Home Page Search Final Report Interim Report Evidence - Transcripts - Witness Statements - Submissions - CCNR Report and associated documents - Statistical Reports and associated documents - Background Papers - Expert Papers Inquiry Seminars About the Inquiry Help		Daily transcripts Hearing summary 6th October 1999 Hearings this week focus on evidence from Regional Health Authority and hospital staff commenting on the Bristol Services and the adequacy of the service provided.   Today the Inquiry heard from Dr Marianne Pitman, Public Health Consultant, South West Regional Health Authority (SWRHA). She told the Inquiry about the role of public health consultants within the SWRHA and the delegation of responsibilities for clinical specialties between them. She described the structure of the Regional Medical Advisory Committee and sub-committees. Dr Pitman then commented on the expectations of the Department of Health and Supra-Regional Services Advisory Group for expansion in cardiac services in Bristol, and she described the efforts of the SWRHA to achieve this, particularly in relation to referrals from Wales. She concluded by commenting on correspondence between herself and Mr Wisheart during 1992 in which the issues of outcome data and case mix were discussed.

FULL TRANSCRIPT

   1                     Day 58, 6th October 1999
   2   (1.10 pm)
   3   THE CHAIRMAN: Good afternoon, everyone. Good afternoon,
   4     Mr Langstaff.
   5            STATEMENT BY THE CHAIRMAN:
   6   THE CHAIRMAN: Before we begin, perhaps I could just mention
   7     one matter. I can report that I have received a letter
   8     from the Permanent Secretary at the Department of Health
   9     in which he apologises unreservedly on behalf of his
  10     department for the difficulties encountered by
  11     Miss Catherine Hawkins in preparing her evidence and the
  12     consequent inconvenience experienced by the Panel. We
  13     are grateful for the letter and hope there will be no
  14     repetition of any such breakdown in support and
  15     communication.
  16        Mr Langstaff?
  17   MR LANGSTAFF: Sir, for my part, I also have to follow up
  18     something that was said at the outset of the hearings
  19     earlier this week.
  20            STATEMENT BY MR LANGSTAFF:
  21   MR LANGSTAFF: On both Monday and Tuesday I have referred to
  22     the position of Dr Bolsin. To my horror, it was pointed
  23     out by him by e-mail from Australia that the transcript
  24     records that I referred to him as a "businessman". It
  25     is perhaps a testament to the quality of the

   1     stenographers that we have so few occasions in an
   2     inquiry of this length when words which sound very like
   3     other words are in fact mistranslated. What I had said
   4     was that he was a 'busy' man. It is easy to see how
   5     that became elided into "businessman", and it is also
   6     easy to see how such a description would give either
   7     offence or concern, or both, to a man who in fact is in
   8     full-time employment as a clinician.
   9        Lest there be any further concern in the reference
  10     which I made to his media commitments, that was of
  11     course a reference to the lectures which we understand,
  12     and have been told by him, that he undertakes, no doubt
  13     addressing the matters of clinical concern to him. It
  14     should not be regarded as being any wider in intent than
  15     that. If it was a misdescription, then I apologise and
  16     the fault is mine.
  17        Sir, it needs to be understood that of course he
  18     is a busy man, with, and I quote from what I had said
  19     earlier, clinical commitments.
  20        I should say, just following up what I said
  21     earlier about the likelihood of a video link, that
  22     arrangements have yet to be confirmed for that, and
  23     there remains, we hope, some possibility that Dr Bolsin
  24     will, despite his commitments, nonetheless be able to be
  25     here in person to give his evidence, and of course, to

   1     have it tested, as it needs to be to have full value, in
   2     the week beginning 15th November. That is a week that
   3     we have kept clear for some time, so that his evidence
   4     can be heard at the proper time.
   5        Hearing him in that week rather than at any other
   6     time is in order that other Health Service professionals
   7     may then be required to respond to the evidence that he
   8     is likely to give.
   9        We simply have, as it were, to watch this space to
  10     see what final arrangements one way or the other can be
  11     made, with, I am quite sure -- despite the
  12     mistranslation of him as a "businessman" when he was in
  13     fact a "busy man" on the transcript -- no doubt the
  14     full co-operation of Dr Bolsin.
  15   THE CHAIRMAN: Thank you, Mr Langstaff.
  16   MR MACLEAN: Sir, this afternoon's witness is Dr Marianne
  17     Pitman. Perhaps she could come to the chair, please.
  18        Could I ask you to stand, please, to take the
  19     oath?
  20         DR MARIANNE ALICE PITMAN (SWORN):
  21            Examined by MR MACLEAN:
  22   Q. Your full name is Dr Marianne Alice Pitman?
  23   A. That is right.
  24   Q. Before you were married, your surname was Pearce?
  25   A. That is right.

   1   Q. Can we look on the screen at WIT 317/1. If we see the
   2     whole page, that is the first page of a written
   3     statement that you have made to the Inquiry?
   4   A. That is right.
   5   Q. I think that statement was taken by the solicitors to
   6     the Inquiry in conjunction with yourself?
   7   A. That is right.
   8   Q. You having been provided with some relevant
   9     documentation by the Inquiry?
  10   A. That is correct.
  11   Q. Can we go to page 10, please. That is your signature,
  12     is it?
  13   A. That is right, yes.
  14   Q. That is the last page of your statement?
  15   A. Yes.
  16   Q. Have you read that statement through recently?
  17   A. Yes.
  18   Q. Is there anything in it that you want to change or add
  19     to?
  20   A. There are one or two grammatical errors, but that is
  21     because of the time-scale. Perhaps as we are going
  22     through it I can point them out. They were my errors.
  23   Q. There is nothing else of substance?
  24   A. No.
  25   Q. You worked for the Regional Health Authority throughout

   1     the period that the Inquiry is concerned with, 1984 to
   2     1995?
   3   A. Yes.
   4   Q. Within the Regional Health Authority, the boss, if you
   5     like, was the Regional General Manager; is that right?
   6   A. That is right.
   7   Q. Throughout the vast majority of the Inquiry's period,
   8     the Regional General Manager was Catherine Hawkins?
   9   A. Yes, that is right.
  10   Q. Between, I think, August 1984 and 1992?
  11   A. I think that is correct.
  12   Q. Your immediate line manager was the Regional Medical
  13     Officer?
  14   A. That is correct.
  15   Q. Or the Regional Director of Public Health. Those two
  16     terms are to be read interchangeably, are they?
  17   A. No, it depended where you were. Initially it was the
  18     RMO and it was changed to the Director of Public Health
  19     about the time when community medicine became public
  20     health medicine, which was roughly in the middle of the
  21     period.
  22   Q. The Regional Medical Officers were sequentially
  23     Drs Reynolds, Freeman and Mason?
  24   A. That is right.
  25   Q. Can you just help me by giving me an overall flavour of

   1     the role of the Regional Health Authority in the days
   2     before the purchaser/provider split and before NHS
   3     Trusts were introduced? What did the Region do?
   4   A. You may have had some of this already from Catherine
   5     Hawkins, but basically, there were a number of
   6     departments. The RGM was the sort of head of the
   7     officers of the RHA, but there was also a health
   8     authority with a chair. The regional team of officers
   9     were the executive officers and the lay members, who may
  10     have been drawn from clinical specialties as well as
  11     from other groups, were the non-executive directors
  12     intersect. Together they form the Health Authority.
  13        The Regional General Manager had a number of
  14     departments with the equivalent of directors at the head
  15     of them. One of them was community medicine or public
  16     health medicine, which also included pharmacy and dental
  17     advice, and the Regional Scientific Officer, who
  18     administered the scientific equipment budget for the
  19     Region, and that was things like linear accelerators,
  20     radiotherapy, and the larger pieces of investigational
  21     equipment, some of the catheterisation equipment.
  22   Q. Can I interrupt you for a moment? You naturally speak
  23     very quietly.
  24   A. I am not sure where to address my comments, that is why.
  25   Q. Could I ask you to speak up a little? I think you have

   1     a microphone on. Can I ask you to speak up a little
   2     bit?
   3   A. Okay, I will do my best.
   4   THE CHAIRMAN: It is a dilemma for our witnesses because
   5     they neither wish to disrespect us nor the more
   6     important person over there. The most important person
   7     is the person on your right, the stenographer, so if you
   8     speak to Mr Maclean, we will entirely understand.
   9   A. Okay. There were roughly five departments but there was
  10     also a Works Department, which I did not really mention
  11     in my statement; they were linked to capital planning.
  12     There was a Service Planning Department which I was much
  13     more closely involved with, and Human Resources, which
  14     was to do with training and also human resources across
  15     the Region, and a Finance Department. They were
  16     obviously very closely involved with services planning
  17     as well.
  18   Q. How did it come about that you became involved in
  19     cardiac services?
  20   A. I cannot remember the details but the Regional Medical
  21     Officer would, depending on how many people he had in
  22     his department in terms of not just public health
  23     consultants but also the other professional staff,
  24     allocate responsibilities to cover areas. It did not
  25     mean he or she would not necessarily also be involved in

   1     those areas, but we would do some of the routine work.
   2     If something needed to be done, if that person was
   3     there, he would go to that person first.
   4   Q. So it was a question of delegation from the Regional
   5     Medical Officer?
   6   A. That is right, yes.
   7   Q. How many "patches" did you have to keep a watch on?
   8   A. It varied from year to year. It depended on what the
   9     priorities were and how many other consultants there
  10     were in the department. For substantial periods of time
  11     I was the only consultant with the Regional Medical
  12     Officer, and at other times there were three
  13     consultants, so we had 30 specialties altogether, but
  14     the Scientific Officer would have looked after probably
  15     radiology and pathology and the Dental Officer would
  16     have looked after the dentists.
  17        So probably between us there would have been about
  18     25, but they were not all active, necessarily, at the
  19     time we were, each year. Sometimes, like in cardiac
  20     surgery, four or five specialties would be involved.
  21     It depended on the priority of the work, but it could be
  22     up to 10 groups.
  23   Q. Is it right that the key committee of the Regional
  24     Health Authority for our purposes was the Regional
  25     Health Authority Medical Advisory Committee and its

   1     various sub-committees?
   2   A. Yes. That was one of our key links to the profession.
   3   Q. Who would sit on the Medical Advisory Committee?
   4   A. The regional hospital one started off when I first went
   5     to the RHA with Chairmen of the various specialties'
   6     sub-committees, and then around the time that we knew
   7     the purchaser/provider split was going to happen, we got
   8     nominations from the shadow Trust as to a medical
   9     representative from each Trust, but the RMO was at pains
  10     to try and mix the specialties. There was also
  11     representation from primary care because they had their
  12     own separate committee in the latter part of the period.
  13   Q. So sitting on that committee would be people who worked
  14     for what were going to become providers, as well as
  15     people who worked for what were going to become
  16     purchasers?
  17   A. No. I think there was only one purchaser
  18     representative. I cannot remember but I do not think
  19     they were there all the time. I think it was latterly
  20     that they were there.
  21   Q. So the District Health Authorities had a minimal role to
  22     play in that committee?
  23   A. Yes, because the RMO had another committee of Directors
  24     of Public Health and I think, as far as I remember, what
  25     happened was that a representative of the DPHs sat on

   1     the sat on RHMAC, so they were like another
   2     sub-committee.
   3   Q. The Regional Health Authority Medical Advisory Committee
   4     produced a number of advisory statements, did it not,
   5     some of which were concerned with cardiac services,
   6     which we will look at in a moment.
   7   A. That is right.
   8   Q. How much of your time then was devoted to cardiac
   9     surgery and cardiology?
  10   A. Probably when the statements were being developed, say
  11     over a couple of months, a day a week, and that would
  12     include going to several sub-committee meetings. At
  13     other times it could be half an hour a week, or maybe
  14     a day because I had to go to a bigger meeting with the
  15     RMO.
  16   Q. Did this work mean that you became familiar with the
  17     clinicians who worked in that field?
  18   A. If I went to the sub-committees -- I remember going to
  19     a number of cardiac sub-committee meetings. I became
  20     familiar with the clinicians across the Region in that
  21     field. It depended on them which clinician they sent,
  22     so I would only really have known the sub-committee
  23     members.
  24   Q. So that would have included, would it, cardiologists and
  25     cardiac surgeons from Bristol?

   1   A. Yes, and radiologists.
   2   Q. So you would have known Dr Joffe and Dr Jordan?
   3   A. Well, I think it was Dr Joffe that was mostly on the
   4     committee, but Dr Jordan may have been at some time
   5     because they tended to rotate.
   6   Q. What about the surgeon representatives?
   7   A. I cannot remember the details, but initially it was
   8     Mr Keen, who I think retired quite early on, and was at
   9     one time Chairman of the committee. Then probably it
  10     was Mr Wisheart, for a period of time. Then I think it
  11     was Jonathan Hutter who came latterly. I do not
  12     remember Mr Dhasmana being on that committee, but he may
  13     have been.
  14   Q. This sub-committee of the Medical Advisory Committee was
  15     not concerned specifically with adults or with
  16     paediatric cases; it was concerned with both?
  17   A. It was concerned with heart disease of all types.
  18     It was to a great extent concerned with adults because
  19     there was a deficit in the service in the Region.
  20     The other forum in which there would have been some
  21     discussion about cardiology and cardiac problems in
  22     children was the paediatric sub-committee.
  23   Q. Did you sit on that, or attend that?
  24   A. I attended it when I could.
  25   Q. Just so that the Inquiry has it right in terms of the

   1     different health authorities that existed, rather
   2     confusingly, at different times throughout the Inquiry's
   3     period, can I take you, please, to the statement of
   4     Pamela Charlwood, who is the Chief Executive of the Avon
   5     Health Authority, at WIT 38/5.
   6        Can I ask you to read, please, paragraphs 3 and 4
   7     on that page? (Pause). Have you read that?
   8   A. Yes, thank you.
   9   Q. You agree with that, do you?
  10   A. I was trying to work out whether it really was 11
  11     district health authorities, but ... it was certainly of
  12     that order.
  13   Q. Let us go over the page, page 6. Can you look, please,
  14     at paragraphs 6 and 7? (Pause).
  15   THE CHAIRMAN: Did you ask for paragraphs 6 and 7, not (vi)
  16     and (vii)?
  17   MR MACLEAN: Paragraph 6 deals with the institution of
  18     Trusts under the National Health Service Community Care
  19     Act 1990 and the UBHT which, as we know, came into being
  20     on 1st April 1991.
  21        Then paragraph 7, the Bristol & Weston District
  22     Health Authority was abolished on 1st October 1991 and
  23     that old authority combined with Frenchay and Southmead
  24     district health authorities into the new Bristol and
  25     District Health Authority; right?

   1   A. Yes.
   2   Q. Then if we go over the page again, please, page 7,
   3     paragraph 8(ii):
   4        "During the life of the Bristol and District
   5     Health Authority, the government determined a further
   6     reorganisation of health authorities by the amalgamation
   7     of district health authorities and family health service
   8     authorities and the abolition of the regional health
   9     authorities."
  10        Then Ms Charlwood says:
  11        "For the reasons I have mentioned in paragraph 1.1
  12     above, Bristol and District Health Authority and the
  13     Family Health Services Authority, the Avon Family Health
  14     Services Authority, decided to anticipate that
  15     legislation and made arrangements under its remit
  16     jointly under the name of Avon Health Commission in
  17     order to conduct business, with the Commission's
  18     decisions being ratified by formal meetings of the two
  19     authorities."
  20        Then she mentions legislation. So from 1st April
  21     1996 -- over the page again to page 8 -- the South West
  22     Regional Health Authority was abolished. So was the
  23     Bristol and District Health Authority. The South and
  24     West regional office of the NHS Executive was created.
  25     So was the Avon Health Authority, which Pamela Charlwood

   1     remains the Chief Executive of; is that right?
   2   A. Yes. Certainly the regional part is. I do not have the
   3     memory to remember about the Commission, I am afraid.
   4   Q. So the Avon Health Authority is essentially, for our
   5     purposes, the successor to the Bristol & Weston Health
   6     Authority which existed through the 1980s, and the
   7     Regional Health Authority, which was abolished at this
   8     time, as it were, disappeared into the South and West
   9     Regional Office of the NHS executive?
  10   A. Yes. There was a step in-between where we took on part
  11     of the old Wessex region. It is not actually included
  12     in this.
  13   Q. That was in 1994?
  14   A. Yes.
  15   Q. What was the impact of that?
  16   A. It did not quite double the population the office was
  17     responsible for, but it was pretty well doubled, so we
  18     had something over 6 million people in the population.
  19   Q. I think the South Western Regional Health Authority merged
  20     with the Wessex region in 1994?
  21   A. That is right. That was to form the South and West RHA.
  22   Q. Did you retain the position you had held before that
  23     merger took place?
  24   A. We were slotted in. It was a concept the NHS had of
  25     trying to match people against similar jobs, so 75 per

   1     cent of the job had to be similar for you to be slotted
   2     in. If there were other people who could claim the same
   3     job, there was then a competition; or if the job was
   4     less than 75 per cent the same, there was an external
   5     competition. But the job that I had was reckoned to be
   6     more than 75 per cent similar.
   7   Q. So you, as you put it, slotted into a very similar job?
   8   A. Yes.
   9   Q. In the new merged authority?
  10   A. Yes.
  11   Q. And working still for the same boss?
  12   A. From year to year it varied, and by then it was not
  13     exactly the same. I was very closely involved with
  14     cancer services from the late 1980s, and that gradually
  15     became a much greater part of my job.
  16   Q. What was the role of the regional office of the NHS
  17     Executive?
  18   A. It was different in that it did not have a health
  19     authority, so there were only civil servants in the
  20     regional office, in effect.
  21   Q. No doctors?
  22   A. No, some of the civil servants are doctors, but we were
  23     civil servants and not members of the NHS in the same
  24     way, and we were not responsible to the Health
  25     Authority; we were responsible to the Secretary of

   1     State, obviously through the various tiers.
   2   Q. What was the difference between that and the regional
   3     outposts?
   4   A. They were set up about the same time, I think, as the
   5     Trusts were separated from the health authorities, to
   6     performance manage the Trusts, and they were directly
   7     responsible to the Secretary of State.
   8   Q. So the regional outposts had a role vis-a-vis the
   9     Trusts, but not a role in connection with the Regional
  10     Health Authority?
  11   A. There was liaison between them. They were based in
  12     Bristol. I do not remember the details, but there may
  13     have been slightly different boundaries. For our
  14     purposes, our regional outpost was in Bristol.
  15   Q. The regional outposts have been described to the Inquiry
  16     by Steve Boardman, who was originally one of the
  17     directors of the Trust, as being "very low profile".
  18     Is that a description you would recognise of the
  19     regional outposts?
  20   A. They were at my level within the RHA, but I cannot say
  21     what the profile would have been at Miss Hawkins' or
  22     Dr Mason's level.
  23   Q. But for you they were low profile?
  24   A. Yes, because they did not contain medical advisory
  25     staff. That was the main reason.

   1   Q. Can we move to supra-regional services? As you know,
   2     Bristol was designated as a supra-regional centre for
   3     neonatal and cardiac surgery in 1984. What did you
   4     understand the selection criteria to be for that
   5     nomination in Bristol?
   6   A. It was fairly early on in the development of the
   7     supra-regional services that neonatal and infant cardiac
   8     surgery up to 1, in effect, were included in the list.
   9     So far as I can remember, the department put out feelers
  10     as to places that might be interested in being
  11     recognised. One of the conditions was that they should
  12     serve more than their local regional population -- it
  13     was to be truly supra-regional but there would not be
  14     one in every region. Certainly in the later returns
  15     they had to enumerate the number of patients that they
  16     treated and what they anticipated treating in future.
  17   Q. That would explain why there might be a supra-regional
  18     service for neonatal and infant cardiac surgery, but why
  19     did you understand Bristol to be selected as one of the
  20     centres?
  21   A. I was not intimately involved with the very early
  22     stages. I think it went through the RGM who would have
  23     been somebody prior to Miss Hawkins. I think first of
  24     all it would have been informal and then they would have
  25     set up a draft list and then tried it out informally on

   1     the RHA and the health authorities to see whether they
   2     agreed that it would be helpful or whether they wanted
   3     to send patients to centres elsewhere, because Oxford
   4     did not have a centre at that time.
   5   Q. These feelers that were put out by the department: they
   6     would be put out to the Regional Health Authority, would
   7     they?
   8   A. That is what I anticipated. I was not actually in line
   9     with that, but I remember, when they set up the eye
  10     bank, which was a supra-regional service in the Eye
  11     Hospital, that there was a statement of interest by the
  12     clinicians and the managers of the Eye Hospital that
  13     they had something which they recognised was a service
  14     that was wider than the regional service. What
  15     I anticipated was that the RGM facilitated a dialogue
  16     and eventually the forms to be filled would appear, but
  17     there would have been a discussion in the supra-regional
  18     forum about whether they wanted to consider that
  19     specialty, which we would not have taken part in, or
  20     I would not have taken part in.
  21   Q. So the clinicians would say, "We have a potentially
  22     supra-regional service and we think we ought to be
  23     designated as a centre", and would then effectively
  24     lobby the Region to put their name forward to the
  25     Department, who would then choose from the list that was

   1     submitted from the different regions?
   2   A. Or it could have come the other way, because the
   3     Department had medical advisors who would have spotted
   4     specialties that needed development in a supra-regional
   5     setting.
   6   Q. But you cannot help us with precisely why Bristol was
   7     designated?
   8   A. No. I think -- no, I have no idea.
   9   Q. The South West Regional Health Authority had a Cardiac
  10     Surgery Working Party already by 1984?
  11   A. I think that was probably linked to knowing that
  12     supra-regional funding was there.
  13   Q. Can we look at HA(A) 95/4? This is the notes of the
  14     Working Party. If we just scan down the page, just stop
  15     at the people present, please. You are the fourth name
  16     down there, are you not, Dr MA Pearce?
  17   A. Yes.
  18   Q. Who was Mr Everest?
  19   A. He was the chair. He came I think from either Capital
  20     Planning or Service Planning, but he was an
  21     administrator/manager in the RHA.
  22   Q. We see from the Bristol & Weston Health Authority,
  23     amongst others, Dr Joffe, Mr Nix, Dr Wilde and then two
  24     surgeons, Mr Keen and Mr Wisheart; and Dr Jordan sent
  25     his apologies?

   1   A. Yes.
   2   Q. If we go to page 8, please -- just before we look at
   3     this page, what is your recollection of the position
   4     about throughput of paediatric cases in Bristol in 1984
   5     at the time when designation first took place?
   6   A. That it was relatively small for a supra-regional centre
   7     because the population served was not much more than
   8     a regional population.
   9   Q. What were the bits outside of the Region which were
  10     served by the centre?
  11   A. Gwent and Wiltshire, because Bath was outside the
  12     Region, so Bath was included within Wiltshire.
  13   Q. So essentially the South West region, plus Gwent plus
  14     Bath?
  15   A. Yes, the middle to north part of the South Western
  16     region.
  17   Q. And what about the rest of the South West region?
  18   A. For a long period, I think from probably the beginning
  19     of the start of services in London, patients were sent
  20     to London and to Southampton because that centre was set
  21     up prior to the Bristol one. What I am saying to you is
  22     hearsay because I was not actually around when the
  23     Southampton centre was set up or the Bristol centre, but
  24     what they said to me was that they had a long history of
  25     sending patients to Southampton and prior to that, to

   1     London.
   2   Q. Southampton was outside the South West Regional Health
   3     Authority's area; it would be in Wessex?
   4   A. It was in Wessex, yes.
   5   Q. Did the Regional Health Authority ever try to persuade
   6     the southern part of the region to stop sending its
   7     patients to London or to Southampton and start sending
   8     them to Bristol instead?
   9   A. I do not think I can answer that because I cannot answer
  10     for the regional team of officers and the discussions
  11     that they had.
  12   Q. Would that be something you would have expected the
  13     Region to have done, to want its own Region to send its
  14     patients to the supra-regional centre located within
  15     that Region?
  16   A. No. The regional boundaries were set up for
  17     administrative purposes rather than for health
  18     purposes. No, there was always going to be travel
  19     across regional boundaries.
  20   Q. I think we are getting quiet again. We are having
  21     a discussion between ourselves. The audience, I think,
  22     is struggling to hear what we are saying.
  23   A. I will try harder. I am having some difficulty hearing,
  24     I think because it is vibrating a bit.
  25   Q. Can we scan down that page, please? 4.1.4:

   1        "Throughput of paediatric cases. Observations to
   2     be discussed at next meeting of Working Party.
   3        "It was agreed that these considerations (which
   4     formed part of the adult/paediatric cardiology package)
   5     should be brought to the attention of the project team
   6     on 13th February 1984."
   7        The action there was Mr Everest, the Chairman. Do
   8     you remember what that was all about?
   9   A. Can we go back up the page a bit (page scrolled) and
  10     back down. I think it was to do with the BRI and trying
  11     to get the ... because it was cardiology. I think it
  12     was to do with trying to get the catheterisation
  13     situation sorted out.
  14   Q. To get the cath' lab at the Children's Hospital?
  15   A. Yes.
  16   Q. Can we look at WIT 74/565, please? This is a letter to
  17     you from Dr Baker dated 1st March 1984. If we go to the
  18     bottom of the page, we see Dr Baker was Acting District
  19     Medical Officer at the Bristol & Weston District Health
  20     Authority.
  21        If we look at the text of that letter, you had
  22     prepared a draft discussion paper on open paediatric
  23     cardiology and surgery. You replied to this letter at
  24     HA(A) 95/69. I want to look at the penultimate
  25     paragraph:

   1        "With regard to the funding arrangements for the
   2     expansion, we do not yet know what form they will take."
   3        That is the expansion of cardiac services.
   4        "At the moment, the expansion of up to 600 cases
   5     is inclusive of paediatric cases because it was
   6     considered that they would increase markedly in the
   7     short term. However, if the population increases under
   8     supra-regional arrangements, this may need to be
   9     reassessed, or if any children who are not at present
  10     operated on are included, this may again lead to
  11     reassessment."
  12        What was the reason why it was considered that
  13     paediatric cases would increase markedly in the short
  14     term? Who considered that that would be the case?
  15   A. I think it was one of the options that we were
  16     discussing within the RHA, that it might increase.
  17   Q. How was that going to happen if the southern part of the
  18     region was going to keep sending its patients to
  19     Southampton or to London and if it was only the rest of
  20     the South Western region plus Gwent plus Bath that was
  21     sending patients to Bristol? Why should there be
  22     a marked increase, in the short term, of paediatric
  23     cases?
  24   A. It would really be if the Welsh Office decided they
  25     wanted the patients to come in to.

   1   Q. So this is an anticipated increase from Wales?
   2   A. As far as I remember.
   3   Q. Can you help me then with the next sentence:
   4        "If the population increases under supra-regional
   5     arrangements, this will need to be reassessed."
   6        What does that mean?
   7   A. I think there were moves by the supra-regional forum
   8     that the populations for the units which they were
   9     serving should be as large as possible, and as I said
  10     before, Oxford did not have a service in its own
  11     region. I think there were discussions also with Oxford
  12     about what was going to happen there, but I was not
  13     party to that.
  14   Q. You mean Bristol had its eye on getting patients from
  15     Oxford?
  16   A. I cannot answer that. I do not know whether Bristol
  17     itself made overtures, but certainly the RGMs would have
  18     discussed the position across not only the Welsh Office
  19     but neighbouring regions.
  20   Q. So the Regional General Manager in this area would have
  21     had discussion with other Regional General Managers for
  22     areas which did not have a supra-regional centre? Would
  23     that be right?
  24   A. Yes. They would have met with other Regional General
  25     Managers on a regular basis.

   1   Q. There was no Regional Health Authority in Wales?
   2   A. That is right.
   3   Q. So who was the equivalent of the Regional General
   4     Manager in Wales? Who would Catherine Hawkins want to
   5     talk to in Wales?
   6   A. I do not know. I would anticipate she would talk to
   7     both the Welsh Office and certainly South Glamorgan, as
   8     it was a teaching authority.
   9   Q. That is Cardiff, essentially?
  10   A. Yes, that is right. I do not know what other
  11     arrangements they had to link together the health
  12     authorities. They may well have had their own
  13     arrangements.
  14   Q. Let us have a look at WO 1/124, please. Do you remember
  15     this document, the Bristol & Weston Health Authority
  16     Strategy for Neonatal Care?
  17   A. I did not until I was given a copy of that by
  18     Mr Whitehouse.
  19   Q. But you have seen this copy?
  20   A. Yes, I have read it recently.
  21   Q. So this is not a regional document, it is a Bristol
  22     & Weston document?
  23   A. Yes.
  24   Q. It is covering an eight-year period. It is dated
  25     I think, if we look down the page, May 1986.

   1        Can we go to page 129, paragraph 3.3? There is
   2     reference made there to targets, surgical targets. We
   3     see in the fourth line:
   4        "Services have surgical targets for children of
   5     all ages of 180 open procedures at the BRI and 70 closed
   6     procedures at BCH..."
   7        Who would have set those surgical targets?
   8   A. I think they originally would have been discussed by the
   9     Health Authority with the clinicians because they would
  10     have wanted to draw information from other units and the
  11     clinicians would have had access. They would probably
  12     have been discussed with us, but as it is a Bristol
  13     & Weston document, they would have set the targets
  14     themselves.
  15   Q. And they would have been based on what? On the
  16     population in the catchment area and the prevalence of
  17     heart disease among the population?
  18   A. On the best information they could get their hands on at
  19     the time.
  20   Q. So those targets would be district targets?
  21   A. Well, they are certainly in a Bristol & Weston document,
  22     and whether this is a daft document or one that has gone
  23     to the Health Authority, I am not sure.
  24   Q. Let us look at paragraph 4.3, page 131.
  25        "Resources for neonatal cardiology and cardiac

   1     surgery will be made available as these services expand
   2     to meet regional targets. The revenue requirements have
   3     to be kept to agreed average costs nationally."
   4        So there is a reference to regional targets. What
   5     sort of targets did the Region set?
   6   A. There are some other papers with a number of options in
   7     them, and they would have been very similar because we
   8     would have got the advice from some of the same sources.
   9   Q. But targets about what? Targets about number of
  10     operations?
  11   A. They are likely to be targets about catheterisations and
  12     operations.
  13   Q. So the Region said there should be X catheterisations
  14     per year and Y operations per year?
  15   A. In fact I think what happened was, there were a number
  16     of options in the documents that were discussed.
  17   Q. You see, what I am trying to get at is what is the
  18     relevant hierarchy of target setting?
  19   A. Right.
  20   Q. If somebody sets a target, then one might expect if the
  21     target is not met there is some sanction for missing
  22     a target or somebody checking whether the target has
  23     been met.
  24   A. I think there would not just have been clinical targets,
  25     there would have been financial and other targets in

   1     there. They are likely to have said, "Given a certain
   2     amount of resource, we can provide a certain amount of
   3     service".
   4   Q. Let us go back to page 125. Perhaps it will put it in
   5     a little more context.
   6        "This strategy takes into account the state of the
   7     present services, future demands, resource requirements
   8     and the policies of the District and Regional Health
   9     Authority."
  10        Then you see in the third paragraph:
  11        " ... the District Health Authority, in following
  12     Regional policy guidelines, has advised that in the
  13     present financial circumstances of the district, no
  14     additional district resources can be put to acute
  15     services ...", etc.
  16        If we scan down the page:
  17        "The strategy has been accepted as one which takes
  18     into account the regional commitment to provide adequate
  19     facilities for the intensive care of infants and
  20     consultation with neighbouring authorities if
  21     necessary ..."
  22        So that would all tend to suggest that the Bristol
  23     & Weston document was subservient to overarching targets
  24     set by the Regional Health Authority and that the
  25     District was constrained by the policies of the Regional

   1     Health Authority in what it could or could not do?
   2   A. For infants it would have been set by the supra-regional
   3     group because they would have set the level of finance
   4     they were prepared to give against a number. This is
   5     talking about infants, in the less than one year.
   6   Q. Leaving that exceptional group aside, what I said was,
   7     generally speaking, the position?
   8   A. Yes. To me, the regional target is something which has
   9     gone through the RHA, it is a commitment. The regional
  10     guideline is something that officers within the
  11     authorities would have discussed and aimed to achieve.
  12   Q. The Region held the purse strings, did they not?
  13   A. It had the overall budget, but health authorities had
  14     some, as you suggested on the acute side, in deciding
  15     how they spent their budget.
  16   Q. But for the major development of a major service,
  17     especially a service serving a Region or an area greater
  18     than a Region, it was not something that a District
  19     Health Authority could embark upon without specific
  20     support from the Region?
  21   A. Yes. They would certainly have had support from the
  22     Region. I am not sure how the Regional Finance Officer
  23     would have carried out his discussions, what sort of
  24     levels were expected and what would happen if they did
  25     not met them, so far as the finance was concerned.

   1   Q. If there were targets for operations, catheterisations
   2     or full-blown operations set by the Region, amongst
   3     others, what happened if those targets were not met?
   4   A. That was what I explained to you, that there were
   5     a number of people involved. It would have been
   6     a regional team of officers, the Regional Finance
   7     Officer and probably the RMO and others who were
   8     involved like the Service Planning Officer who decided
   9     at what level they should be encouraging the District,
  10     and districts at that time were encouraging their units
  11     to hit those targets or guidelines.
  12   Q. Did the Region have any role itself in encouraging -- if
  13     for example the target was missed in a particular year,
  14     could the Region do anything itself positively to try to
  15     ensure the target was met the following year by, for
  16     example, trying to persuade those places in the Region
  17     which sent its work elsewhere to send its work to the
  18     centre within the Region?
  19   A. It would have first enquired of the district in question
  20     why they thought they were not hitting the target. If
  21     that appeared to be something they had included within
  22     the options as to how they might hit the target, yes,
  23     they might in the reviews of districts, but I was not
  24     directly involved in the reviews. I do not know how
  25     that was handled.

   1   Q. You got a letter, I think, from the Supra Regional
   2     Services Advisory Group which said that the Department
   3     was anxious to encourage referrals being made to
   4     Bristol. Just let me find the reference for that. We
   5     will come to it; it is in here somewhere. As far as
   6     Wales was concerned, when Bristol was designated there
   7     was potential, was there not, for Cardiff to be
   8     designated as a supra-regional centre?
   9   A. I cannot tell you that. I do not know what the
  10     arrangements were in the Welsh Office.
  11   Q. In your statement at paragraph 34, you say that it was
  12     clear that both Cardiff and Bristol could not be
  13     designated given the available population in the South
  14     Western Region and South and West Wales?
  15   A. What I was meaning was, I think the Welsh Office had
  16     a different arrangement for recognising supra-regional
  17     centres and, yes, the populations were quite small
  18     compared to larger regions in the north, or in London,
  19     and a joint arrangement was suggested later as one of
  20     the options.
  21   Q. There was some confusion as to whether or not Welsh
  22     children sent to Bristol were within or without the
  23     supra-regional arrangements; is that right?
  24   A. That is right, yes.
  25   Q. Let us look at HA(A) 29/60. This is a letter from you

   1     to Dr Baker. He was then Acting District General
   2     Manager?
   3   A. Yes.
   4   Q. You had had an enquiry from a Dr Skone in South
   5     Glamorgan, which was Cardiff?
   6   A. That is right.
   7   Q. His reply is at HA(A) 29/59. He says:
   8        "I think it is critical that the service given
   9     from Bristol relates to the supra-regional catchment
  10     population for which we are funded. If you are advising
  11     me that South Glamorgan lies outside this catchment
  12     population, then I think we would have to ask Dr Skone
  13     and his authority to be quite explicit about their
  14     service requirements in order that this can be costed
  15     and an appropriate direct revenue and capital charge
  16     made upon them. Perhaps you could confirm whether or
  17     not South Glamorgan lies within the supra-regional
  18     catchment population and if they lie outside, whether or
  19     not the Region would be happy to encourage a direct
  20     charging mechanism made for any services required by
  21     South Glamorgan."
  22        In other words, "Are we going to charge South
  23     Glamorgan for neonatal and infant patients sent to
  24     Bristol?"
  25        Your reply is HA(A) 29/58, 20th October 1986.

   1     You say:
   2        "As I understood it, the supra-regional units were
   3     expected to take up infants they were offered from
   4     whatever region and that Wales was included for this
   5     purpose as a region."
   6        In other words, you do not get any extra money
   7     with patients coming from Wales as opposed to coming
   8     from along the road in Bristol; right?
   9   A. Yes. It was related to the number of infants they
  10     actually treated.
  11   Q. Exactly. You also wrote to the Supra Regional Services
  12     Advisory Group on the same day to check the position,
  13     did you not? UBHT 62/213. It was the next day you
  14     wrote, actually. This is a reply from Anthony Hurst,
  15     who was the Administrative Secretary at the beginning of
  16     the period of supra-regional services. If we go up the
  17     page again:
  18        "Dear Dr Pitman,
  19        "Thank you for your letter of 21st October ..."
  20        Then he essentially says what you have said to
  21     Dr Baker in the first large paragraph. Then he says
  22     this:
  23        "Having said that, I confirm that when the
  24     decision was made to designate Bristol as
  25     a supra-regional centre for neonatal and infant cardiac

   1     surgery, it was anticipated that it would treat babies
   2     referred from South and West Wales. The supra-regional
   3     procedures would have enabled us to allocate additional
   4     funds to the Bristol centre as the workload increased.
   5     We are anxious to do what we can to encourage referrals
   6     from Wales because we would like to see activity levels
   7     in Bristol rise, but there is no mechanism which enables
   8     us to influence clinicians, particularly Welsh ones,
   9     since health services in Wales are not a DHSS
  10     responsibility."
  11        So he would like the numbers to go up, but there
  12     is not a lot he can do about it is what he is saying.
  13        Having received that letter, what did you draw
  14     from that paragraph, that penultimate paragraph of the
  15     letter?
  16   A. In what way?
  17   Q. What impact did that have on you, the Department saying
  18     they were anxious to do what they could to encourage
  19     referrals from Wales?
  20   A. I am sorry, I cannot remember. I would obviously have
  21     given the letter to Ian Baker, but what other actions
  22     I took I would have discussed, I am sure, with the RMO
  23     and probably with people in the other parts of the
  24     regional office, such as finance and planning.
  25   Q. We may have touched on this earlier, but the Department

   1     is saying it would like to encourage referrals, but they
   2     cannot influence clinicians.
   3        Did the Regional Health Authority also want to
   4     encourage referrals to Bristol?
   5   A. They were certainly in support of a continuing dialogue
   6     with Wales, which would mean, yes, they did want to
   7     increase their number of referrals.
   8   Q. What was the mechanism by which the Region could bring
   9     about an increase in referrals?
  10   A. Initially, the Regional Medical Officer would have
  11     talked to the Chief Medical Officer for Wales, which was
  12     what was happening at the time.
  13   Q. Dr Crompton?
  14   A. Yes, by then, yes.
  15   Q. So essentially, it was a process of exhortation, was it,
  16     from the Regional Medical Officer to the Welsh Medical
  17     Officer, saying, "Please send your patients to
  18     Bristol"?
  19   A. I am not sure it was necessarily in those terms, but
  20     there would have been a continuing dialogue where the
  21     Welsh Office stood.
  22   Q. I am still slightly puzzled as to why the South West
  23     Regional Health Authority should be going to all this
  24     trouble in trying to attract business from Wales that
  25     for a long time had been going elsewhere, and yet still

   1     saw a large part of its own area sending patients to
   2     Southampton and to London?
   3   A. I think in fact that it was not that we were necessarily
   4     trying to divert patients, but there was an increasing
   5     need because the cardiologists were able to investigate
   6     more efficiently and the surgeons were able to treat
   7     more effectively as well, so the numbers were going to
   8     increase anyway.
   9   Q. It must have been diverting from somewhere?
  10   A. No, not necessarily. They could do more for small
  11     babies. It came at a time when there were improvements
  12     in equipment and treatment.
  13   Q. If there was an established referral pattern in the
  14     South West Region, there would also be an established
  15     referral pattern in those parts of Wales that did not
  16     send people to Bristol, and yet the focus seems to be on
  17     garnering business from Wales rather than making sure
  18     that the South West Region sent its patients to its own
  19     supra-regional centre?
  20   A. Well, I can only conclude that there had been
  21     discussions right at the beginning, as Mr Hurst implies,
  22     about including Wales in the Bristol centre in some
  23     form, and that was why there was an emphasis on that.
  24   Q. The ones that Mr Hurst is talking about is Wales in the
  25     context of the supra-regional service, but that was only

   1     for neonates and infants; it would not apply to anyone
   2     over the age of 1 because then they would tip outside
   3     the supra-regional service and then it is like any
   4     cross-region referral?
   5   A. I think once a child has been referred to a centre,
   6     although there would be local paediatricians and
   7     cardiologists who would help with the care, it is
   8     unlikely they would then be referred to another similar
   9     centre. Drs Jordan and Joffe were actually visiting and
  10     doing outpatients in South Wales.
  11   Q. If we just look at that letter from Mr Hurst again,
  12     please, in the last paragraph he says:
  13        "I have discussed this matter with Dr Jennifer
  14     Lloyd in the Welsh Office, copying her your letter and
  15     my reply."
  16        Do you remember if Dr Lloyd ever got in touch with
  17     you?
  18   A. No, I am sorry, I do not.
  19   Q. Let us look at HA(A) 29/57. This is a letter from John
  20     Skone, who was the Chief Administrative Medical Officer
  21     in the South Glamorgan Health Authority, to you dated
  22     27th October 1986.
  23        Let us look at that. You see from the second
  24     paragraph that there was a project team that had been
  25     set up to plan the cardiac development at the University

   1     Hospital of Wales, Cardiff. Then he says:
   2        "The Professor of Cardiology has recommended that
   3     neonatal and infant cardiac surgery should be undertaken
   4     in Wales but the project has run into difficulties."
   5        He refers to the costs and so on. Then he says:
   6        "I have not seen the report but understand that
   7     Bristol is the nominated centre for Wales and the South
   8     West."
   9        He then goes on to say:
  10        "It was indicated in documents attached to your
  11     letters to Dr Thomas that a small number of patients
  12     from Wales, presumably living in Gwent, were being
  13     referred to Bristol ..."
  14        If we look down the page, please:
  15        "There is debate about the number of operations
  16     that would be generated and no doubt you have figures
  17     from the South West on this point. As far as I know,
  18     I have not written to you asking whether Bristol
  19     & Weston were able to take on further neonatal cardiac
  20     surgery from Wales, and under the circumstances it seems
  21     sensible to await a ministerial decision about
  22     paediatric cardiac surgery in the principality."
  23        The decision that was taken in the end was that
  24     there should be an encouragement of Welsh cases to be
  25     referred to Bristol; is that right?

   1   A. It was Welsh cardiac surgery, and I think, as
   2     I remember, they were hoping to do some of the
   3     investigation in Cardiff.
   4   Q. But there was going to be a link between Cardiff and
   5     Bristol for the surgery?
   6   A. Yes, that is right.
   7   Q. You have read the evidence of Dr Crompton, Professor
   8     Crompton as he is now, and Mr Gregory to the Inquiry on
   9     this point?
  10   A. Yes.
  11   Q. This correspondence with South Glamorgan was separate,
  12     was it not, from the correspondence that South West
  13     Region was having with the Welsh Office?
  14   A. Can you expand what you mean by "separate"?
  15   Q. Let us look at HA(A) 29/56.
  16        This is 4th November. You received "the attached
  17     letter" from South Glamorgan, and I assume that the
  18     "attached letter" is the letter we just looked at,
  19     partly because the time-scale is right and partly
  20     because it is the next document on in this file.
  21   A. Yes.
  22   Q. "I am at present trying to get hold of a copy of the
  23     1986 joint report on cardiac surgery. It is the Welsh
  24     Office, not South Glamorgan, who are visiting at the end
  25     of November."

   1        So there were two different strands going on:
   2     there was correspondence from South Glamorgan and
   3     correspondence with the Welsh Office?
   4   A. I think we were actually having a four-sided debate,
   5     although it appears separate. I think my letters are
   6     only part of the jigsaw.
   7   Q. On 21st November 1986, there was a meeting with
   8     Dr Crompton and other representatives from the Welsh
   9     Office. Let us have a look at UBHT 165/15. That is
  10     your letter to Mr Dhasmana, inviting him to that
  11     meeting?
  12   A. Yes.
  13   Q. What did you understand the trigger for that meeting to
  14     have been?
  15   A. It could have been a discussion Mr Hurst had with them.
  16     It could have been discussions that either Miss Hawkins
  17     or Dr Mason or somebody else within the Regional Health
  18     Authority had had. I do not know. I cannot remember.
  19   Q. Do you remember what the purpose of the meeting was?
  20   A. As it says, to see the paediatric cardiac and cardiology
  21     unit.
  22   Q. The "highlight" purpose is to come and have a look
  23     around, but what are they going to do with the
  24     information they glean from the visit?
  25   A. Consider the Welsh position, internally in Wales, and

   1     possibly with us once they come to a clear line on where
   2     they wanted to go, because I think they were still in
   3     doubt as to which direction they were wanting to pursue.
   4   Q. Can we have a look, please, at WIT 70/4, paragraph 10?
   5     This is the statement from Dr Crompton to the Inquiry.
   6        "The second visit was in the autumn of 1986 and
   7     a report of this written by Dr Jennifer Lloyd ...
   8     appears as a minute in the Welsh Office bundle referred
   9     to earlier in this document. On this occasion we were
  10     motivated to explore for ourselves whether there was any
  11     substantiation of Professor Henderson's critical
  12     comments about the unit."
  13        Did you know about critical comments Professor
  14     Henderson had made about the Bristol unit?
  15   A. No. I was not aware of them.
  16   Q. You were at the meeting in November 1986?
  17   A. I can remember being at a meeting with Professor
  18     Crompton. Whether it was that one, unless you have
  19     a note ...
  20   Q. You cannot explicitly remember whether it was this one?
  21   A. No. I do remember being at a meeting with Professor
  22     Crompton, but which of those it was ...
  23   Q. What is your recollection of the meeting that you do
  24     remember being at?
  25   A. The part I remember was a meeting with him in the RHA

   1     offices and I am fairly sure there were District Health
   2     Authority people such as Dr Baker there, but who exactly
   3     it was, I cannot remember, as well as ourselves, which
   4     would probably have been the RMO and myself, plus
   5     possibly people from service planning.
   6   Q. And Dr Crompton and his people?
   7   A. Yes.
   8   Q. Do you remember any discussion there about whether the
   9     Bristol unit was falling below acceptable standards?
  10   A. I do not remember it. I think I would have remembered
  11     it if there had been a major part of the discussion
  12     about it, because we would also have been concerned.
  13   Q. But if Dr Crompton is right and the raison d'etre of
  14     this meeting was to see for themselves, as he puts it,
  15     whether there was anything in the criticisms that
  16     Professor Henderson had made of Bristol, it is very
  17     likely, is it not, that those matters would have been
  18     ventilated by the Welsh people at the meeting?
  19   A. Yes, but as I say, I cannot remember which of the
  20     meetings I went to. I am fairly sure if they went to
  21     the supra-regional unit, they may well, at at least one
  22     other of those meetings, have come to the RHA.
  23   Q. So your evidence is that you, in November 1986, do not
  24     remember ever having heard that Professor Henderson had
  25     expressed concerns about Bristol?

   1   A. Yes.
   2   Q. And you do not remember Professor Henderson's concerns
   3     having been raised at any meeting you were at, although
   4     you do remember being at one meeting, albeit you cannot
   5     remember specifically, if it was the November 1986 one?
   6   A. No, I cannot remember specifically which one it was.
   7   THE CHAIRMAN: Mr Maclean, I wonder, it being one and
   8     a quarter hours since we began, whether this would not
   9     be an appropriate time to take 10 minutes for a break?
  10   MR MACLEAN: It would.
  11   THE CHAIRMAN: And therefore come back at just around 2.30.
  12   (2.20 pm)
  13               (A short break)
  14   (2.35 pm)
  15   THE CHAIRMAN: Mr Maclean?
  16   MR MACLEAN: Dr Pitman, we were dealing before the break
  17     with the Welsh Office and Dr Crompton and the meeting
  18     that took place and so on.
  19        Before I come back to that, I just want to take
  20     you in your statement to paragraph 18. This must be
  21     WIT 317/4. You say there:
  22        "Any consultant could ask for an interview with
  23     the RMO if they had confidential information to input.
  24     I would not necessarily have been invited to every
  25     meeting in my area of interest."

   1        In so far as you are aware, how often were such
   2     interviews with the RMO requested by consultants?
   3   A. Relatively frequently. I would know because I would
   4     meet individual consultants walking along corridors.
   5     I was not in the office every day, so I would probably
   6     meet a consultant out of a meeting, a sub-committee
   7     pattern, about once a week in the offices. So quite
   8     frequently.
   9   Q. With the corollary of the consultant being able to ask
  10     for an interview with the RMO, be it that the RMO was
  11     equally able to request an interview with the consultant
  12     if the RMO wished?
  13   A. Yes, that is correct.
  14   Q. So if the RMO was concerned about, let us say, referral
  15     patterns, the RMO would be able to call up or write to
  16     the consultant whose referral pattern was in question
  17     and ask them to explain themselves?
  18   A. Yes. They could either ask them to come and see them or
  19     go and see them themselves, or telephone them. It
  20     depended on the matter in hand.
  21   Q. So that could have happened had the RMO wished with
  22     respect to that part of the South West Region which was
  23     sending its work to Southampton or to London?
  24   A. Yes, if they wished.
  25   Q. The RMO could have rung up the referring consultant

   1     paediatricians, I assume it would have been, and asked
   2     them what they were playing at?
   3   A. It would have been within his jurisdiction to do that,
   4     yes.
   5   Q. Did that ever happen, so far as you are aware?
   6   A. I do not recall being told about it.
   7   Q. Well, that is a careful answer. Do you ever remember
   8     hearing of such contact?
   9   A. I do not remember.
  10   Q. Do you think it is likely that there was such contact?
  11   A. Possibly, but as I say, I do not remember.
  12   Q. It would have been the obvious thing to do if the RMO
  13     had wanted to alter the referral pattern?
  14   A. It would have been one of a number of things, yes.
  15   Q. What would the others have been?
  16   A. I am sure the majority of RMOs would also have talked to
  17     the DPH or the DMO of that district as well.
  18   Q. The DPH?
  19   A. The Director of Public Health.
  20   Q. On the question of the November 1986 meeting, I took you
  21     to a passage from Professor Crompton's witness statement
  22     to the Inquiry. He certainly recollected meeting you at
  23     some stage in Bristol. Do you remember meeting him?
  24   A. Yes. As I said previously, I had certainly been at one
  25     meeting with him.

   1   Q. As best you can, when would you date that meeting?
   2   A. I am afraid I cannot. I remember being in a room so
   3     there was no sort of outside influence to tell me
   4     whether it was summer or autumn, or when it was.
   5   Q. Do you remember if Mr Dhasmana was there?
   6   A. No, I am sorry, I cannot.
   7   Q. Do you remember where the meeting took place?
   8     Whereabouts in Bristol? Which building?
   9   A. The part of the meeting I remember took place in the
  10     Regional Health Authority Committee Room on the first
  11     floor, but I cannot remember whether it also took place
  12     anywhere else in Bristol that day.
  13   Q. So in the Regional Health Authority's building?
  14   A. Yes.
  15   Q. Can we look, please, at WO 1/264? If we go back
  16     a page to 263, to give it a little bit of context, this
  17     is a report of a meeting drawn up by Dr Lloyd, I think.
  18     It is a report of a meeting which took place in Bristol.
  19        If you look down the page:
  20        "In September 1996 the Expert Joint Working Party
  21     of the Royal College of Surgeons ... reaffirmed in their
  22     third report on the provision of neonatal and infant
  23     cardiac surgery, that cardiac surgery for this element
  24     of paediatric services should be undertaken in a limited
  25     number of units identified and funded for this purpose."

   1        That is the supra-regional system.
   2   A. Yes.
   3   Q. Over the page, please. Then there is a reference to the
   4     strategy for neonatal care in 1986 to 1994, and then
   5     a reference to Professor Henderson. He argued for
   6     a totally comprehensive service, self-standing, based in
   7     Cardiff.
   8        Then under the heading "Progress":
   9        "In order to resolve the conflict of opinion, the
  10     CMO [Dr Crompton, the Chief Medical Officer for Wales]
  11     and senior medical staff have now had a series of
  12     meetings to discuss this issue with colleagues within
  13     the DHSS who have responsibility for infant and neonatal
  14     cardiac surgery and with clinical and community medicine
  15     colleagues in the South Western Regional Health
  16     Authority and Bristol Royal Infirmary and Bristol
  17     Children's Hospital."
  18        You would be one of the "community medicine
  19     colleagues", would you not?
  20   A. I may have been. I think probably there would also have
  21     been people from Bristol & District there, or Bristol
  22     & Weston as it was.
  23   Q. But it says "community medicine colleagues in South
  24     Western RHA", which would be you?
  25   A. No, it could be the RMO. I think it unlikely we would

   1     have had a meeting with just the BRI and the Children's
   2     Hospital without somebody from the District there.
   3   Q. If you were at this meeting or such a meeting and not
   4     the RMO, or vice versa, would whichever one of you was
   5     at the meeting discuss it with the one who was not at
   6     the meeting?
   7   A. If the CMO was there, it is very unlikely the RMO was
   8     not there.
   9   Q. Because that would be the politic thing to do?
  10   A. That is right, yes. Only if the outcome was something
  11     which he or she felt I needed to take action on or
  12     needed to know about would there be this discussion.
  13   Q. We have already established that one of the areas within
  14     your purview was cardiac services?
  15   A. Yes, but I did say the RMO was also involved.
  16   Q. And those areas were handed out by the RMO, delegated by
  17     the RMO to you?
  18   A. Work in those areas was.
  19   Q. So if there was a meeting specifically about cardiac
  20     services which for some reason you did not attend but
  21     the RMO did, it would be surprising, would it not, if
  22     the RMO did not discuss it with you subsequently?
  23   A. It depends to some extent on the content of the
  24     meeting. I cannot remember.
  25   Q. If it was a meeting the trigger for which was concerns

   1     about the Bristol service expressed by Professor
   2     Henderson in Cardiff, it would be surprising if you did
   3     not get to know about it?
   4   A. I would have thought so, but I cannot say categorically
   5     that it was discussed with me.
   6   Q. But it would be surprising, would it not?
   7   A. As I said before, this was quite a high profile
   8     specialty. The CMO in Wales was involved with it. So
   9     some things were dealt with at director level and some
  10     aspects -- it depends what his view was about what he
  11     was being told.
  12   Q. Who would the RMO have been at this stage?
  13   A. What was the date?
  14   Q. 1986?
  15   A. I am not sure. I cannot remember.
  16   Q. Dr Freeman?
  17   A. I think it might have been, yes, because she was only
  18     there about 18 months.
  19   Q. Let us go back to WIT 70/4, please. This is Professor
  20     Crompton's statement. I showed you previously
  21     paragraph 10. In paragraph 11 -- he is referring to two
  22     visits. You have to go to the top of the page to
  23     discover that the first visit he is referring to, he
  24     says, was probably 1984. The second visit was in the
  25     autumn of 1986; that is the one we have been

   1     discussing. Paragraph 11:
   2        "On both visits we met with Dr Jordan and Dr Joffe
   3     who accompanied us throughout. Also seen were
   4     Mr Wisheart and Mr Dhasmana, the latter only very
   5     briefly on the 1986 visit. From the RHA I recall
   6     Dr Freeman and Dr Pitman being present on one or both
   7     occasions."
   8   A. Yes.
   9   Q. If you were at the meeting in November 1986 along with
  10     the RMO, Dr Freeman, then you would have known what was
  11     discussed, obviously.
  12   A. Yes.
  13   Q. If you were not and she was, then you would have learned
  14     about it afterwards, or it would have been surprising if
  15     you had not?
  16   A. It depended what value she placed on information and
  17     what weight -- she may have gone off and talked directly
  18     to Miss Hawkins about it, if it was of sufficient
  19     concern.
  20   Q. You had had some contact with Dr Lloyd in setting up the
  21     meeting in November 1986; is that right?
  22   A. Yes.
  23   Q. And it was Dr Lloyd who drew up the report of the
  24     meeting that we have just seen?
  25   A. Yes.

   1   Q. Do you remember any correspondence, any contact, with
   2     Dr Lloyd subsequently?
   3   A. I believe she was at the Welsh Office for some time
   4     afterwards and then moved to London. She was also
   5     involved in a number of other issues. I cannot
   6     remember -- I am sure I would have had contact with her,
   7     but what it was about, I cannot remember.
   8   Q. There was a further meeting with the Welsh Office in the
   9     early part of 1987, was there not?
  10   A. Yes.
  11   Q. Let us have a look at WO 1/296. We see that it is
  12     attended by Mr Gregory and Mr McGlinn from the Welsh
  13     Office?
  14   A. Yes.
  15   Q. By Catherine Hawkins and by Dr Freeman, but not by you?
  16   A. That is right.
  17   Q. And not by Dr Crompton?
  18   A. Yes.
  19   Q. So this would not have been the occasion where you would
  20     have met Dr Crompton, as he then was, because neither of
  21     you were at this meeting?
  22   A. No.
  23   Q. At about this time, I think shortly after this meeting,
  24     the Welsh Office made the decision that Bristol should
  25     be the centre where I think almost all the children from

   1     Wales should be sent. There were some in the north of
   2     Wales who were going to continue to be sent to
   3     Liverpool, no doubt for good reasons.
   4   A. That is right.
   5   Q. You had some further correspondence in 1987 with
   6     Dr Baker. Can I take you to UBHT 278/333? This is
   7     a letter to you replying to your letter of June 1st.
   8     I do not think it is necessary to take you to your
   9     letter, although I can if you want.
  10        Dr Baker says:
  11        "The development of expanded cardiac services for
  12     South Wales has become more problematic. As you are
  13     aware, South Wales were unable to attract any applicants
  14     for the paediatric cardiology post. We started in
  15     a position of attracting three applicants for the post
  16     we were advertising here in Bristol, but all three have
  17     withdrawn mysteriously. I suspect that there is some
  18     plot afoot within the higher echelons of cardiology
  19     which could be the influence of London and elsewhere in
  20     order to maintain their grip on South Wales."
  21        What did you understand Dr Baker to be referring
  22     to when he referred to the "higher echelons of
  23     cardiology"?
  24   A. Well, cardiological consultants with a special interest
  25     in paediatrics.

   1   Q. Where?
   2   A. In London.
   3   Q. So they were the ones who got the work sent to them from
   4     Wales at that stage and they wanted to hang on to it.
   5     The suggestion, I think, that is being made here
   6     implicitly is that these "higher echelons of cardiology"
   7     had scuppered Cardiff and Bristol's attempts to attract
   8     paediatric cardiologists to their own centres?
   9   A. I think that is probably how I read it.
  10   Q. Does that seem credible to you?
  11   A. I do not know where the applicants came from, whether
  12     they were from outside of the country or whether they
  13     were within England. So I do not know.
  14   Q. Does it seem like a credible suggestion?
  15   A. I have no evidence for it.
  16   Q. Does it seem like a credible suggestion?
  17   A. I really do not know. I am not a cardiologist. I think
  18     that is something --
  19   Q. I do not think you need to be an expert in cardiology.
  20     I think it is more a politics with a small "p" point, is
  21     it not?
  22   A. I have no evidence to suggest that. It does seem
  23     strange that all three withdrew, but he gives no reasons
  24     for why.
  25   Q. Do you know of any other reasons as to why three

   1     potential applicants for the paediatric cardiology post
   2     should all have withdrawn? After all, at this time the
   3     new cath' lab at the Children's Hospital was either
   4     about to open or had just opened.
   5   A. I do not know. They may have been offered better
   6     conditions in their own local departments. As I say,
   7     I do not know where they came from.
   8   Q. Was this abject failure to attract applicants to this
   9     post something of concern to the Regional Health
  10     Authority?
  11   A. Well, yes, because although Bristol would have been the
  12     employing authority, it was in our interests to have
  13     a stream of consultants filling posts so that everybody
  14     was not at the same age when they retired, for example,
  15     so this would have probably meant a younger consultant
  16     coming into the department.
  17   Q. And it is something that obviously concerns you
  18     specifically within the Region, hence the correspondence
  19     with Dr Baker at District?
  20   A. Yes.
  21   Q. So what did the Region do about this, in order to try to
  22     find out why these three applicants should mysteriously
  23     have disappeared at the last minute?
  24   A. I do not know. I cannot remember. I can imagine the
  25     RMO would have had a discussion, possibly with the

   1     cardiologists. I certainly do not remember being given
   2     any information.
   3   Q. So something would have been done about it?
   4   A. I think somebody would have enquired of Drs Jordan and
   5     Joffe if they had. It may have been Dr Baker relaying
   6     it back to us.
   7   Q. If we go to UBHT 62/321, please, this may help
   8     a little. It is a letter to you of 7th July 1987 from
   9     Dr Baker. You see the reference "IAB" at the top of the
  10     page. If we scan down a bit, please:
  11        "Neither South Wales nor ourselves have been able
  12     to appoint a paediatric cardiologist. Something
  13     diverted the three applicants we shortlisted from
  14     attending for the interview. This in part reflects that
  15     they are in a buyer's market. There was a Yugoslavian
  16     applicant who was difficult to assess and was not
  17     short-listed ..."
  18        That may help a little to explain it. So there
  19     was, it would seem, some further correspondence from
  20     you, to which this is a response, following up the
  21     failure to fill that post.
  22   A. Yes.
  23   Q. There was an expansion of cardiac services, cardiac
  24     surgery, in Bristol throughout the 1980s for both adults
  25     and children. We have heard evidence about that

   1     already. What was the Regional Health Authority's
   2     attitude to further expansion by the end of the 1980s?
   3   A. I think the Working Party were concerned that it should
   4     have been in a planned fashion, that this should not
   5     happen ad hoc. I know we were concerned that the
   6     numbers had not increased as much as we were led to
   7     believe by clinicians. There was need for a service,
   8     particularly for the adults, and yet we had waiting
   9     lists particularly for adult cardiac surgery. So we
  10     were keen not to increase the number so much that the
  11     waiting list increased, but on the other hand, we were
  12     keen to make sure that there were services available for
  13     the local regional population that they were requesting,
  14     in effect. The cardiologists in the South were asking
  15     for more service and as time went on, it became clear
  16     they were wanting a service in Plymouth.
  17   Q. So would a summary of that be that the Health Authority
  18     was happy for there to be a further expansion of cardiac
  19     services in the Region, provided it was done in
  20     a planned and methodical way?
  21   A. Yes, and they could ensure they had the income to
  22     support it.
  23   Q. The Regional Health Authority had reviews with the
  24     various districts, did it not, on an annual basis?
  25   A. Yes.

   1   Q. If we go to HA(A) 24/6, please, this is, I hope, the
   2     review for 1991. This is a briefing paper written by
   3     Dr Baker for the Region and District Review, 1991.
   4        If we go to page 7, please, the bottom of the page
   5     under the heading "Health Priorities ...", we see about
   6     six lines down:
   7        "The authority has not been able to increase
   8     investment in cardiac surgical and cardiological
   9     services."
  10        "The authority" there is a reference to which, to
  11     the District or to the Regional Health Authority?
  12   A. I do not remember seeing this paper before. I would
  13     assume that it is the District Health Authority, but
  14     I have no basis -- that is how it reads to me.
  15   Q. Was there, as far as you remember, a willingness in
  16     principle to increase investment in cardiac surgical and
  17     cardiological services at both District and Regional
  18     level?
  19   A. Yes. It was based on a stepwise increase and it meant
  20     that they needed to be assured of a certain number of
  21     patients to employ another consultant, because it would
  22     be a consultant workload they were taking on, and
  23     therefore all the supporting facilities that were
  24     required. If they failed to achieve that stepwise
  25     increment, the income would not flow back in -- although

   1     it was obviously delayed, they would not be assured of
   2     it.
   3   Q. Do you ever remember the Regional Health Authority
   4     actively resisting the expansion of the cardiac service
   5     in Bristol as opposed to merely being unable to fund it
   6     because of competing demands?
   7   A. When you say the "Regional Health Authority", do you
   8     mean the Health Authority itself or those in the
   9     regional office?
  10   Q. I mean those at the top of the Regional Health
  11     Authority: Catherine Hawkins, for example.
  12   A. I do not remember that happening, but I would have
  13     relied on the RMO for my information.
  14   Q. Would it surprise you to learn, if it were the case,
  15     that the Regional General Manager was actively resisting
  16     the expansion of the Bristol service?
  17   A. Is this in 1991?
  18   Q. It would be earlier than that: in the late 1980s.
  19   A. It certainly was not relayed to me by the RMO in very
  20     clear terms. I certainly do not remember getting that
  21     message, because we were concerned about the level
  22     available to the population for adult surgery.
  23   Q. You asked me if it was 1991 --
  24   A. It is 1991 in this report; that is why I was asking.
  25   Q. Do you remember there being an active resistance to the

   1     expansion of the service earlier than that, in the early
   2     part of the 1980s?
   3   A. No. As I say, we ...
   4   Q. From the transcript, I asked you, "Do you remember there
   5     being an active resistance to the expansion of the
   6     service earlier than that, in the early part of the
   7     1980s?". You said "No. As I say, we ...", and then --
   8   A. I am sorry, you turned your head away, so I lost all
   9     thread of what was going on.
  10   Q. Let us start again. You mentioned 1991 to me --
  11   A. Because it is on this report and I did not understand
  12     what you were asking.
  13   Q. But there was nothing more specific to generate 1991 in
  14     your head?
  15   A. No.
  16   Q. The Cardiac Services Medical Advisory Subcommittee
  17     produced a document called "The Strategy for 1988 to
  18     1998"?
  19   A. Yes.
  20   Q. You were heavily involved in drawing that up?
  21   A. Yes, I acted in support of the Chairman.
  22   Q. UBHT 156/255, please. That is it, is it not, and those
  23     are your initials "MAP" at the bottom of the page?
  24   A. Yes.
  25   Q. 29th September 1988. If we go to page 284, this table,

   1     which was part of this report, shows the referral
   2     pattern to the Supra-regional Paediatric Cardiology
   3     Centre in Bristol over an eight-year period, 1980 to
   4     1987. We see the scale of the expansion, especially
   5     from Wales, from 1 in 1980, under 1 case, to 63 in 1987.
   6     So the Regional Health Authority was monitoring the
   7     referral pattern to Bristol, as this table demonstrates?
   8   A. Yes, those figures would have come from the clinical
   9     unit.
  10   Q. What was the purpose of gathering that information?
  11   A. Because we were putting a strategy together and we
  12     needed the baselines.
  13   Q. And the idea was to do what? It was to --
  14   A. It was for the Professional Advisory Group to advise
  15     RHMAC and the RMO, and through them the RGM, as to the
  16     direction in which they felt, clinically, the Region
  17     should be moving.
  18   Q. Let us look at page 289, please. Still the same paper,
  19     paragraph 5.5.1:
  20        "A range of congenital heart defects occur ..."
  21        After the reference to table 7, you say:
  22        "Mortality rates at 30 days for those aged under 1
  23     relate to the increasing difficulty of operations with
  24     corrections in infants under 2 now who previously could
  25     not have survived. The higher rates for Bristol may be

   1     an effect of later entry into the field, or sicker
   2     babies. Some babies are operated on outside the
   3     Region."
   4        Before I develop that, the figures which were
   5     presented in this report are at page 291. That is
   6     the table that is referred to in the paragraph,
   7     table 7. You see that for Bristol the date is given for
   8     four years, 1984/85/86/87?
   9   A. Yes.
  10   Q. And for the UK, over two years, 1984/85. Under 1 year
  11     mortality for open-heart surgery at Bristol is 27 per
  12     cent and the UK in 1984/85 is 21.8 per cent.
  13        We see the relevant data for closed-heart cases
  14     below.
  15   A. Yes.
  16   Q. First of all, do you remember why data should be taken
  17     for four years at Bristol, but only over two years for
  18     the UK?
  19   A. We would have got this data from the clinicians and they
  20     would have given us what they had available.
  21   Q. Do you think it would be reasonable to assume that the
  22     UK mortality data for 1987 would be lower than the
  23     mortality data for 1984/85?
  24   A. What I say to you is that they are no statistical tests
  25     on this; we cannot actually tell in probability terms

   1     whether it is actually different or not. It may appear
   2     to the layman to be different, but I would want some
   3     statistical tests to be run on it. And no, I did not
   4     have them run at the time, otherwise I would remember.
   5   Q. We are getting ahead. I am just asking a general
   6     question, really as a matter of common sense. You would
   7     expect the mortality rates to be decreasing over time,
   8     would you?
   9   A. If you were comparing like with like. We do not know
  10     what the disability levels were in those two populations
  11     of children.
  12   Q. I am not a statistician and you are not a statistician,
  13     so I am not going to ask you about the degree of
  14     statistical significance that can be read into the
  15     difference between the UK and Bristol figures that are
  16     shown here, but if we go back to page 289, in that
  17     reference after table 7, in the middle of the paragraph,
  18     there is a recognition, in the last sentence in the
  19     paragraph, that the Bristol mortality rates are higher
  20     than the UK on average, and there is an explanation
  21     advanced for it.
  22        From where did that explanation come?
  23   A. That sort of detail would have come from the clinicians,
  24     who would have been collaborating with clinicians in
  25     other centres. At that time they were trying to develop

   1     scoring systems for disability. They were quite
   2     successful with adults, in working out a scoring
   3     system. I do not know how far they got with children.
   4   Q. So when you say "the clinicians", you mean the cardiac
   5     surgeons or --
   6   A. The cardiologists, for the most part.
   7   Q. And that would be -- I think you said earlier that
   8     Dr Joffe was the main attender of the sub-committee?
   9   A. Yes.
  10   Q. So would it be a reasonable inference that this
  11     explanation for the higher mortality data had come from
  12     Dr Joffe?
  13   A. As I remember it, because he was quite closely involved
  14     with the strategy. That does not mean to say that the
  15     cardiac surgeons were not involved. Certainly by that
  16     time Jonathan Hutter was also on the scene -- around
  17     that time he was on the scene, and one of his main
  18     interests was the scoring system.
  19   Q. When I showed you the statistics, you said that you
  20     would want to verify them and check them before trying
  21     to draw any conclusions from them. Fair enough. To
  22     what extent was this potential explanation for the
  23     higher mortality at Bristol subjected to any analysis in
  24     order to justify it or not?
  25   A. I think later on in the correspondence there is

   1     a reference to Dr Mason asking for quality statistics to
   2     be produced.
   3   Q. I am not sure that quite answers the question.
   4   A. But that was what happened as a consequence, that he
   5     asked for more information.
   6   Q. What degree of confidence could you have, as the author
   7     of this paper, in advancing this possible explanation
   8     for the higher mortality rates at Bristol?
   9   A. I was the author in so much as I got it typed up.
  10     There were a number of authors to the paper because it
  11     belonged to the sub-committee.
  12   Q. Where was it going to go to, this paper? Who was going
  13     to see it?
  14   A. When the sub-committee were happy with it, it would go
  15     to RHMAC and to the RMO, but the RMO would have seen it
  16     before RHMAC. It would have been passed into -- because
  17     I would have made sure he saw it.
  18   Q. If we go to page 256, we will see -- you said there were
  19     a number of authors. There were three main authors,
  20     I think: Dr Christine Hine, yourself and Mr Teague?
  21   A. Yes. That meant that we did the editing.
  22   Q. Christine Hine was a Community Medicine Registrar at the
  23     district level?
  24   A. Well, she was seconded to us to help, as well as being
  25     in district, as part of her training.

   1   Q. We see the long list of other consultants in cardiology
   2     and cardiac surgery, including Dr Jordan, Dr Joffe,
   3     Mr Dhasmana and Mr Wisheart?
   4   A. Yes.
   5   Q. So it is perhaps not clear from that where this --
   6   A. They would all have contributed sections to it and then
   7     we would have put it together and asked them questions
   8     about it. They may have rewritten it, or we may have
   9     rewritten it.
  10   Q. How did it happen that this explanation was advanced?
  11     Was the mortality data collected by you, or by somebody
  12     else at the Region, and then shown to the cardiologists?
  13   A. No, it was their data. As I understood it, it was from
  14     a national exercise that they were doing with other
  15     cardiologists.
  16   Q. So to what extent was that explanation subjected to
  17     scrutiny by anyone else before the paper was written?
  18   A. There were a number of drafts. Certainly it would have
  19     been seen by all the members of the sub-committee who
  20     would have been able to ask Dr Joffe about it.
  21   Q. It is certainly right that there were a number of
  22     drafts. Can I show you a later draft from the one we
  23     have just been looking at, UBHT 174/67,
  24     paragraph 5.5.1. Again, I think it is in all material
  25     respects the same except that table 7 has become

   1     table 6.
   2   A. Yes.
   3   Q. So does that suggest that in the consultation exercise
   4     of the circulation of the draft report no-one had picked
   5     up or wished to comment on paragraph 5.5.1?
   6   A. This was still a draft?
   7   Q. I am not sure this is a draft.
   8   A. Is it draft or final?
   9   Q. I think it is the final one, certainly the latest
  10     version I have seen.
  11   A. Can you show me the front of it?
  12   Q. Yes, page 33.
  13   A. Yes. The final one would have said "RHMAC" on it.
  14   Q. In that paper that we are looking at -- let us take the
  15     earlier draft; it does not much matter -- UBHT 156/294.
  16     This is dealing with the split site.
  17        Paragraph 5.7, the third paragraph:
  18        "The children's cardiac surgery beds are split
  19     between two sites and some children are housed in what
  20     is predominantly an adult ward, which is not
  21     satisfactory."
  22        The later draft I have at 174/72 is to the same
  23     effect; we need not go there. What I would like to turn
  24     to is page 307, still in the same paper.
  25        Paragraph 7.5:

   1        "For children to have their services in the same
   2     site for both cardiology and open and closed surgery
   3     would be a major step forward. It is suggested that
   4     this possibility is explored, even though splitting the
   5     staff could be difficult at present numbers."
   6        So this is the 1988 document. Who was going to
   7     explore the ending of the split site?
   8   A. It would have been done by the District Health Authority
   9     and the Trust.
  10   Q. There was no Trust in 1988.
  11   A. Well, the unit, the BRI.
  12   Q. The hospital?
  13   A. Yes.
  14   Q. The two hospitals in fact?
  15   A. In fact they were run as one, I think.
  16   Q. It is clear from this document, I think, from 308, that
  17     there was at this time, if we go to 308, contemplated
  18     further expansion of the service.
  19        If we go to 309, paragraph 7.9, we will perhaps
  20     see it more clearly.
  21        "The Regional Health Authority needs to have
  22     available to it in the order of 1500 operations ..."
  23        It did not have them at that stage, so there was
  24     going to be a further expansion?
  25   A. Yes.

   1   Q. If we go ahead three years to 1991, a very similar
   2     document, in fact an update, really, of this document
   3     was produced, called "Towards a strategy for cardiac
   4     services within the South West Regional Health
   5     Authority"?
   6   A. Yes.
   7   Q. If we go to UBHT 156/114, that is the draft of the
   8     document?
   9   A. That is right.
  10   Q. It has your initials, MAP, at the bottom of the page?
  11   A. Yes.
  12   Q. I think what had happened was that you had sent a draft
  13     to the members of the cardiac sub-committee and then
  14     they no doubt responded and then you sent out an updated
  15     version.
  16        If we go to page 113, this is your letter.
  17   A. I think we need to note it is now a "professional
  18     statement".
  19   Q. What does that mean?
  20   A. It is because the Trusts were being set up independently
  21     from the health authorities and I think the RHA was
  22     being told that it was not in a position to write
  23     strategies in the way that we have been writing them,
  24     but we could encourage the professional committees to
  25     give their advice in a coherent form.

   1   Q. If we go back into the document, UBHT 156/115, the top
   2     paragraph, we see what this document is endeavouring to
   3     do. It is professional advice from the Regional
   4     Hospital Medical Advisory Committee's sub-committee in
   5     cardiology and cardiac surgery on "the development of
   6     cardiac services in the South West Region."
   7        Over the page, 116, just above paragraph 2, if we
   8     scan down a little:
   9        "The Cardiology and Cardiac Surgery Sub-committee
  10     will report on progress on audit to the RHMAC at regular
  11     intervals."
  12        Do you remember what was going to be audited by
  13     whom and what was the interest of the RHMAC in audit?
  14   A. The professional committee of the Regional Health
  15     Authority and audit was initially a medical process. It
  16     was widened later to become clinical audit which
  17     included all clinicians -- nurses, physios, what have
  18     you.
  19        At that time Dr Mason took on a consultant in
  20     public health medicine to deal with all audit.
  21   Q. Who was that?
  22   A. Charles Shaw. So I was not directly involved. I knew
  23     that they had committed themselves to an audit
  24     programme.
  25   Q. So that became something that Charles Shaw was

   1     responsible for, answerable to the Regional Medical
   2     Officer?
   3   A. Yes, and I would help if asked. If I was asked to write
   4     letters chasing things up, I would do it.
   5   Q. If we go to page 130, still in the same paper, the top
   6     paragraph, just after the reference to table 6, this is
   7     the equivalent, I think, to the paragraph at 5.5.1 we
   8     were looking at in the document of three years before:
   9        "Mortality rates at 30 days are close to the
  10     national average", which I suspect means close to but
  11     not quite at the national average.
  12        "The higher mortality rate in the UK for those
  13     aged under 1 relates to the increasing difficulty of
  14     operations with corrections in infants who previously
  15     could not have survived. Bristol has only recently
  16     undertaken open-heart surgery on significant numbers of
  17     these sick babies. Some babies are operated on outside
  18     the Region."
  19        Can you help us with the slightly different
  20     emphasis that is placed there, in this paper, compared
  21     to the equivalent paragraph we looked at in the paper of
  22     three years before?
  23   A. I think what the clinicians were saying, as I said to
  24     you, we were not necessarily comparing like with like
  25     and there were no records in this statement of what the

   1     condition of the infants referred outside the Region was
   2     compared to those operated on within the Region.
   3     I cannot remember the detailed discussions, but I had
   4     that in my mind, that was one of the things that they
   5     discussed within the sub-committee.
   6   Q. There was a slightly later paper to the one we have just
   7     been looking at in 1991, HA(A) 11/217. It is a further
   8     draft, I think. I am afraid I cannot be any more
   9     specific as to the date, but certainly it was no later
  10     than 1992. The reason I come to that conclusion, if you
  11     look at page 234, there is a reference in the first main
  12     paragraph, you see beginning "Cheltenham and
  13     Frenchay .... Appointments will be made in 1992", so
  14     obviously this document is no later than 1992.
  15   A. I think it is more likely to be 1991 or before, but I do
  16     not know.
  17   Q. It is more likely to be a further draft of the one we
  18     were looking at?
  19   A. Yes.
  20   Q. If we go to page 219, do you remember in the 1988
  21     document we saw the reference to the split site being
  22     not satisfactory?
  23   A. Yes.
  24   Q. Now it says here, in the penultimate line:
  25        "Integration of children's services on a single

   1     site in Bristol is essential."
   2        What accounted for the heightened emphasis put on
   3     ending the split site in 1991 compared to 1988?
   4   A. I think there was a move to build an integrated
   5     Children's Hospital as is being built now, nearer the
   6     BRI. I think there may have been movement on that.
   7   Q. Why had that become a higher priority than before?
   8   A. I cannot tell you. I do not know.
   9   Q. Can I show you a letter from Catherine Hawkins,
  10     UBHT 38/430? It is a letter from Catherine Hawkins to
  11     Dr Roylance, 20th November 1991. It is only a short
  12     letter. Can I ask you to read it through? (Pause).
  13        Do you remember seeing that letter?
  14   A. No, but ...
  15   Q. Was it something that Catherine Hawkins ever discussed
  16     with you?
  17   A. No. I am sure she did not, because I rarely spoke to
  18     her.
  19   Q. Did you ever have any discussion with the Regional
  20     Medical Officer about gross dissatisfaction region-wide
  21     with the Bristol cardiac unit?
  22   A. Not that I can remember. I remember that -- as you see
  23     here, Oxford now has a cardiac unit that they had
  24     recently set up and that it was cheaper for the
  25     referrals to go to Oxford, and quicker. They had very

   1     little waiting list.
   2   Q. You see that Catherine Hawkins' letter in the third
   3     paragraph says:
   4        "I would more than welcome your comments and
   5     action if you feel you are not in sympathy with the
   6     current rate and quality of the performance of the
   7     cardiac unit."
   8   A. Yes.
   9   Q. "Rate" would deal with waiting times, how many
  10     operations were being done, how quickly the work was
  11     being got through?
  12   A. I think it may have been numbers rather than how long
  13     they waited.
  14   Q. And "quality", what would that be?
  15   A. That could be waiting time, amongst other things.
  16   Q. Could it?
  17   A. Yes.
  18   Q. Just help me with your role as a specialist in community
  19     medicine, later becoming a public health role. What
  20     would a consultant in public health medicine do in terms
  21     of contact with those who might refer patients to
  22     a cardiac centre?
  23   A. In the RHA or in a DHA?
  24   Q. You say in your statement, paragraph 20, that you had
  25     some of the public health departments of the District

   1     and you kept your ear to the ground through your
   2     District consultant colleagues as much as possible.
   3        What would you be keeping your ear to the ground
   4     about? What would you be listening for?
   5   A. I would be telling them about the things that we were
   6     getting from the Department, the changes in services
   7     which might come up in the future, so they could prepare
   8     themselves, and looking for their comments on what might
   9     be planned. Sometimes it would be by sending papers.
  10     It would usually be through the DPH meeting, but I would
  11     come across them in other meetings.
  12   Q. Let us just go to that bit in your statement. It is
  13     317/4, paragraph 20. When you refer to "District
  14     consultant colleagues", do you mean only public health
  15     consultant colleagues, or do you mean, for example,
  16     cardiologists and --
  17   A. No, "District" to me meant District Health Authority, so
  18     it was those employed by the District Health Authority,
  19     who would be public health or dental health,
  20     occasionally pharmacists.
  21   Q. But not, for example, cardiologists?
  22   A. No.
  23   Q. If we can just go back to the Hawkins letter at UBHT
  24     38/430, Catherine Hawkins has here picked up concerns
  25     about rate and quality, whatever that means, rate and

   1     quality of the Bristol cardiac unit, and those concerns
   2     have come, it would seem, from interim reviews of the
   3     district health authorities and family health service
   4     authorities region-wide.
   5        Who would have an input into those reviews from
   6     the district health authorities?
   7   A. Well, certainly the District General Manager and whoever
   8     on their staff they felt appropriate. Often they had
   9     a planning -- like a planning director on there, a DHA
  10     and a Finance Director. I am not sure whether all the
  11     DPHs were necessarily involved every time, depending on
  12     the topic.
  13   Q. Would you have a role in conducting those reviews from
  14     the Region end?
  15   A. No.
  16   Q. Would that explain how these concerns would have reached
  17     Catherine Hawkins but have bypassed you?
  18   A. Well, yes, I would not have direct access.
  19   Q. Would the Regional Medical Officer have access to this
  20     type of material? Would the Regional Medical Officer be
  21     the source, feeding to Catherine Hawkins?
  22   A. I do not know. All I can see on here, it says
  23     "purchasing managers", which is not the RMO, it is
  24     somebody in a service planning type of role.
  25   Q. Can we look at JDW 4/826, please? This is a letter to

   1     Mr Wisheart from you. Just scan down the page.
   2     13th August 1992.
   3        Dr Mason is concerned -- he was by now the
   4     Regional Medical Officer?
   5   A. Yes.
   6   Q. You have been asked by Dr Mason to write this letter,
   7     because cardiac surgery was one of your areas of
   8     influence, concern?
   9   A. Yes. He was still using me in that area, but not
  10     solely.
  11   Q. What are "contra-indications for cardiac surgery"? What
  12     is that a reference to?
  13   A. Some patients would not be considered for cardiac
  14     surgery, perhaps adults, because they might have lesions
  15     that made them too ill at that particular time. They
  16     would hold them back until they could stabilise them.
  17   Q. So that would be an explanation for an apparent delay in
  18     carrying out surgery?
  19   A. Yes. Sometimes they might be deferred, or they may be
  20     told that they would not benefit, that the risks were
  21     greater than the surgery.
  22   Q. What about referral protocols?
  23   A. It was a time when we were encouraging -- this is part
  24     of the audit process for clinicians to compare their
  25     practice, and referral protocols were one way of

   1     identifying factors that could be compared.
   2   Q. So you mean one clinician would compare where he got his
   3     cases from against another clinician --
   4   A. No, it would be the level of disability in patients.
   5     There were choices in treatment for cardiac conditions
   6     that ranged from medical to catheterisation, angioplasty
   7     was just coming in, to surgery, plus the medical
   8     treatment. So it would be how they would channel
   9     patients into those various pathways.
  10   Q. So the criteria they applied to decide what kind of
  11     treatment was appropriate?
  12   A. Yes. Most of them would have come through the
  13     cardiologist first, obviously.
  14   Q. Why should Dr Mason have been anxious to illustrate the
  15     positive nature of results from Bristol?
  16   A. As I understand it, he had had access to some of the
  17     audits they had been doing and he knows the details of
  18     those, but what he said to me recently was that the
  19     dependencies were considered and that the case mix was
  20     different; they had some very high dependent patients,
  21     and their results compared well, but I did not actually
  22     know the detail of that at the time.
  23   Q. Why was Dr Mason anxious to illustrate the positive
  24     nature of results from Bristol?
  25   A. There had been considerable debate about the waiting

   1     times. Some patients who were quite ill were having to
   2     wait 18 months because of the demands and there was also
   3     a move to set up a unit in Plymouth.
   4   Q. You refer in the next sentence to Dr Mason being
   5     concerned with the "adverse effects that recent
   6     publicity may have on referrals". Do you remember what
   7     that publicity was?
   8   A. Yes, it was long waiting times. I cannot remember the
   9     details, whether it was more than one. Certainly
  10     I remember in a number of instances patients from the
  11     southern part of the region were waiting a considerable
  12     amount of time and actually getting into the papers
  13     because of it.
  14   Q. So where had the publicity been? Which medium?
  15   A. Into the papers.
  16   Q. There had also been some expressions of concern about
  17     the Bristol cardiac unit in Private Eye about this
  18     time. Can I show you SLD 2/5, please? This is 3rd July
  19     1992. If we look on the left-hand side, the first
  20     bullet point, do you see the passage that begins there
  21     and goes on to the next column? And the reference to
  22     the arterial switch mortality in Bristol being 3 per
  23     cent in Bristol and 0 per cent somewhere in America.
  24     Might that not have been publicity that had come to
  25     Dr Mason's attention by August 1992?

   1   A. I anticipate that the press department would have made
   2     him aware of it, because they did give a news cutting
   3     service.
   4   Q. Did you ever see any cuttings from Private Eye being
   5     circulated from the Regional Office's press department?
   6   A. I cannot remember any. I think I would have remembered
   7     something like that.
   8   Q. Do you think it is likely that Dr Mason would have been
   9     aware of this?
  10   A. If the press department identified it.
  11   Q. Would you have expected the press department to have
  12     identified it?
  13   A. I am not sure if it was one of the things they normally
  14     took. It would have been an exception rather than a --
  15     they tended to produce press cuttings on the national
  16     papers, so if it had been reported in that he might have
  17     got a copy of Private Eye.
  18   Q. This column was a well-known source of news, gossip,
  19     however one might call it, about the Health Service,
  20     this column in Private Eye. Had you heard about this
  21     column?
  22   A. I cannot tell you that. The reason I cannot is because
  23     I have seen so much in the press since then that I am
  24     not sure when I became aware of it.
  25   Q. You wrote to Mr Wisheart on 13th August. We have seen

   1     that letter. Can we go to JDW 4/827, please, which is
   2     another letter from you to Mr Wisheart two months later
   3     on 8th October.
   4        You had had a discussion, it would seem, with
   5     Mr Wisheart between the two letters. We see from the
   6     first sentence "Following our recent discussion". Do
   7     you remember what the nature of the discussion was that
   8     you had with Mr Wisheart?
   9   A. I do not know. I cannot even remember whether he
  10     actually approached me. It may have been literally
  11     a chance meeting.
  12   Q. In the second paragraph, you say "As I mentioned to you
  13     when we met, we were concerned that parties should
  14     receive more specific information about outcome from
  15     your unit". Who is the "we"?
  16   A. That would be Dr Mason.
  17   Q. Was Dr Mason a party to the discussion you had had with
  18     Mr Wisheart, or was it just between and you Mr Wisheart?
  19   A. I do not know. I cannot place it in context.
  20   Q. You then send some data. Where did you get that data
  21     from, do you remember? Mr Wisheart takes issue with it,
  22     as we will see in a moment.
  23   A. Can you show me the data?
  24   Q. I cannot show you the data, I am afraid.
  25   A. If you show me the bottom, I might have a clue from

   1     the --
   2   Q. I have not seen the data. These files come from
   3     Mr Wisheart himself.
   4   A. Right. He may have produced it himself.
   5   Q. It is obvious from the last paragraph that the data
   6     being discussed is not simply perhaps at all about
   7     children, because there is a reference to over 60s and
   8     over 70s, and so on.
   9   A. In some of the correspondence I have, there is a mention
  10     of two registers, one about valves, which I think was at
  11     the Hammersmith, and there was something like
  12     a cardiothoracic surgeon's register. I think that was
  13     the Sir Terence English one, but I cannot remember.
  14     That was the internal audit stuff that they would not
  15     allow anybody except cardiac surgeons and cardiologists
  16     to see, so it could have been an extract from that he
  17     gave me.
  18   Q. If we look at JDW 4/828 --
  19   THE CHAIRMAN: Before we move on, Mr Maclean, is it just an
  20     oversight that on both the letters to Mr Wisheart we see
  21     you describe him as a "consultant cardiologist"?
  22   A. Yes. It is my fault.
  23   MR MACLEAN: If we look at JDW 4/828 which is on the screen
  24     now, this may be the data:
  25        "Cardiac surgical procedures for all patients

   1     treated by Bristol Royal Infirmary in 1991/1992. Number
   2     of deaths by age group in years".
   3   A. That has come of out their Patient Administration
   4     System. That is what PAS means. It was called "health
   5     collectivity analysis" prior to that.
   6   Q. I see. That is the data you sent to Mr Wisheart?
   7   A. I cannot remember which way round it was, but if he was
   8     saying I got the numbers wrong, I probably sent it to
   9     him and had got it directly from the information system
  10     and was trying to verify it, rather than him sending it
  11     to me.
  12   Q. If we just go back to the letter, to 827, the second
  13     paragraph of the letter:
  14        " ... I appreciate the difficulties of setting up
  15     a scoring system that takes account of initial
  16     disability relating to outcome."
  17        Am I right in thinking that the question of case
  18     mix and adjusting for the degree of sickness, if you
  19     like, of the patients, was something Mr Wisheart had
  20     raised at the meeting you had had with him?
  21   A. As I understand it, Jonathan, who was another cardiac
  22     surgeon, had a great interest in it and was trying to
  23     develop a scoring system in concert with other people in
  24     the country and was using the Bristol data, and
  25     Mr Wisheart and Mr Dhasmana would have been involved.

   1   Q. Let us look at 831, please. This is Mr Wisheart's reply
   2     to your letter. You see in a long paragraph there that
   3     he takes issue with the data that you had produced.
   4   A. Yes. I had not actually produced it. It had come from
   5     the system that we had access to. It was an
   6     administration system, not a clinical system.
   7   Q. You then sent some revised data to Mr Wisheart?
   8   A. Yes.
   9   Q. If we go to JDW 4/835, we see that Mr Wisheart is
  10     somewhat puzzled by the data that has been sent and he
  11     is extremely concerned that you are generating these
  12     numbers "as their significance and meaning is extremely
  13     obscure to me."
  14   A. It came from the hospital systems.
  15   Q. Then the final bit of this stream of correspondence is
  16     from you to Mr Wisheart on 24th November 1992, at
  17     page 836.
  18        There is the reference to Mr Hutter and the
  19     scoring system.
  20   A. That is right.
  21   Q. That is what you were referring to earlier?
  22   A. Yes, that is right.
  23   Q. Then you say:
  24        "Mr Hutter came to see Katherine Garston ..."
  25        Who was she?

   1   A. She was one of our administrative assistants.
   2   Q. And yourself, on 23rd November. Then you say this:
   3        "We did have a discussion about infants and he
   4     agreed to discuss with you the best way of presenting
   5     the data".
   6        Why should you have had a discussion specifically
   7     about infants with Mr Hutter?
   8   A. I think the Parsonnet that he had produced was to do
   9     with adults and ischaemic heart disease, so we were
  10     asking for information about the whole patient
  11     population.
  12   Q. But "infants" would only cover those up to 1 year old?
  13   A. He may have suggested that there were scores. That is
  14     why I particularly put that. I do not remember.
  15   Q. The point I am making is that infants would not cover
  16     all children?
  17   A. No. I understand what you are saying, but he may have
  18     said that there was a scoring system being developed for
  19     infants.
  20   Q. And that would be developed by Mr Wisheart because he
  21     was a paediatric surgeon?
  22   A. It would probably be by a group of cardiac surgeons
  23     across the country, because these things were usually
  24     done by groups of experts in the areas. One person
  25     might have started them off, but they would then be

   1     developed.
   2   Q. If this scoring system was produced so that comparable
   3     data could be produced about outcome, what was the
   4     Regional Health Authority going to do with that data
   5     when it got it?
   6   A. It would have gone through the audit system.
   7   Q. What was the Region's role in the audit system?
   8   A. It was to ensure that there was an audit system which
   9     was appropriate to each specialty.
  10   Q. And who would select which topics were to be audited,
  11     specifically?
  12   A. I cannot answer that, because some of them were agreed
  13     district-wide rather than region-wide. I was not
  14     totally involved with the auditing system; I just knew
  15     that we had some that were labelled "regional audits"
  16     and some which were labelled "hospital audits".
  17   Q. If we go back to your letter of 8th October, 827, did
  18     you ever get the examples from the national register
  19     that you asked Mr Wisheart to provide?
  20   A. Not that I can remember, but -- what was the date of
  21     that one?
  22   Q. 8th October 1992.
  23   A. Not that I can remember.
  24   Q. (Pause) Just a couple of points. One is just
  25     tidying-up the transcript. I asked you whether it would

   1     have been reasonable to assume that the mortality data
   2     for 1987 would be lower than that for 1984 to 1985. Do
   3     you remember that?
   4   A. Yes.
   5   Q. What you are recorded as saying is, "What I say to you
   6     is that [something] statistical tests on this, we cannot
   7     tell in probability terms." I suspect what you intended
   8     to say, or did say, was "without statistical tests"?
   9   A. Yes. I probably mumbled that bit. I did actually
  10     answer the question as well afterwards.
  11   Q. Yes. Then the final point, I think, is this: I said
  12     that when I showed you the statistics, you would want to
  13     verify them and check them before trying to draw any
  14     conclusions from them. I said "To what extent was this
  15     potential explanation for the higher mortality at
  16     Bristol [you remember, 5.5.1] subjected to any analysis
  17     in order to justify it or not?" You said:
  18        "I think later on in the correspondence there was
  19     a reference to Dr Mason asking for quality statistics to
  20     be produced."
  21   A. Yes.
  22   Q. Were you intending there to refer to the letters that
  23     I have shown you subsequently, or to something else?
  24   A. No, these letters, that there were scoring systems being
  25     set up that would take account of disability.

   1   Q. So I have covered the further enquiries that Dr Mason
   2     was going to make?
   3   A. Yes, that I knew about. As I said, I was not involved
   4     with the audit programme in any detail, so there may
   5     have been others.
   6   MR MACLEAN: I do not have any other questions for you,
   7     Dr Pitman, you will be pleased to know. Is there
   8     anything that you want to say to the Inquiry now, having
   9     given your evidence? Anything that I have not covered
  10     or anything I have got wrong?
  11   DR PITMAN: No. I think we have covered where I was not
  12     clear as we went through. I do not think there is
  13     anything else that I had in my statement that I felt
  14     should have been brought out, thank you.
  15   MR MACLEAN: There is always an opportunity to say some more
  16     later. You may want to look at today's transcript and
  17     check it through and if you feel on reflection that you
  18     would want to say more, then you can do so. I do not
  19     have any other questions. There may be some questions
  20     for you from the Panel.
  21   THE CHAIRMAN: Yes, Dr Pitman. First, Mrs Maclean.
  22            Examined by THE PANEL:
  23   MRS MACLEAN: Dr Pitman, I am just trying to understand
  24     a little better how the Region worked as an organisation
  25     itself. At one point you mentioned that you rarely

   1     spoke with Catherine Hawkins, whom we heard from
   2     yesterday. Could you tell us a little bit more about
   3     why that was, were there other channels of
   4     communication, were there regular meetings of senior
   5     staff? How did pe