day.
17 Q. How were you approached about the question of
18 a postmortem?
19 A. I think we were spoken to by a charge nurse on the
20 intensive care. We expressed that we did not want to
21 have a postmortem, but we were told it was law because
22 she died within 48 hours.
23 Q. So you actually said you did not want to have one?
24 A. Yes.
25 Q. Obviously you did not like the idea. Was it dealt with
0064
1 sympathetically or not?
2 A. They told us by having a postmortem we would come to
3 know exactly how she died, and it could help other
4 children in the future.
5 Q. Did you want to know?
6 A. Yes, we did want to know, but we asked that they would
7 only do a postmortem on her heart and not touch her
8 brain or head.
9 Q. So you had some idea that the brain might be involved?
10 A. Yes.
11 Q. Was that from general knowledge or from something that
12 was said to you?
13 A. No, just that they would probably want to look at her
14 whole body, but we were told by looking at the brain
15 they would be able to see what effect anaesthetic had on
16 babies.
17 Q. Who were you discussing that with? With a nurse?
18 A. That was with the charge nurse.
19 Q. You say in your statement it was a male charge nurse?
20 A. Yes.
21 Q. So he was explaining to you, was he, why it might be
22 that the pathologist may want to look at the brain?
23 A. Yes.
24 Q. You were saying "We do not want that, please"?
25 A. Yes.
0065
1 Q. What was the result of that conversation?
2 A. We could express our wishes by putting it in writing
3 that we would not wish them to touch the brain.
4 Q. Did you do that?
5 A. Yes.
6 Q. So you expressed those wishes in writing. You then
7 understood that the postmortem was taking place?
8 A. Yes.
9 Q. How long after that was it before Corinna was buried?
10 A. I cannot remember.
11 Q. Roughly?
12 A. It all happened within a week from the time she died.
13 Q. When you saw her again after the postmortem, before she
14 was buried, did it seem to you that indeed, contrary to
15 what you wanted, that there might have been some
16 examination of the brain?
17 A. Yes.
18 Q. How did you work that out?
19 A. She had a bonnet on her head, covering her head, so we
20 asked why and they said it was because of the scar on
21 her head, to hide her scar.
22 Q. You then buried Corinna and you were still wanting to
23 know, no doubt, really why things had gone wrong?
24 A. Yes.
25 Q. So you tell us -- this is the top of page 15 -- that you
0066
1 met Dr Martin the cardiologist about six weeks later?
2 A. Yes.
3 Q. You describe in that paragraph how you asked Dr Martin
4 if you could see the postmortem report, and his response
5 to that.
6 A. It was that we would not understand it because it was
7 very complicated.
8 Q. Did he in fact try to explain to you broadly what had
9 happened?
10 A. He explained that the vessels in her lungs were not
11 working, they had shut down.
12 Q. Can we have on the screen, please, MR 2529/8? This is
13 a letter of 11th July. Is it on your screen now?
14 A. Yes.
15 Q. This is a letter to you from Mr Martin. It says:
16 "Further to our recent conversation, I thought
17 I would try and describe Corinna's abnormalities."
18 He then sets out some of the details.
19 The conversation he refers to: was that the
20 conversation about six weeks after the death that you
21 mentioned in your statement?
22 A. Yes, I think it was.
23 Q. Do you remember getting this letter?
24 A. I do not recall it, no. I am not saying I did not, but
25 I do not recall it.
0067
1 Q. He says at the very bottom of the letter:
2 "I hope this gives you enough information that you
3 can show to the rest of the family and I hope it makes
4 things a little clearer."
5 Did you want to explain to the rest of the family
6 what had happened and why Corinna had died?
7 A. Yes, I did explain.
8 Q. You gave to them the explanation that Dr Martin had
9 given you, even though you had not seen the postmortem
10 report; you did your best with the information you had?
11 A. Yes.
12 Q. Thinking back on it, was the information given to you
13 enough to deal with your concerns and curiosities?
14 A. At the time, I just took what he said because I was not
15 really up to questioning him more, but as time has gone
16 on, I did wonder more.
17 Q. So at the time you could have asked him more questions
18 if you had wanted to, do you think?
19 A. Yes. I think it was because I was not really up to it,
20 to push him more.
21 Q. But it would have been helpful from what you are saying
22 to have had someone to talk to later on when you had
23 much more time to come to terms with what happened?
24 A. Yes.
25 Q. I do not know if you heard what Mr Bradley was saying
0068
1 before you gave evidence, but he was suggesting to us
2 that it might be useful to have some sort of formal
3 system whereby, a while after, months or even a year
4 after a death, an arrangement was made to come into the
5 hospital to speak to a counsellor, who would really say,
6 amongst other things, "Is there anything you want to
7 know which you do not know and feel we can help you
8 with?", something along those lines.
9 What do you think about that suggestion?
10 A. Yes, that would have been a good idea.
11 Q. That would have helped you, would it?
12 A. Yes, a lot, yes.
13 Q. When you buried Corinna, did you understand that any
14 part of her body had been kept for further examination?
15 A. No, not at all.
16 Q. So no-one mentioned the chance that it might have been?
17 A. No.
18 Q. When did you first begin to wonder whether, as it
19 happened, some parts of her body may have been kept?
20 A. I think I read it in one of the main newspapers about
21 another parent who had found out that her child's heart
22 had been kept.
23 Q. That might be Helen Rickard, possibly.
24 A. Yes.
25 Q. When you read that, did alarm bells start to ring, or
0069
1 did you try and put it from your mind? How did you
2 react?
3 A. I thought it was a one-off, I did not think it would
4 happen like this.
5 Q. So when did you find out for certain?
6 A. I found out from Bristol Heart Children's Action Group,
7 which we became a member of. They had sent us a letter
8 to say, you know, what had been happening, and we might
9 be hearing from the Bristol hospital, which we did, the
10 next day. We had a letter from them saying that they
11 had retained some of her organs.
12 Q. Did you want to know?
13 A. Yes.
14 Q. When you heard for certain that some organs had been
15 retained, what was your reaction?
16 A. Very upset and shocked.
17 Q. You heard, I think, that it was the heart, the lungs and
18 part of Corinna's liver that had been kept?
19 A. Yes.
20 Q. Did you ask anyone why it had been necessary to keep
21 those parts of her body?
22 A. I think in the first letter we had, they explained why
23 they kept the organs and what they did with them and
24 what use it was for keeping them.
25 Q. Two questions, really: what did you think of the
0070
1 explanation? Was it a sufficient explanation so far as
2 you were concerned?
3 A. If I had known in the first place, if they had asked me,
4 "Could we keep your daughter's organs to look at
5 further", which would help, you know, in the future for
6 other operations, then, yes. But because I did not
7 know, I did not feel any explanation would be enough,
8 really.
9 Q. So the explanation was satisfactory in itself to you?
10 A. Yes.
11 Q. But the timing of it and the way in which it was given
12 was entirely wrong?
13 A. Yes.
14 Q. And you are saying that to be given that explanation
15 after the event does not help at all with the way you
16 feel about it?
17 A. No.
18 Q. Perhaps it is obvious, but I hope you will forgive my
19 asking, does your husband share your views?
20 A. Yes.
21 Q. So what did you feel that you had to do so far as her
22 retained organs were concerned?
23 A. What we want to do is we want to have them back and have
24 them buried.
25 Q. You say in your statement -- it is page 15, the last two
0071
1 paragraphs, that you just do not want to think about the
2 burial of those organs now?
3 A. Not right now, no.
4 Q. How long ago roughly was it that you heard that the
5 organs had been retained?
6 A. It has been within the last six months. I am not really
7 sure.
8 Q. So it is still taking you time to come to terms with it?
9 A. Yes.
10 Q. Is it the case that you are upset about it and your
11 annoyance is perhaps less now than it was six months
12 ago?
13 A. Yes. It is the thought of having to basically go
14 through another funeral again.
15 Q. But eventually -- it may be some time -- you think that
16 is what you would like to do?
17 A. Yes.
18 Q. The postmortem was, as we know, a postmortem which the
19 Coroner had asked for?
20 A. Yes.
21 Q. He was required to have. Your understanding of the
22 Coroner's job was to report on the cause of death, was
23 it?
24 A. Yes.
25 Q. So as far as you were concerned, that was it and there
0072
1 was nothing more to be done?
2 A. No.
3 Q. To what extent, if at all, did you feel cheated by
4 finding out that instead of simply being used to
5 establish or help establish why Corinna had died, the
6 organs had been kept presumably for other purposes after
7 that?
8 A. Mainly the way we were told about the postmortem was
9 that it would be done by a sympathetic team from outside
10 Bristol that only did postmortems on children, and that
11 they were very careful in what they did, so I would not
12 have expected them to retain organs like that.
13 Q. In fact, we know from the papers that it was Dr Michael
14 Ashworth who performed the autopsy.
15 A. Right.
16 Q. Have you ever, to this day, seen the postmortem report?
17 A. I have, yes.
18 Q. The last thing I want to ask you about is how you think,
19 looking back on it, the difficult questions of
20 postmortem and keeping tissue should have been dealt
21 with?
22 A. Just to have been asked if that is what we wanted.
23 Q. I hope you will forgive me just asking you a few more
24 questions on that. At the time of the death, as any
25 parent would be, you were terribly upset?
0073
1 A. Yes.
2 Q. Would that have been the right time to mention it, or
3 would it have had to have been a bit later?
4 A. Before she was buried. I mean, it would have to have
5 been quite soon after the death, but I think it is
6 better to ask then than to come this far down the line
7 and find out, and then you have to go through a funeral
8 again.
9 Q. We heard the suggestion again from Mr Bradley this
10 morning that it might be sensible to discuss the
11 possibility, when difficult surgery is contemplated,
12 some time in advance -- not the night before, for
13 obvious reasons, but some time before -- that if, God
14 forbid, the worst should happen, a postmortem might have
15 to be arranged and tissues might be kept.
16 What do you think of that? Would that have upset
17 you very much in advance, to have that sort of
18 discussion?
19 A. Yes. Definitely before an operation.
20 Q. So your reaction is that that would not be helpful to
21 you?
22 A. No, not to me personally, no.
23 Q. I am not going to ask you any more questions about your
24 statement and about what you can tell us about Corinna,
25 but there may be things that you want to tell us which
0074
1 I have not asked you about, which you feel we should
2 know about. If there is anything, now is your chance to
3 tell us and to add to what you have said.
4 A. Only the fact from what I said about, I was told that
5 the postmortem would be carried out by a team from
6 outside Bristol, who only did postmortems on children.
7 I cannot understand why they said that, if it was not
8 going to happen.
9 Q. Might it have been that they said it was a team
10 independent of the hospital, and you understood that as
11 being from outside Bristol?
12 A. I just recall them saying it is a sympathetic team from
13 outside Bristol who only do postmortems on children.
14 Q. Because I think we will be told when Professor Berry
15 gives his evidence that the role that the pathologist
16 occupies when he does a Coroner's postmortem is, in law,
17 independent of the hospital, so it is outside Bristol in
18 that sense, even though not geographically outside
19 Bristol.
20 Again, it is very difficult to look back on
21 conversations that took place at times of distress, but
22 do you think something along those lines might have been
23 what was said, and you remember it obviously in the way
24 that you do?
25 A. It may have been said that way, but if it was, it was
0075
1 still misleading.
2 Q. Would it have been helpful to have information written
3 down?
4 A. Yes.
5 Q. So that you could take it and think about it and
6 understand it when you had a chance to get your mind
7 around it?
8 A. Yes.
9 Q. I rather stopped you saying what you wanted to say at
10 the end. Is there anything else you would like to add
11 to us?
12 A. No.
13 Q. You will be told I know by our Chairman that if at any
14 stage you want to add something, something which you
15 feel you basically would like to tell us, then do not
16 hesitate to do so. We shall be here for a long time and
17 happy to receive anything else that comes to your mind.
18 Sir, those are all the questions that I have.
19 THE CHAIRMAN: Thank you, Mr Langstaff. Thank you,
20 Mrs Tarantino. Mr Trusted?
21 MR TRUSTED: I have no questions, thank you, sir.
22 THE CHAIRMAN: I am very grateful to you. The Panel have no
23 questions, Mrs Tarantino, but I would like to echo two
24 things Mr Langstaff said to you. First of all, if there
25 are other things that you, when you leave, think about
0076
1 and would like us to know about, then I do encourage you
2 to, having talked to your husband, let us know.
3 Secondly, you remember what Mr Langstaff said at
4 the outset, when he said he was going to be
5 concentrating on one part of your statement, but I echo
6 what he says, that it in no way diminishes the rest of
7 your statement. All of it is important and we will take
8 account of it and have read all of it, even though we
9 have just concentrated on one aspect of it in our
10 conversation now. I wanted you to know that.
11 May I thank you on behalf of the Panel for coming
12 to talk to us and for telling us Corinna's story. Thank
13 you very much.
14 (The witness withdrew)
15 MR LANGSTAFF: Sir, Mrs Rex is not physically here at the
16 moment. Perhaps it would be convenient to have a 5 or
17 10 minute break before she gives her evidence?
18 THE CHAIRMAN: Shall we say 10 minutes, Mr Langstaff, in
19 other words, reconvene at 11.50?
20 (11.40 am)
21 (A short break)
22 (11.50 am)
23 MISS GREY: Sir, we are to hear now from Mrs Brenda Joyce
24 Rex.
25 Mrs Rex, we have been taking evidence on oath or
0077
1 affirmation. Could you please stand to do that?
2 MRS BRENDA REX (AFFIRMED):
3 Examined by MISS GREY:
4 Q. Your full name is Brenda Joyce Rex?
5 A. Yes.
6 Q. You have come today to tell the Inquiry about the life
7 and death of your second son, Steven; is that right, and
8 specifically about the subject of tissue or organ
9 retention after his death?
10 A. Yes.
11 Q. If we could look at WIT 219/2, please, this is the first
12 page of a statement which you have already provided to
13 the Inquiry; is that right?
14 A. Yes.
15 Q. If we turn to page 16, we see there the last page and
16 your signature at the bottom; is that right?
17 A. Yes.
18 Q. Are the contents of that statement true to the best of
19 your knowledge and belief?
20 A. Yes.
21 Q. Mrs Rex, as I said initially, we are concentrating on
22 the subject of tissue retention, so if I move through
23 other aspects of your statement, it will be because of
24 that, but you know of course that it has been thoroughly
25 read in its entirety?
0078
1 A. Yes.
2 Q. Steven was born on 18th May 1986?
3 A. Yes.
4 Q. Was he a premature baby?
5 A. No, he was 38 weeks.
6 Q. And the birth took place at St Michael's Hospital in
7 Bristol?
8 A. Yes.
9 Q. It took a little while I think before anything was
10 thought to be wrong with Steven's heart in particular?
11 A. It was six days after he was born.
12 Q. At that stage, the breathing of your son was noticed to
13 be abnormal?
14 A. Not by the hospital, by my husband and my son.
15 Q. What happened then?
16 A. We went to get a nurse. He was taken to the nursery and
17 we could hear him screaming and crying in the nursery,
18 in the ward. He was brought back to us on the ward.
19 Q. At some point you were seen by a doctor; is that right,
20 and he stated that Steven had a severe congenital heart
21 defect?
22 A. He stated that, but at some point you go -- everything
23 is blank, and that is the only blank part that I have.
24 I can remember walking up the ward with a nurse and she
25 said "Did you understand that?" and I said "Yes", but
0079
1 really, it was never explained to us after a --
2 Q. You are saying two things there. One is that you are
3 blanking out the details because it was new and it was
4 very distressing and upsetting. The second is that it
5 was not actually explained to you at that stage?
6 A. No, it was not explained at any time after. That is the
7 only time that I take it they did explain it fully. All
8 we knew was that he had a severe congenital heart
9 defect. They gave us two types of medicine, Frusemide
10 and Digoxin, and we were sent home and told we had to
11 give it to him every 12 hours, 8 o'clock in the morning
12 and 8 o'clock at night.
13 Q. When you met with the doctor who initially told you
14 about the problem, did you ask what this meant for
15 Steven, how severe the condition was?
16 A. This is the blank section.
17 Q. If we turn to paragraph 4 of your statement, page 3,
18 you discussed the blank part there. You say there that
19 you asked if Steven would die as this was --
20 A. This is one, I asked the nurse if Steven would die and
21 she said "No".
22 Q. So is it fair to say that at that stage you would have
23 been looking for reassurance from staff?
24 A. Oh, yes, yes, which we did not receive.
25 Q. What do you mean by the fact you did not receive it?
0080
1 A. They did not go into any details at all.
2 Q. If we look at the medical records, MR 2156/51, if we can
3 scroll down a little, please, do you see just above the
4 date "26/5" there is "Mother seen, outline of problem,
5 management explained."
6 Can you remember having a discussion in which the
7 problem was outlined and management explained?
8 A. Not at all, no. All they said was medicine twice a day,
9 and that was it.
10 Q. So he was discharged from the hospital and you were
11 placed under the care of the premature nursing team?
12 A. That is right, from the Maternity Hospital.
13 Q. I think at that stage his care was transferred, or
14 rather, more accurately, after six weeks his care was
15 transferred to the BCH because of the fact that Steven
16 had a cardiac problem?
17 A. Yes. He had his six weeks check at the BCH rather than
18 the doctor's.
19 Q. So if we look at medical record MR 2156/78, this is
20 a record, if we can just take out the address, please,
21 before putting it on the screen?
22 THE CHAIRMAN: And the other address, perhaps.
23 MISS GREY: This is a record of a letter to your GP after
24 you have been seen by the Registrar at the Bristol
25 Maternity Hospital.
0081
1 At the bottom of that letter there is a discussion
2 there about you having a number of questions about his
3 general management and being advised to treat Steven as
4 much as possible as an entirely normal child.
5 Can you remember how much information you were
6 being given about Steven's treatment at that stage?
7 A. He did not have any treatment.
8 Q. And about how severe his condition was?
9 A. Nothing.
10 Q. What sort of questions were you asking, then?
11 A. Only about letting him cry, if it was wise to let him
12 cry, and just general questions. He was getting very
13 tired when he was feeding, whether to take him off
14 breast feeding and put him on to a bottle. Just general
15 questions like that.
16 Q. So what was the overall impression you had of the
17 severity of his condition?
18 A. We did not realise how severe it was.
19 Q. If we see then in the third paragraph down, the
20 Registrar is writing that further follow-up should be by
21 Dr Jordan at the Children's Hospital. That is what we
22 have mentioned already, is it not, that the care was
23 transferred to the Children's Hospital because --
24 A. Yes, but still with the premature nurses coming in every
25 two to three days.
0082
1 Q. If premature nurses were coming in every two to three
2 days, did this not indicate to you that there was
3 actually a serious problem which required careful
4 attention?
5 A. I have since spoken to one of the nurses who was coming
6 in to us, and she has admitted they did not know how
7 seriously ill Steven was.
8 Q. Steven was being kept at home at that stage, but there
9 came a time where he had to be readmitted to the
10 Children's Hospital; is that right?
11 A. Yes.
12 Q. And that, I think, is described at paragraph 11 of your
13 statement, page 6 of WIT 219, please.
14 So in June you noticed problems with him?
15 A. The nurse noticed the problems. We noticed nothing at
16 all.
17 Q. He was taken initially to your GP?
18 A. Yes.
19 Q. And then into the Children's Hospital?
20 A. The GP rang the Children's Hospital and then he arranged
21 for an ambulance to pick us up.
22 Q. I think when you got to the Children's Hospital, there
23 was a diagnosis made of a viral chest infection?
24 A. A viral chest infection.
25 Q. Steven continued to be ill at the Children's Hospital,
0083
1 and after a couple of days, by the 28th, you were
2 advised that a cardiac catheterisation would be needed?
3 A. He was not very well on the Saturday and the Sunday, he
4 was taking oxygen when he was feeding. When I saw him
5 on the Monday morning, they told me that he was better,
6 so I decided to go home to get some more clothes.
7 When I got back, I was told he was going down for
8 a catheterisation and had the consent form put in front
9 of me.
10 Q. And you gave your consent to that procedure?
11 A. Yes.
12 Q. How well do you feel it was explained to you?
13 A. Not very well.
14 Q. Why do you say that?
15 A. Because we were not told of any dangers that could
16 happen, anything that could happen whilst he was having
17 it.
18 Q. Did you get the impression this was being done as an
19 emergency procedure?
20 A. No.
21 Q. A very urgent one?
22 A. No.
23 Q. Merely a routine one?
24 A. Yes.
25 Q. After the cardiac catheter had been taken, you had an
0084
1 interview with Dr Joffe in which he explained to you the
2 results and what had been discovered?
3 A. After he had the catheterisation, he was put into ITU
4 immediately. The anaesthetist told us he had stayed up
5 until 2 or 3 in the morning to try and stabilise him.
6 Q. If we can just move on to the --
7 A. We saw Dr Joffe, who told us unless he had an operation,
8 he had 6 to 8 weeks to live.
9 Q. How did you feel being told of that news?
10 A. We just realised the severity of what was wrong with
11 him.
12 Q. Was the nature of the operation explained to you?
13 A. Not in great detail. Not by Dr Joffe at all.
14 Q. But you were told that you would see a surgeon in order
15 to discuss the proposed operation further?
16 A. Yes.
17 Q. So did it come that you then saw Mr Dhasmana in order to
18 discuss the surgery?
19 A. We saw Mr Dhasmana on Wednesday afternoon. He invited
20 us into a little room just off ITU: very brusque, and
21 said that Steven needed an operation, he did not say how
22 quickly he needed it, and he explained that he would be
23 ordering parts from another hospital to be used.
24 A very, very quick sketch. The whole interview only
25 lasted 10 to 15 minutes.
0085
1 Q. But he did a sketch, did he, to show what sort of
2 operation --
3 A. Very, very simple sketch.
4 Q. Did you feel, when you had got through that interview,
5 that you understood what was to happen to Steven in the
6 operation?
7 A. No.
8 Q. Did you go back and ask any further questions?
9 A. He was not to be found. We did not go looking for him.
10 It was a case at that time that if the doctors were
11 doing a ward round on ITU the parents were asked to
12 leave. You did not actually have any opportunity.
13 Q. There are two parts to that. One is that he was not to
14 be seen. The second is that you were not actually
15 looking for him. Did you want to ask him further
16 questions?
17 A. No, we were just in complete and utter shock.
18 Q. What about other people? Were there other people like
19 nurses for instance whom you might have spoken to?
20 A. No, the nurses were very, very distant. You felt as
21 though you were in the way while you were on ITU. You
22 could not actually physically do anything to help.
23 Q. So the position is that you say that the interview was
24 short and you were left feeling that you did not
25 understand what was happening. Did you know or was any
0086
1 advice given to you about how you could get further
2 information if you needed it?
3 A. No, nothing at all.
4 Q. Did Mr Dhasmana discuss with you the risk of the
5 operation?
6 A. He gave us a 50:50 chance.
7 Q. What did you understand then about Steven's chances?
8 A. That he did not have a lot of chance.
9 Q. Did you understand that by 50:50 there was a 50 per cent
10 chance of death?
11 A. Oh, yes, we understood that.
12 Q. Was the word "death" mentioned to you?
13 A. No.
14 Q. But you were in no doubt as to what 50:50 meant?
15 A. Not with those odds.
16 Q. When you returned to ICU from your meeting with
17 Mr Dhasmana, you were introduced I think to Dr Sally
18 Masey, who approached you?
19 A. Yes.
20 Q. I think she showed you around the ICU?
21 A. She just showed us around the ITU on Ward 5, down at the
22 BRI.
23 Q. Was there any further discussion then of what the
24 operation might entail?
25 A. No.
0087
1 Q. The operation took place in the event on Friday,
2 1st August?
3 A. Yes.
4 Q. How long did it take?
5 A. He left the Children's Hospital at about a quarter to
6 8 in the morning, in an incubator. We were told to
7 leave the hospital and to walk around. We rang at 2.30
8 to be told he was not out of the theatre. We rang again
9 at 3.30 to be told that he was in recovery.
10 Q. And after that you went --
11 A. We went to the hospital, but it was in the middle of the
12 rush-hour so it took quite a while to get there.
13 Q. And you got there, I think, about 5 o'clock?
14 A. 5.30, yes.
15 Q. When you got there you were met by Mr Dhasmana?
16 A. He came out to meet us at the door, smiles all across
17 his face, everything went well, he did everything that
18 he wanted to do.
19 Q. Were you given hope of a positive outcome at that stage,
20 or were you still concerned about the --
21 A. No, he was very, very positive.
22 Q. So what did you do?
23 A. We stayed with him for a little while, but it is very
24 intimidating to see your own child in the situation of
25 ITU in the BRI. You try to prepare yourself, but there
0088
1 is no way that you can.
2 Q. Can you just explain a little bit what you mean by
3 "intimidating"?
4 A. With the ventilators, with all the machines around him,
5 and he was not even -- he had a nappy on. The wound was
6 only covered by a piece of gauze. That was the only
7 covering on there.
8 Q. You had been shown round the ITU by Dr Sally Masey. Had
9 that helped in preparing you for this sight?
10 A. No, not at all. You see other children and you can
11 detach yourself, but when it is actually your own child,
12 it is a totally different feeling.
13 Q. So you were explaining that it was a difficult and
14 intimidating sight to see Steven on the ICU. So did you
15 leave the ward after a while?
16 A. We only stayed about 10 to 15 minutes, and then we made
17 our way back up to the Children's Hospital where we had
18 a room.
19 Q. What happened there?
20 A. We tried to come back down, I cannot remember the exact
21 timing. It must be about 7, a quarter to 7, 7-ish, we
22 tried to come back down, and as we were coming through
23 we were stopped by the nursing staff.
24 Q. Who told you what?
25 A. That there was a problem with Steven.
0089
1 Q. So did you go any further?
2 A. No, they made us stay on the ward -- in the office, in
3 the nurses' office.
4 Q. In the BCH?
5 A. No, the Children's Hospital.
6 Q. When you say they made you stay there --
7 A. They would not let us go down to the BRI.
8 Q. How did they stop you from going there, was it advice?
9 A. Not physically, they advised us not to go down.
10 Q. Did they say why not?
11 A. No, not for ages.
12 Q. So you were left waiting?
13 A. Up in the air.
14 Q. What wa