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Daily transcripts
Hearing summary
22nd 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 Dr Michael Ashworth, Consultant Paediatric Pathologist, at
the St Michael’s Hospital, Bristol since 1993. He explained that on taking up his
post in Bristol his primary interest became paediatric cardiac pathology. Dr Ashworth
described the differences between a post mortem carried out independently by the hospital
pathologist on behalf of the coroner and one carried out at the request of the hospital.
He went on to explain the role of the pathologist in establishing the cause of death
following a death in hospital after surgery and discussions with surgeons to confirm
conclusions. Dr Ashworth told the Inquiry about monthly meetings attended by surgeons,
cardiologists and pathologists to discuss the previous month’s deaths. He concluded
by discussing the subject of retention of tissue following post mortem. He commented on
national guidelines and confirmed that local practice in Bristol, during the period of the
Inquiry’s remit, was to retain and store entire hearts and other tissues after cause
of death had been established.
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FULL TRANSCRIPT
1 Day 54, 22nd September 1999
2 (9.30 am)
3 THE CHAIRMAN: Good morning, everyone. Good morning,
4 Mr Maclean.
5 MR MACLEAN: Good morning, sir. This morning's witness and
6 today's only witness, is Dr Michael Ashworth, consultant
7 paediatric pathologist employed by the UBHT. I wonder
8 if Dr Ashworth could come to the witness chair, please.
9 Dr Ashworth, could I just ask you to stand,
10 please, to take the oath?
11 DR MICHAEL ASHWORTH (SWORN):
12 Examined by MR MACLEAN:
13 Q. Your full name is Michael Thomas Ashworth?
14 A. Yes.
15 Q. And as I have already said, you are a consultant
16 paediatric pathologist employed by the UBHT?
17 A. Yes.
18 Q. Could I ask you to have a look, please, at the screen in
19 front of you, at WIT 215/1? That is the first page of
20 a statement that you have made to this Inquiry, is it
21 not?
22 A. It is, yes.
23 Q. If we go to page 5, we see a signature at the end of the
24 statement and that is your signature?
25 A. It is, yes.
0001
1 Q. Have you read that statement through recently?
2 A. I have, yes.
3 Q. Is there anything in it that you now wish to change or
4 add to, or subtract from?
5 A. No.
6 Q. I think there has been one formal written comment, or
7 perhaps it is an informal comment, on your statement,
8 WIT 215/6, from Professor Anderson. Have you had
9 a chance of seeing that as well?
10 A. I have not seen this before.
11 Q. Perhaps you would just like to look at it. He is not
12 saying anything that is hostile or controversial so far
13 as you are concerned (pause), indeed, rather the
14 reverse?
15 A. Thank you, yes.
16 Q. The Inquiry panel will have had your statement and
17 Professor Anderson's comment and they will all have read
18 it, so I do not want to take you exhaustively through
19 your statement. I want to ask you some more general
20 questions about the role of the paediatric pathologist
21 in general and at the Bristol Royal Infirmary or the
22 Bristol Children's Hospital in particular.
23 First of all, just to deal with your own
24 background, you became a member of the Royal College of
25 Pathologists in 1989?
0002
1 A. Yes.
2 Q. You were appointed consultant paediatric pathologist at
3 Bristol in 1993?
4 A. Yes.
5 Q. Can we have UBHT 5/363, please? This, I think, deals
6 with your interview for your job which took place on
7 21st September 1992. I think there were seven
8 short-listed candidates and three were interviewed, and
9 if we just scan down the page, can we just have the
10 names, please? The committee included Professor Berry
11 and Dr Helen Porter, and they were both at that time
12 themselves pathologists?
13 A. Yes.
14 Q. We see also the appointee by the Royal College of
15 Pathologists was Dr Gould from whom the Inquiry has
16 already seen some material.
17 A. Yes.
18 Q. If we go to UBHT 5/243, this is the minutes of the
19 Executive Committee of the Trust of 30th October 1992.
20 If we go down the page, and over, please, take it from
21 me, in those minutes your appointment is reported in
22 October 1992, but you did not formally take up your post
23 until January 1993?
24 A. That is right, yes.
25 Q. You tell us in your statement that you perhaps since
0003
1 1993 developed a specific interest in paediatric
2 pathology?
3 A. Yes.
4 Q. And that was something that was encouraged by Professor
5 Berry?
6 A. Paediatric cardiac pathology.
7 Q. We will come to that subdivision of paediatric
8 pathology. Professor Berry encouraged you to develop
9 the interest in paediatric cardiac pathology?
10 A. Yes.
11 Q. Why was that?
12 A. Because he felt that there should be somebody in the
13 Department who took an interest in the cardiac work.
14 His interest was primarily in tumours and sudden infant
15 death syndrome. Dr Porter, the other pathologist in the
16 Department, her primary interest was in perinatal
17 pathology, i.e. the pathology of stillbirth and foetal
18 malformations, and since Dr Russell had left, who was
19 a senior registrar in the Department, he felt that he
20 had not been able to give as much time as should be
21 devoted to the cardiac pathology as it deserved.
22 Q. Dr Russell was Professor Berry's collaborator in the
23 paper published in the Journal of Clinical Pathology in
24 1989?
25 A. Yes.
0004
1 Q. I think by the time that paper had been published,
2 Dr Russell had already left the Department?
3 A. I am not sure at what point he left.
4 Q. You might not know about that?
5 A. I do not know.
6 Q. But that would mean that he would have left about five
7 years before you took up your post?
8 A. No, three. 1989 to 1993.
9 Q. In 1989 he had already left. I think he left in about
10 1988?
11 A. If you tell me so, yes.
12 Q. You took up your post in 1993, so there had been that
13 gap of time without anyone specifically interested in
14 paediatric cardiac pathology?
15 A. Yes.
16 Q. When you took up your post, there was in place
17 a departmental Code of Practice which had been drawn up
18 by Professor Berry?
19 A. Yes.
20 Q. If we go to WIT 204/34, this is one of the documents
21 Professor Berry has submitted along with his statement.
22 This, I think, is the 1991 version which would have been
23 in force in 1993 when you took up your post?
24 A. Yes.
25 Q. If we look at paragraph 3:
0005
1 "Coroner's cases. Tissue can normally only be
2 retained..." and then we see (a) and (b), and then
3 further text.
4 What did you understand by the word "normally"?
5 In what circumstances did the "normal" situation set out
6 in that paragraph not apply?
7 A. I do not think I can answer that.
8 Q. As far as you are concerned, if one substituted the
9 word "only" or just excised the word "normally" so
10 it read "tissue can only be retained in Coroner's
11 cases... (a) ... (b)...", would that accord with your
12 understanding?
13 A. I think so, yes.
14 Q. Do you recall any situation in which tissue was retained
15 in Coroner's cases which did not fall within the
16 explanation in paragraph 3?
17 A. Yes, for example, there were corneal transplants, heart
18 donations, that sort of thing, where tissue was retained
19 for the purpose of transplantation and not to establish
20 the cause of death.
21 Q. So a patient who died suffering from something else --
22 A. Yes, a head injury, for example, or a neurological
23 condition may have had the heart valve retained or the
24 kidneys donated or corneas, sometimes skin.
25 Q. In that case there would be nothing in writing from the
0006
1 next of kin of the deceased because they would not have
2 had to give consent for the postmortem, it being
3 a Coroner's case.
4 A. There was usually something in writing, yes.
5 Q. Saying what?
6 A. That they consented to the donation of the organ.
7 Q. Was there a situation, do you recall, in this type of
8 example where a patient dies of a head injury and has
9 a heart valve removed at postmortem, where the removal
10 of the heart valve was not accompanied by something in
11 writing from the next of kin?
12 A. Very occasionally we had verbal consent.
13 Q. Which would be reported to you in what form?
14 A. To say the family had given permission but the family
15 were no longer in Bristol, for example, but had given
16 permission for the organ to be donated.
17 Q. Who would tell you that?
18 A. The Coroner's officer.
19 Q. Who would tell him?
20 A. The clinician looking after the child.
21 Q. Or the person who themselves got the consent; presumably
22 the same person?
23 A. Yes, they were normally the same person.
24 Q. These Codes of Practice have been amended twice,
25 Professor Berry tells us. If we go to the next page,
0007
1 page 35, how would you characterise that addendum?
2 Would you characterise that as clarifying the code or
3 tightening up the code? What did you understand the
4 nature of this change to be?
5 A. It is an expansion, I think, in so far as there is
6 a part which now states that if a clinician wishes an
7 organ to be retained, it will only be done with consent,
8 which was not in the original one.
9 Q. So there would be no room now for the reporting orally
10 of a consent through the Coroner's officer because there
11 has to be a record of consent in the case notes?
12 A. Yes.
13 Q. So this is a tightening, is it not, of the 1991 Code of
14 Practice?
15 A. Yes. I think you could characterise it as that, yes.
16 Q. There has been a further amendment, has there not, in
17 1998, on the next page, page 36. You are familiar with
18 this document?
19 A. I am, yes.
20 Q. If we scan down the page, please, "Disposal": to what
21 extent does that represent a codification of the
22 previous practice on the one hand or a change from
23 previous practice on the other?
24 A. I think that codifies it. It puts in writing what was
25 the practice.
0008
1 Q. What about this 1998 document represents a departure
2 from previous practice?
3 A. It is more specific in its requirement for
4 documentation.
5 Q. So it is a continuation of the same tightening trend we
6 have seen in 1996, is it?
7 A. Yes.
8 Q. How did these changes come about? Did Professor Berry
9 decide on his own to introduce them, or was there some
10 discussion with colleagues?
11 A. There was discussion.
12 Q. Were you involved in that discussion?
13 A. Yes, I was.
14 Q. What was your attitude to these tightenings of the Code
15 of Practice?
16 A. I was in agreement with them.
17 Q. The codifications or the tightenings: in your opinion,
18 were they necessary?
19 A. I think they were at the time, yes.
20 Q. Were they necessary in 1993 as well?
21 A. I think the situation was different in 1993.
22 Q. Why?
23 A. I think we were not quite fully aware of the issues
24 involved.
25 Q. The 1996 tightening, if I can characterise it as that,
0009
1 I think Professor Berry tells us came in the wake of
2 a meeting which he had had with one of the parents?
3 A. Yes.
4 Q. With Mrs Rickard. So when you say that in 1993 you
5 collectively as pathologists were not as aware of the
6 issues, what issues are you referring to?
7 A. Effectively public opinion as to the retention of organs
8 and that there was perhaps some antagonism to it.
9 Q. Did you consider, in 1993, that it was public knowledge
10 that hearts taken from cardiac surgery patients as
11 a result of, let us say, Coroner's postmortems, perhaps
12 under rule 9 in order to help establish a cause of death
13 were, after the Coroner has finished with his
14 investigations, retained by the hospital? Do you
15 consider that was public knowledge or was that something
16 that the public were not aware of?
17 A. I do not know.
18 Q. Because there is a difference between an issue which has
19 always been there suddenly exciting the public in 1996
20 on the one hand, and the public first becoming aware of
21 the matter in 1996?
22 A. Yes.
23 Q. So was it that the culture previously had never been
24 such as to encourage the dissemination of this
25 information to parents of children who had died, for
0010
1 example?
2 A. I think that is overstating it. I think it was not that
3 it was not to encourage; it was just that it was not
4 considered an issue, I think.
5 Q. Were you aware of anyone in the community of
6 pathologists who saw this issue as an accident waiting
7 to happen?
8 A. Yes, there were pathologists who had written on the
9 subject, yes.
10 Q. When?
11 A. I think, certainly from the mid-1980s.
12 Q. Bernard Knight, for example?
13 A. Yes.
14 Q. So if some people had gone into print that this was an
15 accident waiting to happen in the mid-1980s, why was it
16 that it was a decade later that the accident did happen
17 and nothing had been done to prevent it?
18 A. These were lone voices, I think. The body of
19 pathological opinion still was that it was not an issue.
20 Q. We will come back in due course to what was in the
21 public domain from the Royal Colleges and the Department
22 and so on.
23 I should have said at the beginning, you gave
24 evidence at the General Medical Council on 5th March
25 1998?
0011
1 A. I did, yes.
2 Q. And on whose behalf did you give evidence there? Who
3 were you called by?
4 A. I was called by the solicitors for James Wisheart,
5 I think.
6 Q. I think that is right. You were examined first of all
7 by Mr Mathieson for Mr Wisheart?
8 A. Yes, it was Mr Mathieson, certainly, yes.
9 Q. The postmortem, the autopsy of a body in a congenital
10 disease case, presumably one of the functions of that
11 postmortem is to provide information to the doctors and
12 to the relatives perhaps in particular to advise them of
13 genetic implications, in some instances?
14 A. Yes.
15 Q. Would it also be right to say that postmortems had, as
16 some of their other purposes, the collection of
17 mortality and morbidity statistics?
18 A. Yes.
19 Q. The harvesting of skin, bone, corneas and heart valves,
20 for example, for the treatment of others?
21 A. Yes.
22 Q. In Coroner's postmortem cases, a part of the legal
23 investigation of violent deaths?
24 A. Yes.
25 Q. And a role to play in the teaching of medical students,
0012
1 doctors and other health care professionals?
2 A. Yes.
3 Q. Another role of the postmortem is this part of the
4 process of confirming the clinical diagnosis that was
5 made before the surgery, for example, was carried out?
6 A. Yes.
7 Q. And also the postmortem will help to rule out,
8 hopefully, a major therapeutic mishap having taken
9 place?
10 A. Yes.
11 Q. So if we look at Professor Berry's statement, please, at
12 WIT 204/5, paragraph 14, can I ask you to look at that
13 paragraph and tell me if you agree or disagree with its
14 contents? (Pause)
15 A. I agree with them, yes.
16 Q. If we go to WIT 303/6, this is a statement which I think
17 you will not have seen, Dr Ashworth, for which
18 I apologise. It only came in yesterday. It is from
19 Dr Russell whom you have mentioned already, Professor
20 Berry's collaborator in the late 1980s.
21 In paragraph 12 he is talking about the article
22 that he and Professor Berry published and he says, at
23 the end of the paragraph:
24 "Indeed, one of the conclusions of the review was
25 that postmortem examination did have a value because it
0013
1 might provide information to clinicians which was not
2 otherwise available to them but which might assist them
3 in treating other patients in the future."
4 That is right, is it not?
5 A. Yes.
6 Q. And Professor MacSween has given a statement to the
7 Inquiry, WIT 54/31, paragraph 3(ii). Again, can I ask
8 you to have a look at that paragraph and tell me whether
9 or not you agree with it. (Pause).
10 A. Yes, I agree with it.
11 Q. Appendix L is a document we will come back to later
12 which is called "Autopsy and audit", which I am sure you
13 are familiar with?
14 A. Yes.
15 Q. We have mentioned Professor Berry's article. That is at
16 UBHT 308/76, Russell and Berry. When did you first
17 become aware of this article?
18 A. I think I would have read it first when it came out in
19 1989. I do subscribe to the journal.
20 Q. This would be standard reading for pathologists?
21 A. The majority of pathologists, yes.
22 Q. I will not read out the summary; the Panel I am sure are
23 familiar with the article by now. Can I take you to
24 page 80, please, the right-hand side? Can we just have
25 the right-hand column? This is in the discussion
0014
1 towards the end of the paper. The first new paragraph:
2 "Scrutiny of highly skilled complex surgery on
3 tiny hearts at necropsy is essential for the continued
4 improvement of surgical technique."
5 Do you agree with that?
6 A. Absolutely, yes.
7 Q. "Flaws in surgical technique were uncommon in our series
8 but when present they provided valuable lessons for the
9 management of future cases."
10 Again, that is what one would expect?
11 A. Yes.
12 Q. I mentioned the document that Professor MacSween kindly
13 sent to us as appendix L, "Autopsy in audit". That is
14 WIT 54/936.
15 It is a Joint Working Party report and it is
16 a Joint Working Party of three Royal Colleges:
17 pathologists, physicians and surgeons. It is dated
18 August 1991. If we go to page 940, please, those are
19 the terms of reference.
20 A. Yes.
21 Q. If we go to page 941, there is a reference in the second
22 paragraph, I think, to the Russell and Berry paper. It
23 is footnote 16:
24 "An audit in a paediatric cardiology unit showed
25 unsuspected abnormalities in 80 per cent, with
0015
1 undiagnosed abnormalities or surgical problems
2 contributing to death in 38 per cent."
3 Take it from me, footnote 16 is Russell and
4 Berry.
5 A. Yes.
6 Q. If we go to 950, still in the same paper, "Autopsy and
7 audit", the foot of the page, "Assessing the results of
8 autopsy":
9 "Regular mortality meetings should be held to
10 discuss and analyse the autopsy findings in individual
11 patients or groups of cases."
12 Do you agree with that?
13 A. Yes.
14 Q. "The major and primary purpose of these meetings should
15 be educational".
16 A. Yes.
17 Q. Educational for whom?
18 A. For the pathologist and the clinicians.
19 Q. Which clinicians?
20 A. The clinicians in charge of the cases.
21 Q. So in the case of a paediatric cardiac surgery patient,
22 that would be whom? The surgeon, certainly?
23 A. The surgeon and cardiologist both would have dealings
24 with the patient, yes.
25 Q. Anyone else?
0016
1 A. Others involved in the care.
2 Q. Anaesthetists, perhaps?
3 A. Anaesthetists, yes.
4 Q. Radiologists?
5 A. In so far as they -- yes.
6 Q. Anyone else?
7 A. Well, nursing staff occasionally, and junior staff of
8 all these groups.
9 Q. "There should be frank discussion concerning diagnostic
10 procedures, clinical management and outcome as far as
11 normal hospital procedures."
12 Do you agree with that?
13 A. Yes, I do.
14 Q. It is good advice?
15 A. Yes, indeed.
16 Q. "They should be used to evaluate both individual cases
17 and the organisation of the hospital as a whole to
18 ensure that in all its aspects it is functioning for the
19 benefit of individual patients."
20 A. Yes.
21 Q. We will come back to this later, but to what extent was
22 that paragraph followed through in Bristol when you took
23 up your post in 1993 and in particular, could you help
24 me with the way in which there was an evaluation of the
25 organisation of the hospital as a whole to ensure that
0017
1 in all its aspects it was functioning for the benefit of
2 individual patients?
3 A. I cannot say that I had a hand in that. As I interpret
4 that sentence, "they", which I presume is referring to
5 the meetings, "should be used to evaluate both
6 individual cases", is what occurred in the clinical
7 pathological meetings that I attended. As to "the
8 organisation of the hospital", I interpret that to mean
9 that the results of the meetings should be used for that
10 purpose, but it was not certainly something that I took
11 part in.
12 Q. When you took up post in 1993, previously there had been
13 clinical pathological meetings?
14 A. Yes. I understand there were, yes.
15 Q. But is it right that your understanding is that there
16 had been no minutes of those meetings taken before you
17 took up your post?
18 A. That is my understanding, yes.
19 Q. So there was no formal recording of the results of those
20 meetings?
21 A. As I understand it, yes.
22 Q. So how would the results of the meetings be fed into the
23 evaluation of the organisation of the hospital as
24 a whole in the absence of any results being recorded?
25 A. I cannot say; I was not there at that time. One could
0018
1 imagine that the results would be taken away by the
2 people who were doing the work, the surgeons and the
3 cardiologists, and used in their audit.
4 Q. But those results, to the extent they were taken away,
5 would only be taken away in the heads of the people who
6 were there?
7 A. Yes, for a small number of the cases.
8 Q. We will come back to that. Just dealing then with the
9 role of the postmortem and the role of pathologists, the
10 Russell and Berry paper was concerned, as Dr Russell and
11 I think Professor Berry explained in their statements,
12 to demonstrate that there was a role, a value to the
13 postmortem, even in modern times, as it were, by
14 indicating that the postmortem could pick up differences
15 or points of diagnosis which were not picked up before
16 the death of a patient.
17 A. Yes.
18 Q. The postmortem is also a useful way of picking up trends
19 or patterns of problems which are recurring in patients?
20 A. Yes.
21 Q. And the pathologist will always be looking out for
22 common patterns?
23 A. Yes.
24 Q. Trying to learn and build knowledge, case upon case?
25 A. Absolutely.
0019
1 Q. That is a very important part of the pathologist's work?
2 A. It is, yes.
3 Q. And that is how, for example, new diseases, CJD or
4 something of that sort, can be picked up by somebody
5 saying, "I have seen this before; this is new", and
6 matters then come to light that hitherto had not come to
7 light?
8 A. Indeed.
9 Q. If we just turn away from that for the moment to deal
10 with the question of what happens before the postmortem
11 at Bristol, to whom or on whom does responsibility lie,
12 in your opinion, or should it lie, for obtaining consent
13 to a hospital postmortem?
14 A. On the consultant in charge of the case.
15 Q. So they should be the ones who stand with the form in
16 their hand and explain the position to the relatives of
17 the deceased?
18 A. Ideally, yes.
19 Q. To what extent was that ideal met when you took up your
20 post in 1993, as far as you are aware?
21 A. I do not know.
22 Q. Would you have seen a counter-signature, if you like, on
23 the consent form indicating who had obtained it?
24 A. I do not recall.
25 Q. Does that mean you cannot remember whether there was or
0020
1 there was not, or you do not recall there being
2 a signature?
3 A. I cannot remember whether there was or was not.
4 Q. Can we have WIT 214/35, please? Take a moment,
5 Dr Ashworth, to have a look at this form and tell me
6 when you want to look at the bottom half of the page.
7 A. Okay. (Bottom half of page on screen) Yes.
8 Q. You are familiar with that form?
9 A. No.
10 Q. That, I think, is the form of consent presently used at
11 the Bristol Royal Infirmary?
12 A. Yes.
13 Q. So would that explain why you are not familiar with it?
14 A. Yes.
15 Q. Because certainly, now that the split site of cardiac
16 surgery has been ended, your patients would come
17 exclusively from, what, the Children's Hospital and the
18 Maternity Hospital?
19 A. Yes. They also come throughout the Region, but
20 specifically the cardiac cases would come from
21 St Michael's and the Children's. We do have a large
22 referral.
23 Q. But they would not come typically from the Bristol Royal
24 Infirmary at all?
25 A. No.
0021
1 Q. So can we have UBHT 14/278, please? Again, as before,
2 have a look at that form. (Pause). Can we see the
3 bottom half?
4 Are you familiar with that?
5 A. Yes.
6 Q. What is that form?
7 A. That is the consent to postmortem, what we call the
8 PM consent forms.
9 Q. That is the one now used at the Children's Hospital?
10 A. Yes.
11 Q. It does have a provision there for the signature to be
12 witnessed, "Registrar/consultant".
13 A. Yes.
14 Q. Suggesting that either the Registrar or the more senior
15 consultant can witness the signature?
16 A. Yes.
17 Q. Has Professor Berry ever informed you of the history of
18 the consent forms at the Children's Hospital and the
19 considerable difficulties which he had in getting what
20 he saw as a more acceptable form of consent adopted in
21 the mid and late 1980s?
22 A. Not in any detail, no.
23 Q. What is your knowledge of those matters?
24 A. It is probably one sentence, the words "difficulty in
25 the past".
0022
1 Q. Just help me with the practice in terms of this form.
2 You might see a form signed by the mother or the father
3 of the child and then signed by the consultant whose
4 signature you would recognise?
5 A. Yes.
6 Q. Let us take an example: signed by mother or father, and
7 then Mr Pawade's signature appears?
8 A. Yes.
9 Q. You might see the signature of somebody whom you know to
10 be Mr Pawade's Registrar?
11 A. Yes.
12 Q. What about if you saw a signature that said "pp Ash
13 Pawade"?
14 A. I do not think I have ever seen that.
15 Q. Or "pp" anyone else, for that matter?
16 A. Again, I do not recall seeing that.
17 Q. What would happen if you saw a signature which you did
18 not recognise?
19 A. It has to be said that quite a lot are illegible.
20 Q. So if I were to show you a sample -- I am not going to,
21 you will be relieved to know, but if I showed you an
22 example of a form with signatures on, there would be
23 occasions when you would not be able to tell me who had
24 witnessed the signature?
25 A. Yes.
0023
1 Q. That would be cured by having a line below the
2 registrar/consultant signature asking them to write out
3 their name legibly?
4 A. Yes.
5 Q. It is something I think which might have been suggested
6 in the 1980s, but that is a point perhaps Professor
7 Berry will come back to tomorrow.
8 What do you do with the form when you get it?
9 A. I read it and file it with the postmortem request form.
10 That then goes through with the case notes for the
11 postmortem report to be typed once the postmortem is
12 completed.
13 Q. If we get one of these forms that is signed illegibly in
14 the "witnessed by" line, does that prevent you from
15 carrying out a postmortem?
16 A. No. My main concern is that the parent's signature
17 should be on the form.
18 Q. But the only guarantee it is the parent's signature is
19 the counter-signature of the person who has witnessed
20 the signature?
21 A. I suppose strictly so, yes. That is something that has
22 not --
23 Q. If one saw "John Smith" as the mother or father on that
24 line and "Mickey Mouse" on the next line, that would be
25 an indication that perhaps John Smith was not the mother
0024
1 or father or had not given consent?
2 A. I can only say in practice it never concerned to me to
3 doubt the veracity of the parent's signature.
4 Q. When you started work in 1993, there was still the split
5 site?
6 A. There was, yes.
7 Q. So was the form used for paediatric cardiac deaths which
8 had occurred in the Bristol Royal Infirmary different
9 from the form of consent for children who had died at
10 the Children's Hospital?
11 A. It would have to be said that the vast majority were
12 Coroner's cases and therefore did not have a consent
13 form. I think the number of occasions was so small,
14 I cannot recall.
15 Q. To the extent that there were hospital postmortems
16 emanating from the BRI, were you aware of the
17 arrangements in place there for obtaining that consent?
18 A. No.
19 Q. Did you know who Diane Kennington was?
20 A. I am sorry, did I ...
21 Q. Did you know who Diane Kennington was?
22 A. I did not, no.
23 Q. Or what her role was?
24 A. I understand what it is now, but I did not know then,
25 no.
0025
1 Q. What would you expect to be said to parents or relatives
2 of a patient vis-a-vis a hospital postmortem by the
3 clinician?
4 A. I would expect the clinician to explain the reasons for
5 the requesting of the postmortem in the first place; the
6 benefits that it might confer; and to give in very
7 general terms what would happen, in other words, organs
8 would be removed, the cavities would be inspected and
9 the body would be sewn up afterwards in a proper manner.
10 Q. Just before we leave this form, what do you understand
11 to be the purpose of there being provision for the
12 signature of the witness? Why is that line there on the
13 form?
14 A. In so far as I ever thought about it, I suppose it would
15 be that should it ever be contested that the signature
16 was genuine, that the person who had witnessed it could
17 be called upon to provide the corroboration.
18 Q. That is not much good if that signature is illegible,
19 I would not be able to trace the person who had done the
20 witnessing?
21 A. Someone would perhaps recognise the signature. I would
22 recognise the illegible signatures in my department.
23 Q. Let us deal with the question of the Coroner's
24 postmortems. To what extent would you accept, as
25 a broad generalisation, that Coroner's postmortems in
0026
1 paediatric surgery cases would generally take place
2 either where a child has died on the operating table or
3 in the intensive care unit before having recovered from
4 the anaesthetic, or within the first 24 hours after
5 surgery, or when there is some other reason to think
6 that there is potential for there to be a relationship
7 between the operation or the anaesthetic or the
8 treatment in general and the death of the patient?
9 A. I am sorry, the question again is ...
10 Q. I knew you were going to ask me that.
11 To what extent would you accept as a broad
12 generalisation --
13 A. Yes, I would accept that as a broad generalisation.
14 Q. That is a rule-of-thumb test for when there would be
15 a Coroner's postmortem?
16 A. Yes.
17 Q. If we look to Professor Berry's statement, please,
18 WIT 204/5, at the bottom of the page, have a look at
19 paragraph 17, and then over the page, to the rest of
20 that paragraph when you have read it.
21 A. Okay. [WIT 204/6].
22 Q. Do you agree with that?
23 A. Yes.
24 Q. So it is not the case that every time there is
25 a Coroner's postmortem there will be a Coroner's
0027
1 inquest?
2 A. No.
3 Q. Are you able to quote what the percentage is?
4 A. It is very small.
5 Q. The vast majority of Coroner's postmortems do not have
6 inquests?
7 A. Yes.
8 Q. At the top of page 6: "generally only major errors that
9 might lead to an inquest (e.g. mis-matched blood
10 transfusion, major equipment failure or some surgical
11 disaster)."
12 Would you give me an example of a surgical
13 disaster in the cardiac field?
14 A. If one tied the pulmonary arteries.
15 Q. Sewed them up?
16 A. Sewed them up completely.
17 Q. What about a surgical mishap short of a disaster:
18 a surgical error?
19 A. Removing a valve leaflet when not intending to, or
20 putting a patch in the wrong place.
21 Q. Let us take the example of putting a patch in the wrong
22 place. What would you say to the Coroner in a case
23 where you found hypothetically a patch in the wrong
24 place?
25 A. It would very much depend on whether I thought it had
0028
1 caused the death.
2 Q. If you thought it had --
3 A. If I thought it had caused the death, I would say to the
4 Coroner "I think it has caused the death and this should
5 probably go to inquest".
6 Q. If you thought it did not?
7 A. If it did not contribute to the death, or did not cause
8 the death?
9 Q. If you thought it did not cause or contribute to the
10 death, what would you say to the Coroner?
11 A. I would say I did not think it was relevant.
12 Q. In that second situation, would you, in your postmortem
13 report, record the fact that you had found the patch in
14 the wrong place?
15 A. Yes.
16 Q. And that would be seen by the clinician?
17 A. It would be seen by anybody who had a copy of the
18 report, yes.
19 Q. And potentially by anybody who was entitled to see
20 a copy of the notes?
21 A. Yes.
22 Q. In your own statement, WIT 215/2, paragraph 6 about
23 two-thirds of the way through the paragraph, you say:
24 "I found no case in which I suspected that death
25 was a direct result of surgical or anaesthetic mishap.
0029
1 I recognised that I was not in possession of all the
2 information and that a full understanding of the death
3 required close clinico-pathological correlation but
4 I believe I excluded unnatural causes of death. I can
5 recall only one post-operative cardiac case in which
6 I was required to give evidence at an inquest."
7 A. Yes.
8 Q. The word "direct results of surgical or anaesthetic
9 mishap" in that sentence: would there be cases where
10 there was, at postmortem, a suggestion of surgical or
11 anaesthetic mishap which, in your opinion, was not
12 a direct cause of death but, if I can put it like this,
13 certainly did not help?
14 A. I would distinguish between that and saying that they
15 had led indirectly to the death. I did not find that
16 a death was due indirectly to surgical or anaesthetic
17 mishap. I certainly found some things where the anatomy
18 was such where, as you say, it did not help.
19 Q. So would it be right to say that your evidence is that
20 you found no case in which you suspected that death was
21 a direct or indirect result of surgery or anaesthetic
22 mishap?
23 A. Yes.
24 Q. Let us take a case of postmortem which shows
25 a ventricular septal defect, there is still a hole in
0030
1 the heart?
2 A. Yes.
3 Q. How are you able to judge whether that is a hole which
4 ought to have been closed in the operation or not?
5 A. I would read what the surgeon had intended to do.
6 Q. From the operation notes?
7 A. From the operation notes.
8 Q. So you would be able to tell whether or not the hole was
9 intended to be closed in the operation?
10 A. Yes.
11 Q. But you would not be in a position to determine whether
12 the surgeon was, if you like, culpable in not managing
13 in the operation to fill the hole, or close the hole?
14 A. No.
15 Q. How many pathologists carried out postmortems on
16 paediatric cardiac surgery patients from January 1993
17 when you took up your post? Did anyone else do it apart
18 from you?
19 A. Yes.
20 Q. Who?
21 A. Professor Berry, Dr Porter, Dr Adrian Charles, the
22 Senior Registrar in Paediatric Pathology. I can recall
23 one case being done by Dr Lorraine Sheehan, who was the
24 Senior Registrar in Pathology on secondment to the
25 department for two months. It is possible that one or
0031
1 two others may have been done by trainee pathologists in
2 that period, under supervision.
3 Q. They would be under the supervision of a consultant like
4 you, for example?
5 A. Yes.
6 Q. But the ones done by Dr Charles would be done by
7 Dr Charles in his own right?
8 A. No, in that period he was under supervision.
9 Q. So how many postmortems after 1993 were either not
10 carried out by you or were not carried out by someone
11 else under your supervision?
12 A. I do not have the figures with me. Not many.
13 Q. In that "not many" you did not carry out and did not
14 supervise the carrying out of, what knowledge would you
15 have of the results of those postmortems?
16 A. Effectively Professor Berry or Dr Porter would show the
17 heart to me and ask me what I thought of it.
18 Q. What about the ones that you did carry out, or you did
19 supervise: did you share the results of those
20 postmortems with any other pathologist?
21 A. In so far as I brought them to the clinical pathological
22 meetings, yes.
23 Q. All the pathologists would be at those meetings, would
24 they?
25 A. Not always, no.
0032
1 Q. But if possible?
2 A. If possible, yes.
3 Q. So the whole paediatric pathology community would all at
4 least have the opportunity of knowing the results of all
5 the postmortems that have been carried out?
6 A. Yes.
7 Q. By attending the meetings?
8 A. Yes.
9 Q. Professor Berry makes the point that Coroners are best
10 suited to recognising individual or repeated gross
11 deviations from normal medical practice as opposed to
12 picking up more subtle problems?
13 A. Yes.
14 Q. But it is right, is it not, that the Coroner is usually
15 a "lone wolf", one Coroner per district, not much
16 interaction between Coroners because they are
17 essentially confined to districts. Pathologists
18 carrying out postmortems at a very busy teaching
19 hospital have a better opportunity for picking up more
20 subtle problems than would the Coroner?
21 A. They have a better opportunity than the Coroner, yes.
22 Q. How many Coroners have you dealt with in your work with
23 paediatric cardiac patients since 1993 in Bristol?
24 A. Just the one, Mr Forrest.
25 Q. And he is the Avon Coroner?
0033
1 A. He is the Coroner for Avon, yes.
2 Q. Are you able to help to the extent to which his attitude
3 differed from the attitude of his predecessor?
4 A. I did not know his predecessor. Mr Forrest was in the
5 post when I arrived.
6 Q. There was a Coroner previously, I think, Mr Hawkins.
7 A. I understand so, yes.
8 Q. What do you understand his general approach to be?
9 A. I do not know. I have not heard the approach spoken
10 of.
11 Q. Can we have UBHT 308/170, please? It is a letter of
12 September 1992 to Professor Berry from Mr Wisheart.
13 This is before you took up post, but it is just about
14 the time you were being interviewed for the job:
15 "Dear Jem,
16 "Thank you for your letter of August 6th which
17 suggests that we should be a little more rigorous in
18 stating that we have received the permission of the
19 parents to retain part of the heart. I was slightly
20 surprised to receive this advice as I had been recently
21 told by Dr Sheffield that this problem had eased
22 a little under the jurisdiction of the new Coroner."
23 Who is Dr Sheffield?
24 A. He is a senior lecturer in pathology at the Bristol
25 Royal Infirmary who takes a special interest in the
0034
1 adult cardiothoracic work there.
2 Q. That letter would suggest, would it not, that the
3 approach of the new Coroner was different from his
4 predecessor?
5 A. It would seem to, yes.
6 Q. Is that something you were aware of?
7 A. I have no knowledge of it.
8 Q. Have you ever, since you have worked at Bristol, been
9 asked by a Coroner to carry out a postmortem and
10 refused?
11 A. I cannot recall a case, no.
12 Q. What I have in mind is that there might be some good
13 reason why you should not carry out a particular
14 postmortem and you have suggested that somebody else
15 should?
16 A. No, I do not think so.
17 Q. So you do not recall ever having asked the Coroner to
18 ask another pathologist to carry out any particular
19 postmortem?
20 A. No.
21 Q. The postmortems in paediatric cardiac surgery patients
22 took place at the Bristol Children's Hospital?
23 A. They did, yes.
24 Q. Even before the split site ended in 1995?
25 A. Yes, I did.
0035
1 Q. What documentary materials would you have available at
2 the postmortem?
3 A. Normally the hospital case notes and usually a copy of
4 the operation note -- I am sorry is this for a Coroner's
5 postmortem or in general?
6 Q. In general?
7 A. Obviously for a hospital postmortem, a summary,
8 a request for the postmortem together with a signed
9 consent form. In the Coroner's case, usually just the
10 case notes.
11 Q. Why would you not have the operation in some cases?
12 A. If the operation had been done very shortly beforehand,
13 in other words the child had died either on the table or
14 immediately post-operatively, the case notes for the
15 operation were not typed up at that stage, or if it was,
16 a copy had not found its way to the case notes.
17 Q. Why should it be necessary to carry out a postmortem so
18 quickly in some cases?
19 A. We attempted to do the postmortems as soon as we were
20 asked to do so. We thought it was good practice.
21 Q. What would you read of the documentary materials you
22 had? Would you read all of it, none of it, some of it?
23 A. Before doing the PM I would scan through it -- certainly
24 afterwards, when dictating my clinical summary, I would
25 read through it all.
0036
1 Q. Would you typically take photographs during
2 a postmortem?
3 A. Some cases I did and some I did not. I would not say
4 typically.
5 Q. What about videos?
6 A. No.
7 Q. Never?
8 A. Never.
9 Q. Was there provision for a video in postmortems?
10 A. Not then, no.
11 Q. There has been since when?
12 A. Since we moved to our new mortuary last year.
13 Q. Let us take a paediatric cardiac case. In how many
14 cases would the heart be removed during the postmortem?
15 A. It is removed during them all.
16 Q. In order the better to dissect it and inspect it outside
17 of the body?
18 A. It is removed in every postmortem. You cannot do
19 a postmortem really without removing the heart.
20 Q. What about the lungs?
21 A. All the organs were removed from the body during the
22 course of the postmortem.
23 Q. In how many cases would the heart on the one hand and
24 the lungs on the other be returned to the body?
25 A. In a cardiac case, in the majority of cases, the heart
0037
1 was retained.
2 Q. What about the lungs?
3 A. Only in those cases where it was necessary.
4 Q. Which cases would those be?
5 A. For example, cases of pulmonary stenosis, total
6 anomalous pulmonary venous drainage, or any case where
7 the connections of the heart to the lungs was a major
8 factor or possible major factor in the death of the
9 patient.
10 Q. And then heart and lungs would be retained together?
11 A. Yes.
12 Q. In order to allow inspection of the whole system?
13 A. Yes.
14 Q. Help me, Dr Ashworth, with the extent to which the
15 postmortem allows conclusions to be drawn about the
16 surgery. We have touched on this already, but to what
17 extent can you draw conclusions about the surgery from
18 the postmortem?
19 A. You can only draw conclusions by what you see within the
20 heart, or the effects of the surgery on the heart. In
21 other words, if the surgeon has not done what he thinks
22 he has done, you can draw some conclusions from that.
23 If you find a thrombus, a clot in a place you are not
24 expecting to find it, you can draw certain conclusions
25 from that, but in a lot of cases you find that
0038
1 everything is as you expect to find it and that there is
2 nothing unexpected there.
3 In those cases, it is very difficult to draw
4 conclusions without reference to the clinical notes of
5 what happened during the surgery and leading up to the
6 death.
7 Q. So, for example, you can look at the technical quality
8 of the repair, the defect?
9 A. Yes.
10 Q. You can see whether the patch is in the right place?
11 A. Yes.
12 Q. You can see whether the stitching is leaking or not
13 leaking?
14 A. Yes.
15 Q. You can tell whether there is a residual septal defect?
16 A. Yes. You can tell whether there is an occluded coronary
17 artery, for example, or a narrowing that should or
18 should not be there.
19 Q. You might be able to assess the likelihood of
20 regurgitation through a valve?
21 A. That is quite difficult.
22 Q. Say you found a residual ventricular septal defect: to
23 what extent are you able to assess whether that is of
24 any functional significance to the patient?
25 A. Really, you cannot do it without the clinical
0039
1 information.
2 Q. From the clinical notes?
3 A. From the clinical notes, yes.
4 Q. Or from the clinicians themselves?
5 A. Or indeed from the clinicians themselves, yes.
6 Q. Can we look at INQ 8/4, please? I do not know whether
7 you have had a chance to see this, Dr Ashworth. I hope
8 so. It is a statement from Dr Gould.
9 A. Yes, I have seen it.
10 Q. You have seen this, have you?
11 A. I have indeed, yes.
12 Q. Can we look at paragraphs 3.2, 3.3 and 3.4? (Pause).
13 A. Okay.
14 Q. Can we scan down, please? (Pause).
15 A. Okay.
16 Q. Do you have any observations on that?
17 A. I would agree with all of that.
18 Q. Let us take the case of a patch repair to the heart.
19 The postmortem can look at whether the patch is in the
20 right place, detect how competent the repair is?
21 A. Yes.
22 Q. The operation notes would tell you how long the
23 operation had lasted, would they?
24 A. Yes.
25 Q. Tell you how long the patient was on bypass?
0040
1 A. Usually, yes.
2 Q. To what extent would you be able to draw any conclusions
3 about the effect on the patient of the length of time on
4 bypass at postmortem?
5 A. On its own, very little. Nothing, I think, actually.
6 Q. What else would you need to know?
7 A. You would need to know whether there were complications
8 during the surgery to account for the long bypass time;
9 you would need to really speak to the surgeon to put it
10 into context.
11 Q. Can I show you the previous page of Dr Gould's
12 statement, please, page 3, paragraph 2.2:
13 " ... there are probably three main categories of
14 problems where the postmortem may be limited in
15 providing full explanations, even though a cause of
16 death can be identified and provided.
17 "2.3: First, postmortem investigation may have
18 limitations in fully explaining all the events leading
19 to death if a critical event occurs sometime, perhaps
20 many days, before death."
21 A. Yes.
22 Q. The second one, 2.4:
23 " ... there is functional impairment of an organ
24 but no specific structural abnormality can be found."
25 Then thirdly, in areas such as drug therapy,
0041
1 including anaesthetics, it is difficult to make
2 a pathological assessment of that?
3 A. Absolutely.
4 Q. So errors of management of a patient in respect of fluid
5 balance in the intensive care unit: to what extent does
6 a postmortem help us there?
7 A. Per se, the postmortem can show very little there.
8 Q. What about anaesthetic problems?
9 A. Even less.
10 Q. In order to assess the implications of the postmortem,
11 a pathologist would have to be abreast of the latest
12 developments in surgery, pharmacology?
13 A. Yes.
14 Q. What else?
15 A. Anaesthetics, electrophysiology, half a dozen
16 specialties at least.
17 Q. But the real experts in each of those specialties would
18 be the experts and the specialists?
19 A. Exactly.
20 Q. So discussions are necessary with those different
21 specialties?
22 A. Yes.
23 Q. In order for the pathologist to understand the full
24 implications of what he sees at the postmortem?
25 A. Indeed.
0042
1 Q. So when Mr Burgess of the Coroners' Society -- he is the
2 Coroner for Surrey, if I remember correctly -- came to
3 give evidence on Day 43, page 17, he was asked about the
4 factors that he looked for when deciding whether a death
5 was brought about by surgery, for example, or
6 independent of surgery.
7 I think I said to him:
8 "In the case of somebody who has surgery, perhaps
9 very unusual surgery, the patients are obviously ill
10 before the death otherwise they typically would not be
11 having the surgery at all. In the case of somebody who
12 has a congenital defect, if it is a difficult and
13 life-threatening defect, would the Coroner rely on the
14 pathologist essentially for advice as to whether or not
15 it was a congenital defect that proved too much for the
16 patient, or whether there was some failure or error in
17 the surgical correction."
18 A. Yes.
19 Q. That was the question. The answer was:
20 "I think in these particular cases, he has to take
21 a view, not just of what he sees or hears from his
22 pathologist, but also in his understanding as to the
23 degree of congenital defect that itself may have given
24 rise to the death. What he is trying to do is maybe
25 simplify what is probably quite a complex and difficult
0043
1 situation: was death hastened or brought about by the
2 surgery, or did it arise regardless of the surgery?
3 I think that is often a debate that can quite properly
4 result in well held beliefs which are totally opposite",
5 by which I think he means that reasonable people can
6 differ.
7 A. Yes.
8 Q. What role would you play in discussing that difficult
9 question with the Coroner on the one hand and the
10 clinicians who treat the patient on the other?
11 A. Firstly, I would need to be aware that there was
12 a difficulty. In other words, if there was a major
13 difficulty, I would expect to be made aware of it. In
14 other words, if there was an anaesthetic mishap, I would
15 expect the anaesthetist to contact me and say "There is
16 something not right here". Likewise, if there was
17 a surgical mishap, I would expect the surgeon to say to
18 me, "Something went wrong here, I am interested to come
19 and see the postmortem", and I would convey that to the
20 Coroner. Having done the postmortem, discussed it with
21 the anaesthetist and the surgeon, I would then advise
22 the Coroner. If I felt it was something which needed
23 further investigation, I would say to the Coroner,
24 "I think you should get an independent report on this",
25 or "You may wish to satisfy yourself that everything has
0044
1 been done by getting some independent advice in this
2 situation".
3 Q. An independent report from ...
4 A. Another anaesthetist, another surgeon.
5 Q. Just before we have a break, how often have you given
6 such advice to a Coroner since coming to Bristol?
7 A. At least once. I can think of one occasion.
8 Q. In a paediatric cardiac case?
9 A. It was not a cardiac case, no.
10 MR MACLEAN: I am conscious I may have slightly overrun the
11 usual break time, but is now a convenient moment for
12 a short break?
13 THE CHAIRMAN: Yes, thank you. Shall we take 15 minutes,
14 then, and reconvene just after 11 o'clock?
15 (10.48 am)
16 (A short break)
17 (11.10 am)
18 MR MACLEAN: Dr Ashworth, if we just pick up where we were
19 before the break, we were discussing Coroner's
20 postmortem cases?
21 A. Yes.
22 Q. The function of the Coroner, in essence, is to establish
23 the cause of death?
24 A. Yes.
25 Q. Who died, where they died and why they died?
0045
1 A. Yes.
2 Q. In carrying out the postmortem for the Coroner, what do
3 you see your role as pathologist primarily being?
4 A. In giving an opinion as to the cause of death.
5 Q. So you are looking for the cause of death in order to
6 tell the Coroner, who may not be medically qualified,
7 and certainly would not have seen the body himself?
8 A. Yes.
9 Q. Give an opinion to the Coroner as to the cause of death?
10 A. Yes.
11 Q. In doing so, the pathologist is answerable to the
12 Coroner, acting for and on behalf of the Coroner?
13 A. Yes, on the Coroner's instruction, yes.
14 Q. Not on anyone else's?
15 A. Not for that purpose, no.
16 Q. So when you go into the pathology lab, the postmortem
17 room and see the body on the table, your primary purpose
18 in a Coroner's case is to try and find out what caused
19 the death of that patient?
20 A. Yes.
21 Q. And it might be that the patient died because of the
22 illness they had, or it might be that they died because
23 of something that somebody did to that patient?
24 A. It might be, yes.
25 Q. Including potentially something that a clinician did to
0046
1 the patient?
2 A. Yes.
3 Q. We were discussing this morning the rule of thumb, as
4 I think I have characterised it, for when there would be
5 a Coroner's postmortem, and I think we agreed that it
6 was deaths on the operating table that would typically
7 lead to a Coroner's postmortem, or death within 24 hours
8 of surgery?
9 A. That is a fair rule of thumb. It is not a --
10 Q. And the reason for doing that, as we discussed, is
11 because there is potential, obviously, for a link
12 between the treatment that has been given and the death?
13 A. Yes.
14 Q. In a hospital postmortem case, what is the primary
15 function of the pathologist there?
16 A. There are several functions, I think. I am not sure
17 I would say there is a primary function but there are
18 several functions, one of which is to determine the
19 cause of death, but also to assess the progress of the
20 underlying natural disease, to assess the effects of
21 treatment and to look for any other factors which may
22 have contributed to the clinical state of the patient.
23 Q. With a view to learning --
24 A. Learning as much as one can about that individual
25 patient with a view to using that knowledge for the
0047
1 benefit of other patients in future.
2 Q. So the knowledge gleaned from the postmortem would have
3 to be fed back to the clinicians so that they could in
4 turn feed it into the care of future patients?
5 A. It would be useless on its own, yes.
6 Q. Because a pathologist never treats anyone until it is
7 too late?
8 A. Yes.
9 Q. So in the Coroner's postmortem case, establishing the
10 cause of death might involve saying "The treatment --
11 surgical, medical or whatever it might be -- of this
12 patient caused or contributed to the death of the
13 patient"?
14 A. Yes.
15 Q. That might lead to you advising the Coroner to hold an
16 inquest?
17 A. Yes.
18 Q. It might in turn lead to civil proceedings against the
19 hospital or the doctors involved?
20 A. Yes.
21 Q. And that is something doctors by and large wish to
22 avoid: nobody likes being sued?
23 A. Nobody likes being sued.
24 Q. But in order for you to advise the Coroner whether or
25 not there might be grounds for holding an inquest, let
0048
1 us take a surgical example of the ventricular septal
2 defect you find at postmortem but you are not in
3 a position to assess whether it had any function or
4 significance.
5 A. Yes.
6 Q. This is what we were exploring before the break. You
7 said that if there had been an anaesthetic mishap that
8 you detected or were aware of, you would expect the
9 anaesthetist to contact you and say there was something
10 not right?
11 A. Yes.
12 Q. Or if there was a surgical mishap, you would expect the
13 surgeon to come and say "Something has gone wrong here"?
14 A. Yes.
15 Q. It is that information rather than what you found in the
16 postmortem which is the activating factor which can lead
17 you to suggest to the Coroner that there might be
18 grounds for an inquest?
19 A. Yes.
20 Q. Because on its own, the information you obtained at the
21 postmortem is not sufficient?
22 A. Yes.
23 Q. So the system depends, does it not, in the end, on the
24 honesty of the clinician involved in suggesting to you
25 that "Something is not right here, something went
0049
1 wrong"?
2 A. Yes.
3 Q. And unless the clinician is frank with you about that,
4 you are not going to be equipped properly to advise the
5 Coroner whether or not there should be an inquest?
6 A. Yes.
7 Q. And the clinician who is asked by you, "I found
8 a ventricular septal defect, is this of any functional
9 significance?" will know that their answer will be an
10 important factor influencing your advice to the Coroner
11 as to whether or not there should or should not be an
12 inquest?
13 A. Yes. They would be aware of that, certainly.
14 Q. So, other than the integrity of the clinician, the
15 selflessness of the clinician whose honest answer may
16 put them in the frame at an inquest or civil proceedings
17 and lead to their picture being in the paper, what is
18 there to ensure that you have got to the bottom of
19 matters so that you are able to advise the Coroner with
20 the full information he ought to have as to whether or
21 not there should be a further investigation at an
22 inquest into the death of a patient?
23 A. I think there is very little to ensure that.
24 Q. When I asked you whether or not you had ever asked
25 a Coroner to get some independent report from another
0050
1 anaesthetist or another surgeon, whichever discipline it
2 is that the mishap occurred, and you said you had once,
3 but not in a cardiac case --
4 A. Yes.
5 Q. -- does it follow that in your experience at Bristol in
6 1993 with paediatric cardiac surgery cases you have not
7 found surgical mishaps or anaesthetic mishaps sufficient
8 to warrant giving that type of advice?
9 A. Yes.
10 Q. Does that surprise you?
11 A. No.
12 Q. Why not?
13 A. Why should it?
14 Q. Look at the Russell and Berry paper, for example. The
15 Russell and Berry paper tells us that, in looking at 76
16 cases, I think from memory between 1985 and 1987, there
17 was a large number of cases where the antemortem
18 diagnosis was different from the diagnosis at
19 postmortem; right?
20 A. In broad terms, yes.
21 Q. I am happy for you to narrow my broad terms if you want
22 to. And maybe the antemortem diagnosis in all 76 cases
23 was a reasonable one to come to, but nonetheless, the
24 findings of the Russell and Berry paper was that there
25 was a number of cases where had the knowledge acquired
0051
1 at postmortem been acquired before death, there might
2 well have been a different outcome for the patient?
3 A. I have not got the paper in front of me, but my
4 understanding of it is --
5 Q. Let us look at the paper. It is UBHT 308/76. 76 cases
6 were looked at. 80 per cent had unsuspected
7 abnormalities discovered at necropsy. I am reading from
8 the summary now:
9 "29 of the 76 cases had undiagnosed additional
10 cardiac anomalies or surgical flaws which contributed to
11 death in 13 cases. Defects in surgery were uncommon but
12 permitted modification of surgical technique to avoid
13 recurrence. Myocardial necrosis and pulmonary foreign
14 body embolism were common findings, the importance of
15 which is uncertain and requires further study ..."
16 Would it be fair to say that when the postmortem
17 revealed a difference from the antemortem diagnosis of
18 the patient, there is at least a question to be asked in
19 respect of that patient as to whether or not all that
20 could have been done was done before death?
21 A. I have to say to that that it depends what the
22 difference was.
23 Q. But the purpose of the postmortem is to try and --
24 certainly in a hospital postmortem case -- is to
25 increase the learning of everybody involved --
0052
1 A. Sure.
2 Q. -- so that they all get better at treating patients?
3 A. Yes.
4 Q. So when the postmortem throws up something that was not
5 picked up before death, everybody involved will want to
6 know why?
7 A. Yes.
8 Q. So that the antemortem diagnosis can be improved?
9 A. Yes.
10 Q. So when the postmortem picks up a diagnosis that is
11 different from that which was diagnosed before the
12 patient dies, this calls for further enquiry. It does
13 not mean someone has been negligent or hopelessly bad,
14 but there is something to look into?
15 A. Yes, but not necessarily an inquest.
16 Q. Not necessarily an inquest.
17 A. As we said, the purpose of the Coroner's postmortem is
18 to establish the cause of death. If in my opinion it
19 does not contribute to the death, we can certainly learn
20 from it as clinicians, but to ask the consequence, to
21 enquire into that I think is not my function.
22 Q. So when the postmortem reveals a difference in diagnosis
23 from the antemortem diagnosis of the same patient, there
24 is a question to be asked in respect of that patient as
25 to whether everything that could have been done for them
0053
1 was done for them, is there not?
2 A. I do not wish to quibble about terms, but it depends
3 what you mean by "diagnosis". If one is talking about,
4 for example, a small atrial septal defect that was not
5 picked up, that happens. It is probably not
6 significant. That is quite different from saying that
7 one has missed a large ventricular septal defect or
8 a pulmonary stenosis, or something I would actually have
9 to look at the individual cases to see exactly what they
10 meant in this paper.
11 Q. But the significance of the finding, perhaps save in the
12 most gross cases, your understanding of the significance
13 depends crucially on the information that is given to
14 you by the clinicians who are expert in a particular
15 area?
16 A. Yes.
17 Q. That, we have already discussed, would determine
18 essentially whether or not you would advise the Coroner
19 to have an inquest?
20 A. Yes, but there are some things which are so
21 self-evidently not important that that would not be
22 necessary. The example I mentioned, the small atrial
23 septal defect, I do not need to consult a cardiac
24 surgeon to know; I have seen enough of them to know that
25 is not important. In causing death. It may have been
0054
1 important in other respects, but as a cause of death, it
2 is not.
3 When you were talking earlier I understood you to
4 mean by the "significance", did I find something outwith
5 my experience. I would then have cause to consult the
6 surgeon or anaesthetist or whatever. I am sorry if
7 I misled you on that.
8 Q. We got to the Russell and Berry paper because I asked
9 you whether or not you found it surprising that between
10 1993 and now you had never had cause to suggest to the
11 Coroner in a cardiac case that it might be wise to
12 obtain a report from an independent expert from
13 whichever specialty it was that the mishap had cropped
14 up.
15 This paper suggests -- I appreciate it is one
16 paper and it is a while ago, but it is one paper in this
17 area -- 13 out of 76 children had undiagnosed additional
18 cardiac abnormalities or surgical flaws which
19 contributed to their death.
20 A. Yes.
21 Q. Those 13 cases would all be cases, would they not, which
22 would be potentially cases to suggest to the Coroner
23 that there might be an inquest, depending upon the
24 information that the pathologist had as to the
25 significance of the abnormality or surgical flaw.
0055
1 A. I really cannot say without seeing what these 13 cases
2 were. I cannot remember from the paper what they were.
3 Q. Would it not go further: if there was a patient with an
4 undiagnosed cardiac heart abnormality which contributed
5 to death, then would the suggestion to the Coroner that
6 there should be an inquest in order to find out whether
7 there was an error in diagnosis be something that one
8 would expect or not expect?
9 A. If that was the case, yes.
10 Q. So the Russell and Berry paper suggests that there are
11 at least 13 out of 76 cases where the pathologist would
12 be expected, in all probability, to suggest to the
13 Coroner that there ought to be an inquest?
14 A. No, I would not take that inference from it.
15 Q. I am sorry?
16 A. I would not take that inference from it, no, that there
17 ought to be an inquest.
18 Q. Why not?
19 A. May I see the rest of the paper? May I actually see the
20 13 cases they are talking about?
21 Q. If we go to page 77, please, could you scan down the
22 page? Can we see the whole page, please? The left-hand
23 side, group A, 29 cases had additional cardiac lesions
24 found, and they are divided into four groups. Group 1,
25 where the cardiac diagnosis before death was completely
0056
1 wrong, and there was one case in that subgroup; do you
2 see that?
3 A. Yes.
4 Q. Subgroup 2: diagnosis before death was only partly
5 correct and additional lesions were missed that might
6 have influenced the management.
7 Subgroup 3: cases where cardiac surgery was
8 imperfect or inappropriate to the lesion found.
9 In subgroup 2 there are 7 cases, that is 9 per
10 cent --
11 A. I am sorry, I am a little behind you.
12 Q. I am looking at the bottom left-hand column. Then let
13 us go to the top of the next column. "Missed cardiac
14 lesions that would have influenced management had they
15 been detected".
16 A. Right.
17 Q. In the left-hand column of that table are the findings
18 found at postmortem that had not been picked up before.
19 A. Right.
20 Q. Then the text below table 1, the first new paragraph:
21 "In 7 cases, surgical flaws were found at necropsy
22 subgroup 3, table 2. In five of these, the surgical
23 problems were probably a contributing factor in the
24 patient's death. The flaws would have more doubtful
25 clinical importance in the other cases."
0057
1 Would not those be cases where the pathologist
2 ought to be saying to the Coroner, "Well, there is
3 a surgical flaw of functional significance. I suggest
4 we have an inquest"?
5 A. (Pause). I am sorry, I cannot --
6 Q. I think we established this morning you were familiar
7 with this paper?
8 A. I have read it, yes. I do not have the details at my
9 fingertips.
10 Q. All I am really suggesting, Dr Ashworth, is that it is
11 a bit surprising, given these findings of Russell and
12 Berry, published in 1989, that since you took up your
13 position at Bristol in 1993, leaving aside the reasons
14 why we are all here, that there have been concerns about
15 Bristol, it is surprising in any centre, given this type
16 of research paper, that you should not even once in
17 a period of what is now six years have suggested to
18 a Coroner that he have an independent report from
19 another clinician, let alone have an inquest in
20 a cardiac case.
21 I think there has been one inquest?
22 A. Yes. I have to say, I have found abnormalities which
23 were not picked up before surgery, or were not diagnosed
24 by the surgeon, but I think it is a big step in going
25 from that to suggesting that having an inquest --
0058
1 I mean, these I have discussed with the surgeons, I have
2 discussed with the cardiologists, and they tell me that
3 these things sometimes cannot be picked up, it is very
4 difficult to pick them up and it is well-recognised in
5 the cardiological community that that is the case.
6 Q. What is the problem about having an inquest in order to
7 enquire as to what happened? Is that not the job of the
8 Coroner's inquest, to determine whether or not something
9 that was not picked up could have been picked up?
10 A. I am not sure it is. I do not know.
11 Q. So when you find matters that were not picked up and
12 diagnosed as hard surgical flaws, you would have
13 discussions with surgeons and cardiologists?
14 A. Yes.
15 Q. They would essentially reassure you that the problem you
16 found could not have been picked up pre-operatively?
17 A. Yes.
18 Q. So you would say to the Coroner --
19 A. I would say "This is the advice I have received. I am
20 assured this is a complication, a recognised
21 complication or a recognised difficulty and that on the
22 basis of this, I am of the opinion that death was due to
23 natural causes".
24 Q. And you would always take that advice from the
25 clinicians who had actually treated the patient?
0059
1 A. Yes.
2 Q. Never from anyone else?
3 A. Well, there were other cardiologists at the Children's
4 Hospital who did not treat patients. Yes, I would speak
5 to them also.
6 Q. But your first port of call would be the clinicians who
7 had compiled the notes that you had been provided with
8 for the postmortem?
9 A. Of necessity, yes.
10 Q. When dealing with paediatric cardiac postmortems between
11 1993 and 1995, you would have been aware that to the
12 extent the patient had had surgery; not all of them had
13 had surgery, but where they had had surgery, they would
14 of necessity have had surgery from one of two surgeons,
15 Mr Wisheart and Mr Dhasmana?
16 A. Yes.
17 Q. You would always know from the operation notes which of
18 the two had carried out the particular operation?
19 A. Yes.
20 Q. Would you therefore always know that one surgeon tended
21 to carry out a particular kind of operation, for
22 instance arterial switch operations being carried out by
23 Mr Dhasmana rather than Mr Wisheart?
24 A. It is not something I particularly noticed, no.
25 Q. In the case of deaths following surgery, would you
0060
1 always have a discussion with the surgeon who carried
2 out the operation, apart from the meetings, the monthly
3 meetings? Would you have a separate discussion with the
4 surgeon?
5 A. Not always, no.
6 Q. When you did, at whose instigation would the meeting be
7 held?
8 A. Mostly mine.
9 Q. Why would you instigate a discussion in some cases and
10 not others?
11 A. There would be something that I was uncertain about,
12 where I needed clarification on.
13 Q. In order to help you to understand the cause of death?
14 A. In the end, yes.
15 Q. And to advise the Coroner as to whether or not there
16 should be an inquest?
17 A. I think that is putting the wrong context on it.
18 Q. What context should I put on it?
19 A. There would be, for example, a particular anatomical
20 lesion, shall we say, that I was uncertain of, or I was
21 uncertain of what they thought of it, and I would try to
22 clarify that in my mind. It would not necessarily be
23 something which I would consider being germane to the
24 cause of death, but to the case as a whole. So I think
25 that the discussion did not always influence or have the
0061
1 possibility of influencing whether I advised the Coroner
2 as to the cause of death.
3 Q. Before we move on to something else: the hospital
4 postmortem case, the purpose of which essentially is to
5 investigate what had happened to the patient in order to
6 learn more and hopefully improve matters for the future,
7 the instigation of such a postmortem would come from the
8 clinician, would it?
9 A. Yes.
10 Q. First of all they would have the idea that there should
11 be a postmortem because they, the clinicians, wanted to
12 find out more about the patient, and they would then
13 suggest to the relatives that consent might be given and
14 so on?
15 A. Yes.
16 Q. Is it right that the number of hospital postmortems has
17 declined markedly in recent years?
18 A. Among adults, yes. Among children there has been
19 a decline, but a marked decline I think is overstating
20 it.
21 Q. Let us take the adults, then. To what would you
22 attribute that decline?
23 A. People have written books about this. There are lots of
24 reasons. I do not know. There are many factors, one of
25 which is there is a reluctance I think on the part of
0062
1 medical staff to ask for them because they feel that
2 there is little to be gained by it.
3 Q. Might there be something to lose by it, for them?
4 A. That has been suggested in the American literature.
5 I am not sure I have ever seen that discussed in
6 a British context.
7 Q. The removal of tissue at postmortem is essentially
8 governed by the Human Tissue Act 1961?
9 A. Yes.
10 Q. And that provides a scheme by which body parts may be
11 removed after death on the authority of the person in
12 lawful possession of the body, either where the deceased
13 has requested it or where the deceased did not object
14 and neither does the surviving spouse or relatives?
15 A. Yes.
16 Q. I am not going to go into a legal exposition with you,
17 you will be relieved to know, but if we have a look at,
18 please, WIT 43/199 -- let us look at the next one,
19 WIT 43/123, please. This is an Appendix to Guidance
20 from the DHSS, we see in the top right-hand corner
21 "(HC(77)28)". That means it is published in 1977?
22 A. Yes.
23 Q. Can we have WIT 43/119, which is the beginning of this
24 same document? "Department of Health and Social
25 Security, Health Services Development, Removal of Tissue
0063
1 at Postmortem Examination, Human Tissue Act 1961."
2 If we go to paragraph 3, can I ask you to read
3 paragraph 3, please? (Pause).
4 A. Okay.
5 Q. That deals with the situation of removal of materials
6 from the body, but in a Coroner's postmortem case
7 materials will be removed typically under rule 9 of the
8 Coroner's rules in order to assist in the process of
9 establishing cause of death, which is what the Coroner
10 is interested in?
11 A. Yes.
12 Q. And no specific consent or any consent is required from
13 the relatives of the deceased in order to allow a rule 9
14 removal from the body?
15 A. That is my understanding, yes.
16 Q. So rule 9, the retention of tissue, organ or fluid, the
17 removal of tissue, organ or fluid which in the opinion
18 of the pathologist might have a bearing on the cause of
19 death, the initial removal of that material does not
20 need consent.
21 What happens once the cause of death has been
22 established in such a case and the Coroner is satisfied
23 that he has found the answer to the question he has to
24 ask himself?
25 A. In the case of hearts they were retained in the
0064
1 department.
2 Q. For how long, typically, if it is possible to say, would
3 it be necessary to retain the heart for rule 9
4 purposes? How many days or weeks?
5 A. I have no idea.
6 Q. Would it typically be a longer period than one would
7 expect to wait before a body would be buried or
8 cremated?
9 A. Yes.
10 Q. Which would be a matter of perhaps a week, or a few
11 days?
12 A. Yes.
13 Q. So it would be longer than that for rule 9 purposes?
14 A. Yes.
15 Q. So there would be no prospect of putting the heart back
16 into the body before burial or cremation in such a case,
17 normally?
18 A. Yes.
19 Q. What was your understanding, let us say when you arrived
20 in Bristol in 1993, as to who could potentially give
21 directions or instructions as to what should happen to
22 hearts retained under rule 9 once the Coroner's
23 investigations were complete?
24 A. The pathologist.
25 Q. It was up to you?
0065
1 A. That was my understanding, yes.
2 Q. So if you decided one day to dispose of the heart, you
3 could; if you wanted to retain it, you could?
4 A. That was my understanding, yes.
5 Q. If you were to have decided to dispose of a heart or
6 a number of hearts because they were no longer required
7 or something of that sort, you would not have to seek
8 permission or advice from anyone else?
9 A. No.
10 Q. To what extent did the Coroner, Mr Forrest, ever provide
11 you with instructions or advice or guidance as to what
12 you might do with material which had been retained under
13 rule 9?
14 A. I do not recall ever speaking to Mr Forrest on the
15 matter.
16 Q. In a rule 9 case, would he know at the time of the
17 postmortem what material had been removed from the body?
18 A. I do not know.
19 Q. But he would know as a Coroner that you could not do the
20 postmortem without removing the heart in a cardiac case?
21 A. Do you mean retaining the heart?
22 Q. Removing, initially?
23 A. Yes.
24 Q. He would know that?
25 A. He would know that, certainly, yes.
0066
1 Q. He would know that you could not conclude the cause of
2 death enquiries within a sufficient time for the heart
3 to be put back in the body?
4 A. I cannot say for certain whether he would know that.
5 Q. You would expect him to know?
6 A. I would expect him to know, yes.
7 Q. So you would expect him to know, if he thought about it,
8 that the heart must still be not in the body?
9 A. If he thought about it, yes.
10 Q. Did he ever have any contact with you at all about
11 rule 9 material in those circumstances, he having
12 concluded his enquiries?
13 A. No.
14 Q. To what extent did you understand your approach to be
15 shared by the other people within the pathology
16 department in Bristol?
17 A. There were differences of approach.
18 Q. Can you tell me about those?
19 A. Professor Berry was less certain about the right we had
20 to retain the heart.
21 Q. In a rule 9 case?
22 A. In a rule 9 case. In our guidance, you will see that it
23 states, even from the beginning, it is up to the
24 individual pathologist to decide whether the retention
25 is strictly necessary for establishing a cause of
0067
1 death. I took the view that it was. Professor Berry
2 took the view that it sometimes was not.
3 Q. Once a cause of death has been established --
4 A. Yes.
5 Q. -- the heart was retained thereafter?
6 A. Well, we had the heart in our possession, yes.
7 Q. Professor Berry was less sure of his ground in terms of
8 the justification for continued possession of the heart
9 once the cause of death was established; is that right?
10 A. I would not like to put words in his mouth. I think
11 that would probably summarise it, but you would have to
12 ask him what his exact view was.
13 Q. Can we look, please, at UBHT 308/50? This is a letter
14 from Dr Berry, as he then was, to Dr Parker at the
15 National Heart Hospital dated August 1986, well before
16 you came to Bristol:
17 "Thank you for your letter. I think it is
18 important that we should support your work as far as
19 possible. I see two difficulties. Firstly our Coroner
20 in Bristol will quite properly not allow us to take
21 tissues from cases in his jurisdiction without consent
22 of the relatives, which can usually not be obtained.
23 Secondly, my clinical colleagues have not allowed me to
24 change the form of our hospital PM request form to
25 include permission for removal of tissues for teaching,
0068
1 research or organ donation. I am sure you will have
2 encountered these problems before and I should be
3 interested to know how you dealt with them previously."
4 That is part of Dr Berry's concerns about changing
5 the hospital postmortem form --
6 A. Yes.
7 Q. -- about retention. And Dr Berry was always, as I think
8 we will see tomorrow, concerned that the hospital
9 postmortem form at Bristol did not make clear enough, as
10 far as he was concerned at least, that proper permission
11 was given under the Human Tissue Act for removal of
12 materials at postmortem.
13 So do I understand from your evidence that as well
14 as that, on a hospital postmortem, say, you at least had
15 the impression that he, Professor Berry, was also
16 concerned about the rule 9 position and presumably you
17 would know that Professor Berry was involved in the
18 Working Party which was engaged in contemplation of
19 guidelines dealing with retention; is that right?
20 A. I think it would be fair to say he had concerns, yes.
21 Q. Can we have UBHT 308/18, please? Scan down to the
22 bottom of the page, please. It is a letter from
23 Professor Berry to Mr Dhasmana. Let us go back up to
24 the top. August 6th 1992, so again, a little while
25 before you took up your post, but shortly before you
0069
1 were appointed.
2 Can I ask you to look at the paragraph just
3 disappearing off the page, please. (Pause).
4 A. Okay.
5 Q. If we take that letter as a whole, but particularly
6 perhaps there, that is the point, is it not? Professor
7 Berry is making the point that whilst there is no
8 difficulty, as he said in the previous paragraph, in
9 hospital postmortem cases because you have permission to
10 take samples of tissue for teaching purposes, in
11 Coroner's postmortems you have the difficulty that, as
12 he says in the paragraph beginning "when we last
13 discussed ...", the Coroner is only allowed to obtain
14 tissue for the purposes of establishing the cause of
15 death?
16 A. Yes.
17 Q. So "in future we will not be able to retain the heart
18 unless there is a signed statement in the notes from one
19 of the doctors looking after the child that they have
20 satisfied themselves that the parents of the child do
21 not object to the retention of tissue ...."
22 But such a system was not in place when you took
23 up your post in 1993, was it? In other words, in
24 Coroner's postmortem cases there was an absence of
25 a signed statement in the notes from one of the doctors
0070
1 saying they have been satisfied that the parents of the
2 child did not object to the retention of the tissue?
3 A. That is true, I have never seen such a statement.
4 Q. Did Professor Berry ever make you aware of this
5 discussion in correspondence with Mr Dhasmana?
6 A. Yes, he did mention it.
7 Q. And what did you or Professor Berry do in order to try
8 to institute the system that Professor Berry plainly
9 thinks here ought to be instituted?
10 A. We did raise it with the surgeons again, I recall. At
11 least once.
12 Q. With Mr Dhasmana?
13 A. I do not recall.
14 Q. Or Mr Wisheart?
15 A. I do not remember.
16 Q. Was it ever raised formally in meetings through the
17 management of the Trust?
18 A. I do not know.
19 Q. Would that be something that Professor Berry would take
20 the lead on?
21 A. Yes.
22 Q. As the head of the department?
23 A. Yes.
24 Q. We mentioned earlier but did not look at Professor
25 Knight's article. Just before we come to that, I think
0071
1 it is right I should show you WIT 54/974. This is
2 a letter to the Inquiry from Professor Alberti from the
3 Royal College of Physicians, who has given evidence
4 earlier this year.
5 Can we go over the page to 975? The second
6 paragraph:
7 "The Royal College of Physicians has taken a lead
8 in establishing guidelines in the practice of ethical
9 committees in medical research since first recommending
10 such ethical review in 1967 ... When the published
11 guidelines of 1984 were updated in 1990, specific
12 guidance concerning the use of discarded tissue was
13 included ..."
14 He explains that has been updated.
15 If we go to 978, the bottom of the page, look at
16 paragraph 13.20. This is the Royal College of
17 Physicians, and over the page when you are ready.
18 [54/979].
19 WIT 54/980, please, paragraph 8.28 is the updated
20 version of the same advice. (Pause).
21 A. Okay.
22 Q. Does that advice accord with your understanding of the
23 position?
24 A. Yes.
25 Q. So tissues removed at surgery or at autopsy could be
0072
1 used for research purposes?
2 A. Provided they were not taken primarily for the research
3 purpose.
4 Q. So if they were taken for rule 9 purposes originally?
5 A. Yes.
6 Q. Once a Coroner has finished, they could be used for
7 research purposes without recourse to an Ethics
8 Committee?
9 A. Yes.
10 Q. Professor Green from the Royal College of Pathologists
11 has given evidence to the Inquiry, Day 42, page 79. He
12 said that the College had taken the view that "material
13 left over, for example, the heel of a paraffin-fixed
14 block of tissue which has been used to determine the
15 cause of death, once a Coroner has discharged his
16 functions, he is functus officio, that piece of tissue
17 is in effect the property of the pathologist and the
18 department which has processed it."
19 Does that accord with your understanding?
20 A. Yes.
21 Q. And that it was permissible -- these are not his words,
22 I paraphrase -- to use the heel of that block for
23 research purposes, to use an organ for teaching purposes
24 or museum purposes, but that such material was
25 anonymised. In other words, the patient's name was not
0073
1 stuck on it?
2 A. Yes.
3 Q. Again, that is --
4 A. Yes.
5 Q. Professor Knight's article, UBHT 308/44, on the
6 right-hand side, published in the bulletin of the Royal
7 College of Pathologists in 1995.
8 The background was that a legal action had been
9 taken against a pathologist in a Coroner's postmortem
10 case. Concern had been expressed to the Forensic
11 Pathology Sub-committee and the standing Advisory
12 Committee; in Coroner's cases, retention of tissue for
13 teaching and research might not be covered by the
14 Coroner's permission. He was not empowered to give that
15 permission. I think Professor Knight gives the example
16 of the retention of pituitary glands from bodies in
17 growth hormone work.
18 Can you offer any assistance with the attitude of
19 pathologists to Professor Knight's concern as expressed
20 in this article about the legality of practice as it
21 then was?
22 A. I think Professor Knight at the very end of his article
23 says that it probably is not illegal but it may come
24 under media scrutiny. I think that is what he was
25 saying, if I interpret his article correctly.
0074
1 Q. Let us go over the page.
2 A. He is not actually questioning the legality of it.
3 Q. Let us look. If we go to the last paragraph on the
4 left-hand side:
5 "Apart from any potential legal consequences, the
6 alacrity with which the media seize upon any alleged
7 irregularities in relation to mortuaries and post mortem
8 matters in general, make it essential that all aspects
9 of autopsy procedure and retention of material are
10 conducted with the greatest discretion."
11 Let us put that together with the next document,
12 WIT 43/153. I will give you the context of this. Its
13 date is August 1989. Just take that from me, it is
14 August 1989. The source for that is WIT 43/8, but it is
15 not necessary to go to that. It is from the document
16 submitted I think by Professor MacSween, and it is an
17 extract from a Home Office newsletter, as we see. Can
18 I ask you to read paragraph 12?
19 A. Yes.
20 Q. Were you aware of this Home Office view in 1989?
21 A. Certainly.
22 Q. Did you understand the last sentence of that to be
23 referring to the example of taking pituitary glands from
24 a heart case?
25 A. Yes.
0075
1 Q. Or to the retention of rule 9 material after the Coroner
2 was finished?
3 A. I understood that paragraph to mean that one could not
4 take tissue for research or teaching purposes purely for
5 those purposes.
6 Q. So it would apply to my former example but not the
7 latter?
8 A. Yes.
9 Q. Is it right that the practice has changed in recent
10 years in terms of retention of a proportion of the
11 heart? Is it right that it is now possible to retain
12 a smaller portion of the heart than was previously the
13 case?
14 A. Yes.
15 Q. I think Mr Ross has suggested that that change of
16 approach did take place in a letter to the Inquiry.
17 I do not think it is necessary to show you that. What
18 is the change and why has it come about?
19 A. It was felt that there might have been objections to
20 retaining the heart for the purpose of diagnosis and
21 that not to retain the entire heart, to as it were make
22 a gesture in the direction of returning the heart to the
23 body, one would retain only that bit which was
24 absolutely essential to the establishing of the cause of
25 death. In other words, it is best to have the entire
0076
1 heart, but it probably can be done without the apex, the
2 muscular part of the heart. That is my understanding of
3 the thinking behind that. That has been, as
4 I understand it, the practice of Professor Berry since
5 I started here.
6 Q. I do not want to take you in detail through the steps
7 taken once the retention of a number of hearts at
8 Bristol came to public attention, which it did
9 essentially over the last year or thereabouts. Can
10 I just ask you to look at WIT 204/20, please,
11 paragraph 70? Again, say when you want to turn the
12 page. (Pause).
13 A. Okay. [WIT 204/21].
14 Q. We see you are mentioned. (Pause).
15 A. Okay.
16 Q. Do you agree with that paragraph?
17 A. I agree with it, certainly, yes.
18 Q. Is there anything you want to add about your role
19 specifically?
20 A. It is fair to say that the greater part of the work was
21 done by Professor Berry.
22 Q. Can I take you to Dr Russell's statement which we looked
23 at earlier? It is WIT 303 and the page number is 10,
24 paragraph 25:
25 "Dr Russell worked at Bristol for a period of
0077
1 about 18 months in the late 1980s. He attended a number
2 of clinical pathology meetings when he was in the
3 department. The purpose of the meetings was, as far as
4 I was concerned, educational. A case by case study of
5 deaths which had occurred with the purpose of trying to
6 identify any lessons to be learned from those deaths and
7 with the overriding objective of improving and
8 developing further clinical practice. Postmortem
9 findings were of course only a limited part of this
10 process."
11 Does that accord with your understanding of the
12 clinical pathologist meetings you attended roughly
13 monthly from 1993?
14 A. It does, yes.
15 Q. You were asked about this I think at the General Medical
16 Council last year?
17 A. Yes.
18 Q. You instituted a system which was for your own benefit
19 of taking very brief notes of these meetings?
20 A. Yes.
21 Q. The first one we have is UBHT 288/3. That is May 1993.
22 That was not actually the first meeting you attended but
23 it was the first one of which you made a note?
24 A. The first one of which I have a note, yes.
25 Q. And these meetings took place monthly on the second
0078
1 Wednesday of every month?
2 A. Yes.
3 Q. And they lasted for how long?
4 A. Between an hour and an hour and a half.
5 Q. Can we have WIT 204/7, please? Paragraph 21. (Pause).
6 A. Okay.
7 Q. Do you agree with that?
8 A. I do, yes.
9 Q. Let us go to page 12, paragraph 38. (Pause).
10 A. Okay.
11 Q. To what extent does that reflect the practice at the
12 meetings after 1993 when you were there?
13 A. I think that is my description of the meetings, is it
14 not?
15 Q. No, this is Professor Berry's statement.
16 A. It accords with my recollection.
17 Q. Let us take it carefully.
18 "Deaths following paediatric cardiac surgery were
19 reviewed at a monthly meeting in the x-ray department at
20 the BCH attended by paediatric cardiac surgeons,
21 cardiologists, anaesthetists, radiologists and
22 pathologists."
23 A. Yes. They were not attended by anaesthetists or
24 radiologists after I started.
25 Q. "The regular attenders were Mr Wisheart", he is
0079
1 a surgeon?
2 A. Yes.
3 Q. "Mr Dhasmana"?
4 A. Yes.
5 Q. "Dr Wilde", a radiologist?
6 A. He did not attend when I was there. He had another
7 meeting on a Wednesday afternoon and could not come,
8 although he did express several times a desire to come,
9 but other meetings precluded him from attending.
10 Q. What was his other meeting?
11 A. I do not know.
12 Q. "Dr Joffe and Dr Jordan and more recently Dr Martin and
13 Dr Hayes."
14 None of those are anaesthetists?
15 A. No, they are all cardiologists.
16 Q. These meetings that were taking place in your time from
17 1993 onwards were chaired by whom?
18 A. By me.
19 Q. And previously, as you understand it, by Professor
20 Berry?
21 A. That I understand, yes.
22 Q. And they were concerned only with paediatric deaths?
23 A. Only.
24 Q. They discussed, what, all the deaths for which the
25 relevant materials had become available since the
0080
1 previous meeting?
2 A. Yes.
3 Q. In other words, all deaths would be discussed at such
4 a meeting in the ordinary way?
5 A. Yes.
6 Q. Was there any reason why a particular death might not be
7 discussed at such a meeting?
8 A. If the surgeon was not there who would perform the
9 operation, it might be deferred to the next meeting, but
10 the heart would be brought along. I did not know until
11 I got there he was going to attend.
12 Q. So if you got the heart of X and the surgeon who treated
13 that patient was not there, discussion in that case
14 would be deferred until the next time when the surgeon
15 would be there, when the heart would again be there?
16 A. Yes.
17 Q. So surgeons would always attend the discussion of their
18 own patients?
19 A. Yes -- as far as I remember it.
20 Q. You were asked in some detail at the GMC why some
21 meetings were cancelled. These meetings were intended
22 to be held monthly?
23 A. Yes.
24 Q. And were held, with a few exceptions, monthly throughout
25 1993, 1994 and so on?
0081
1 A. Yes.
2 Q. And are still held today?
3 A. They have been subsumed into a paediatric intensive care
4 meeting.
5 Q. So who would attend such meetings now?
6 A. The intensivists, who are basically anaesthetists, the
7 cardiac surgeon, the cardiologist, the nursing staff
8 from intensive care, the pathologists, the juniors from
9 intensive care, pathology, cardiac surgery, cardiology.
10 Q. So all the people that would be involved at the type of
11 meeting that we were discussing earlier that is
12 contemplated as taking part in order to look at the
13 individual case and the management of the hospital as
14 a whole?
15 A. Yes. I do not recall the radiologist being there. I do
16 not think so.
17 Q. What would the nature of the discussion be at these
18 meetings?
19 A. I am sorry, which meetings are we now discussing?
20 Q. The meetings that you attended.
21 A. From 1993 onwards.
22 Q. Or the ones now. What is the difference?
23 A. The format is much the same. The clinical history is
24 presented usually by the cardiologist, together with
25 investigations. The surgery is discussed by the surgeon
0082
1 and the pathology was shown by or is shown by the
2 pathologist, and then the discussion followed as to what
3 had occurred.
4 There is a difference now insofar as I do not
5 bring the hearts to these meetings largely because it is
6 a much bigger audience and effectively we have no hearts
7 to bring.
8 Q. These meetings would typically take place after the
9 postmortem had taken place, obviously, and after you had
10 communicated with the Coroner?
11 A. Yes.
12 Q. So your advice to the Coroner about the cause of death
13 and whether or not there ought to be an inquest will
14 already have been given before these meetings would take
15 place?
16 A. Yes.
17 Q. So to the extent that in order to give your
18 recommendations to the Coroner you had to take advice
19 from the clinicians, that advice would be taken
20 elsewhere than in these meetings?
21 A. Yes.
22 Q. By a separate meeting or discussion --
23 A. Phone call.
24 Q. Can we have a look at the same page that we were on.
25 This is Professor Berry's statement, remember,
0083
1 paragraph 40. (Pause).
2 A. Okay.
3 Q. Do you remember any discussion at meetings you attended
4 of discussing the occurrence of subendocardial
5 myocardial infarction?
6 A. I do not recall it, no.
7 Q. Or any suggestion that it might be associated with long
8 bypass times?
9 A. No, I have no recollection of that.
10 Q. So no discussion as to whether or not this might be
11 a cause or effect of death?
12 A. No.
13 Q. Other than the people who attended these meetings, who
14 else would be aware of the nature of the discussions
15 that took place at them?
16 A. Nobody else, except in so far as people at the
17 discussion discussed it with them.
18 Q. The purpose of the discussion was to understand and to
19 learn so that the problems that had arisen could be
20 better dealt with next time?
21 A. Yes.
22 Q. So that lessons could be learned for the management of
23 future cases?
24 A. Yes.
25 Q. Can we have WIT 204/14, please, still Professor Berry's
0084
1 statement, paragraph 45:
2 "I have reflected on whether pathologists could
3 have recognised if there had been an excess mortality
4 rate from paediatric cardiac surgery at the BRI.
5 A pathologist might recognise that there was a problem
6 if there was a large unexplained discrepancy between the
7 mortality rates of different surgeons, or if there was
8 a consistent pattern of surgical error. This did not
9 appear to be the case."
10 Where for example one surgeon carried out one
11 operation and the other surgeon did not, there would be
12 no scope for comparing the mortality rates of different
13 surgeons in respect of that particular operation?
14 A. Yes.
15 Q. It must follow. Professor Berry refers to
16 a "consistent pattern" of surgical error. Were you
17 ever aware of a consistent pattern or an unusual pattern
18 of death in respect of cardiac patients?
19 A. No.
20 Q. I think the Inquiry has heard evidence recently from,
21 for example, Helen Stratton who works at Ward 5, Bristol
22 Royal Infirmary, that in 1993, I think it was, she at
23 least detected an unusual number of deaths.
24 A. I am sorry, who is Helen Stratton?
25 Q. She was the cardiac liaison nurse at Ward 5, Bristol
0085
1 Royal Infirmary, so she was the nurse in the ward.
2 A. She would have been aware of the number of cases being
3 done.
4 Q. She was aware of the number of cases being done, so she
5 was able to tell which percentage of patients died, for
6 example. You would not know how many cases were done?
7 A. No.
8 Q. You only know about the unsuccessful cases, I do not
9 mean that pejoratively, the number of deaths?
10 A. No.
11 Q. But you did not detect an unusual number of cases coming
12 across your desk, as it were, in 1992?
13 A. No, I did not.
14 Q. At these meetings you discussed earlier the pathologist
15 always being interested in trying to identify patterns
16 at postmortems.
17 It would be important at these meetings to keep
18 a check on to what extent knowledge was developing by
19 ensuring that the lessons that were intended to be
20 learned were learned?
21 A. Yes.
22 Q. To what extent was there an attempt at these meetings to
23 follow up what had happened before, in other words, at
24 the meeting in June, to say "This one looks similar to
25 the one we had back in February", or something of that
0086
1 sort?
2 A. I do not recall that ever being said.
3 Q. I am sorry, could I break off for a minute? I am told
4 I asked you a question a moment ago, "You did not detect
5 an unusual number of cases coming across your desk as it
6 were in 1992". If that is what I said, I intended to
7 say 1993, because you were not there in 1992.
8 A. The answer will still be the same.
9 Q. So it would have been possible, would it not, say in the
10 hearts of children who had died with the same condition,
11 given that all the hearts were retained, they were all
12 in the laboratory, it would be possible to compare the
13 anatomy of one patient with the anatomy of another?
14 A. Yes.
15 Q. So, for example, in the case of the arterial switch
16 procedure, it would be possible to look at the layout of
17 the coronary arteries in the different switch cases?
18 A. Yes.
19 Q. Simply by going to your laboratory and retrieving the
20 relevant samples?
21 A. Yes.
22 Q. Was that type of thing ever done at these meetings?
23 A. No.
24 Q. You were always looking simply at the one individual
25 case?
0087
1 A. Yes.
2 Q. With no link made to previous cases of the same
3 condition?
4 A. No.
5 Q. Nobody saying, "This is terribly similar to X last
6 month"?
7 A. No.
8 Q. So given that state of affairs, how was it possible to
9 tell whether or not the purpose of these meetings was
10 being fulfilled by lessons which were identified
11 actually being learned?
12 A. I do not know.
13 Q. There was no mechanism for checking up whether the
14 lessons were being learned?
15 A. There was no mechanism.
16 Q. And as we have discussed, these meetings did not have
17 any interface with any other aspect of the hospital;
18 there was no committee to which you reported or --
19 A. No.
20 Q. Can we have a look at the autopsy and audit document
21 again just very briefly, WIT 54/951; paragraph 4.4.
22 This is 1991:
23 "The responsibility for co-ordinating the scheme
24 should lie with District Medical Audit and Advisory
25 Committee, but the successful and continuing performance
0088
1 of such a scheme should be monitored and assessed by
2 visitors from various Royal Colleges when they visit
3 hospitals for training and accreditation purposes.
4 A successfully functioning autopsy audit procedure
5 should be an important criterion in such assessments."
6 What contact did you ever have with the Audit
7 Committee of the Trust or the audit machinery, aside
8 from these clinical pathology meetings?
9 A. I had none.
10 Q. Were you ever conscious of visits from Royal Colleges
11 monitoring and assessing the autopsy audit meeting, if
12 that is how it can be described, the clinical pathology
13 meetings you were at monthly?
14 A. No.
15 Q. Did you know Dr Bolsin?
16 A. I have never met him.
17 Q. Did you know who he was?
18 A. No.
19 Q. Did you know about the audit work that he was carrying
20 out over a period before these matters came to public
21 attention?
22 A. Nothing at all.
23 Q. How many anaesthetists undertaking anaesthesia in
24 paediatric cardiac surgery cases were you conscious of
25 meeting?
0089
1 A. Two, possibly three.
2 Q. Who were they?
3 A. There was Dr Pat Weir and there was Dr -- I cannot
4 remember her name, a female anaesthetist.
5 Q. Sally Masey?
6 A. Yes.
7 Q. Do you remember the context in which you met those two
8 people?
9 A. At clinical meetings. I cannot recall exactly which.
10 Q. Just before we conclude, Dr Ashworth, you remember I was
11 showing you the form for the witnessing of the signature
12 before the break?
13 A. Yes.
14 Q. Can you think of any good reason why there should not be
15 provision for the person who witnesses the signature to
16 print their name on the form?
17 A. No.
18 Q. And if I were to suggest that the system ought to be
19 that only the consultant or the Registrar should sign
20 and not anyone else, would you agree with that?
21 A. I think it would be commendable, yes.
22 Q. And that would assist the pathologist in understanding
23 that consent really had been obtained by a consultant or
24 a Registrar at the hospital?
25 A. Self-evidently, yes.
0090
1 MR MACLEAN: Dr Ashworth, those are all the questions I want
2 to ask you. There may be some questions in a moment
3 from the Panel. I do not think there is anything from
4 behind.
5 Before we turn to the Panel, is there anything
6 I have not dealt with that you think I ought to have
7 dealt with, or is there anything else you want to say
8 about any of the matters the Inquiry is concerned with?
9 If you do, then you have an opportunity to say so now.
10 No doubt the Chairman will remind you that you can also
11 do so in writing later.
12 Would you wish to say anything else at this
13 stage?
14 DR ASHWORTH: No.
15 MR MACLEAN: Thank you very much for your evidence,
16 Dr Ashworth. The Panel may have some questions.
17 THE CHAIRMAN: Dr Ashworth, Mrs Maclean, first.
18 Examined by THE PANEL:
19 MRS MACLEAN: Dr Ashworth, you have talked to us about the
20 two different kinds of cardiac pathology meetings which
21 you were involved with, the earlier ones where the
22 hearts were present, brought by you, but the
23 anaesthetists, nursing staff and other members of the
24 team were not, and the later meetings where the heart
25 was not present, but a larger group of these other
0091
1 people were there. Could you tell us a little about how
2 these two kinds of meetings differed in terms of value
3 for the learning process?
4 A. Learning for whom?
5 Q. Learning for the clinicians, the members of the team
6 dealing with future cases. Did you feel one was a more
7 valuable learning experience than the other, and if so,
8 how?
9 A. They are both valuable. I can only speak for myself,
10 really. For my own part, I found the former meetings
11 with the surgeons extremely valuable. I learned a great
12 deal from them. I now learn different things, more
13 about the intensive care aspects of these cases now than
14 I did formerly, but I do not learn so much from the
15 cardiac surgical point of view. I am sorry, I can only
16 speak for myself, I cannot speak for what other people
17 get from these meetings.
18 MRS MACLEAN: That is helpful, thank you.
19 THE CHAIRMAN: Professor Jarman?
20 PROFESSOR JARMAN: I just want to go back to the point where
21 you were asked by Mr Maclean whether you found it
22 surprising, in view of the findings of Russell and
23 Berry, that you had not found it necessary to suggest to
24 a Coroner that an independent report from another
25 clinician should be obtained and there had been only one
0092
1 inquest and you agreed to that, and then to refer to the
2 paper from Dr Gould, INQ 8/8, in which he says that
3 "pathologists conducting autopsies at the request of
4 a Coroner would not consider their role as one of
5 a hospital policeman".
6 It is difficult for doctors to report on other
7 doctors, as it were. Do you think there could be some
8 form of conflict of interest between your loyalty to
9 your colleagues on the one hand and the requirement to
10 act as an agent for the Coroner? That is the first part
11 of the question.
12 The second part is whether you think it would be
13 advisable if the pathologist acting as the agent for the
14 Coroner were independent of the clinicians in the
15 hospital. Would it make his or her life easier?
16 A. To take your first question, as regards conflict between
17 the duties of the Coroner and the relations with one's
18 clinical colleagues, I have not ever found a situation
19 where that had been the case. In fact it has been my
20 experience where I have found something which I was
21 concerned about at postmortem and I have discussed it
22 with my clinical colleagues, it is my interpretation
23 which has been wrong and I felt not theirs.
24 As regards an independent postmortem, well, one
25 loses straightaway the benefit of contact with the
0093
1 clinician, and also, it would be extremely difficult,
2 I think, in terms of logistics, if one were talking
3 about Bristol, if the nearest person competent to do an
4 examination of a child who died of congenital heart
5 disease would be Cardiff, Southampton, Birmingham. It
6 would mean transporting a child a long distance to
7 a mortuary to a pathologist who did not know the
8 clinicians, and I suppose could call them, but would
9 find it more difficult to get in touch with them.
10 So I am not so sure it would be a good idea.
11 Q. You mean it would not be very practical?
12 A. Yes, I beg your pardon.
13 Q. Do you think it might be a good idea if it were
14 practical?
15 A. I am not entirely convinced.
16 PROFESSOR JARMAN: Thank you.
17 THE CHAIRMAN: I have no questions, so if there is no
18 re-examination, may I, Dr Ashworth, thank you on behalf
19 of the Panel for coming this morning. We have been
20 greatly assisted by your evidence.
21 As Mr Maclean has made clear, if there are other
22 things that you would wish to bring to our attention,
23 then we are here for a while and we would be grateful to
24 receive anything that you think will further assist us,
25 but for this morning, at least, thank you very much
0094
1 indeed.
2 (The witness withdrew)
3 MR LANGSTAFF: Sir, it has been one of our shorter days
4 today. It may be one of our longer days tomorrow, when
5 we will hear during the course of the day from both
6 Professor Berry and from Mrs Michaela Willis.
7 THE CHAIRMAN: Thank you, yes, Mr Langstaff. Then we
8 adjourn and reconvene tomorrow morning at 9.30. Thank
9 you to everyone. Thank you, Mr Langstaff.
10 (12.35 pm)
11 (Adjourned until 9.30 am on Thursday, 23rd September
12 1999)
13
14
15 I N D E X
16
17 DR MICHAEL ASHWORTH (SWORN)
18 Examined by MR MACLEAN ...................... 1
19 Examined by THE PANEL ....................... 91
20
21
22
23
24
25
0095
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Published by the Bristol Royal Infirmary Inquiry, July 2001
© Crown Copyright 2001