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Daily transcripts
Hearing summary
7th October 1999
The Inquiry today heard from Mrs Kay Armstrong, staff nurse and later sister in cardiac
theatres at the Bristol Royal Infirmary (BRI). Mrs Armstrong described the management of
the cardiac theatres and the management style of the surgeons. She commented on her
reaction to being shown Dr Steven Bolsin’s audit work. Mrs Armstrong stated that the
surgeon’s findings during operations sometimes differed from the cardiologist’s
original diagnosis. The hours of work of staff, including surgeons, was discussed and she
commented on the precautions taken to prevent under-performance of nurses. Mrs Armstrong
also drew attention to the issue of the punctuality of the surgeons. Mrs Armstrong
concluded by indicating that some nurses had anxieties about assisting with certain
operative procedures and decided to restrict themselves to certain cases.
Mr William Booth, Clinical Nurse Manager, Paediatric Intensive Care Unit (PICU),
Bristol Children’s Hospital, UBHT, was the next witness to give evidence today. He
discussed recent changes in the management of the Trust and the consequent heightening of
the profile and value placed on nurses. He focussed on the importance of having paediatric
trained nurses looking after babies and children and the added benefit of intensive care
training for staff working in the PICU. He added that it was difficult to recruit nurses
with both qualifications. Mr Booth told the Inquiry that when Mr Ash Pawade, Consultant
Paediatric Cardiothoracic Surgeon, started work at the Bristol Children’s Hospital in
1995, he introduced protocols for open and closed paediatric cardiothoracic surgery. Mr
Booth described the transfer of patients between the BRI and BCH and concluded by
discussing staffing levels in the Bristol PICU, comparing them against national averages.
The week’s hearing concluded with evidence from Professor John Vann-Jones,
Consultant Cardiologist, UBHT. He was Clinical Director for General Medicine from
1989– 1993 and Clinical Director for Cardiac Services from 1993–1996. He
described the evolution of the Cardiac Services Directorate. He explained that the Cardiac
Services Directorate did not include paediatric cardiac surgery. He told the Inquiry that
in November 1993, Dr Steve Bolsin, Consultant Anaesthetist at the BRI, showed him data,
which indicated that mortality rates for four paediatric cardiothoracic procedures were
above the national average. He said that he had been aware that the surgical outcome in
Bristol were average, but countered this by saying that as the surgeons were not solely
dedicated to paediatric work, the outcomes would be expected to be worse than at other
centres. He explained the steps he took to check the validity of the data and outlined the
course of events which led to his writing in April 1994, together with Professor Gianni
Angellini, Professor of Cardiac Surgery, University of Bristol, to Peter Drurie, Chairman,
UBHT, suggesting that a new consultant in paediatric cardiothoracic surgery should be
appointed. He commented on his professional relationship with Dr Roylance, Chief
Executive, UBHT and his management style. Professor Vann-Jones also described his role in
liasing with non-medical and surgical staff during 1994 and 1995 about concerns in
paediatric cardiac surgery and commented on difficulties he observed in communications
within the cardiac surgical department. He concluded by commenting on the difficulties of
providing a unified cardiac service from split sites.
|
FULL TRANSCRIPT
1 Day 59, 7th October 1999
2 (9.30 am)
3 THE CHAIRMAN: Good morning, everyone; good morning
4 Mr Maclean.
5 MR MACLEAN: Good morning, sir. Today's first witness is
6 Kay Armstrong. I should say, sir, Mrs Armstrong is
7 represented by Mr Chambers and those who instruct him
8 sit behind me.
9 Could you stand to take the oath?
10 MRS KAY ARMSTRONG (SWORN)
11 Examined by MR MACLEAN:
12 Q. Your full name is Kay Armstrong?
13 A. Kay Frances Armstrong, that is true.
14 Q. Mrs Armstrong, I am going to have to ask you to speak up
15 a little. The acoustics yesterday in this room proved
16 not to be all they might be, so please keep your voice
17 up. The stenographer to your right is taking down
18 everything that you say, and it is more important that
19 she hears what you say than anybody else, with the
20 possible exception of the Panel!
21 Could I ask you to have a look at the screen in
22 front of you? Could I have WIT 132/1.
23 That, I think, is the first page of the first
24 statement that you made to the Inquiry?
25 A. That is correct.
0001
1 Q. If we go to page 16, that is your signature at the end
2 of that first statement?
3 A. That is correct.
4 Q. There have been a couple of comments on that statement
5 which I hope you have had a chance to see. You may not
6 have seen the second of them. The first one is from
7 Mr Dhasmana, WIT 132/24. There is a second page,
8 page 25. Have you had a chance to see that?
9 A. I have.
10 Q. There is a comment from Mr Wisheart as well. Have you
11 seen that?
12 A. I have.
13 Q. That is at WIT 132/67 and 68. We will come back to
14 those in due course.
15 You have supplied two other statements as well to
16 the Inquiry dealing with different topics. The second
17 is at WIT 132/26. That is the first page, is it not, of
18 your so-called Block 4 statement?
19 A. Yes, it is.
20 Q. That statement concludes at page 53?
21 A. Yes, that is my signature.
22 Q. And the most recent statement that you supplied,
23 I think, in the course of this week, begins at page 54
24 and ends at page 66. So those are your three
25 statements?
0002
1 A. That is right.
2 Q. There is a fourth relevant statement which we ought to
3 deal with in opening, which was your statement to the
4 General Medical Council. That is at GMC 14/22. If we
5 go on, please, to page 24, that is respectively the
6 beginning and end of your statement to the GMC?
7 A. That is right.
8 THE CHAIRMAN: Could we redact the one part of that
9 statement if it is going to come up again, please?
10 I apologise, I missed it. It was complicated by me.
11 What I mean is that statement had your address on and
12 unless you are anxious for it to be on, I would prefer
13 it be taken off for everybody's benefit.
14 MR MACLEAN: I think we need not go back to that page.
15 I think in the end you were not called to give evidence
16 at the GMC orally?
17 A. I was excused giving evidence because my husband was
18 very ill at the time.
19 Q. Let us go back then to the beginning. Your first
20 statement, WIT 132/1, paragraph 2. You became a Staff
21 Nurse in the cardiac theatre at the Bristol Royal
22 Infirmary in 1984?
23 A. Yes.
24 Q. And you were made Sister in 1986?
25 A. Yes.
0003
1 Q. And you are still a Sister, although you also work as
2 a surgical assistant at the Children's Hospital?
3 A. I am still a G grade, yes.
4 Q. Paragraph 9 of that first statement on page 3, at the
5 very foot of the page you say there:
6 "In the following years leading up to 1995 the
7 management structure had changed frequently and often
8 with little warning. The cardiac theatre had six
9 different managers over this period ...", and then you
10 name them?
11 A. Yes.
12 Q. Of those managers, of the people you name, some of them
13 are nurses and some of them are involved in the general
14 management side of the hospital. For example, we have
15 heard already from Lesley Salmon, the manager of the
16 Cardiac Directorate, who was replaced by Rachel Ferris,
17 so they were both managers?
18 A. They were managers.
19 Q. Whereas Julia Thomas, who was succeeded by Fiona Thomas,
20 was a Clinical Nurse Manager?
21 A. That is correct.
22 Q. So when you refer in paragraph 9 to "managers", you are
23 referring both to professional, as it were white collar
24 managers and also to professional nurses?
25 A. I am referring to the people that I was answerable to at
0004
1 that point.
2 Q. So you were answerable both to the Julia Thomas or Fiona
3 Thomas nurse figure, and also to the General Manager of
4 the directorate, or subdirectorate?
5 A. Yes, I was. When Julia Thomas first took over the
6 cardiac unit as Nurse Manager, she actually did not have
7 theatre under her at that point, so for some time, we
8 had Lesley Salmon. First we had Gill Kelly and then
9 Lesley Salmon, then Julia was made responsible for us as
10 well. So in that time I had to answer to all of those
11 people.
12 Q. For what aspects of your job would you be answerable to
13 the Nurse Manager and for what aspect would you be
14 answerable to the General Manager?
15 A. On a daily basis, we would be answerable to the Nurse
16 Manager. If there were any issues which we were not
17 happy with or she was not happy with, that would be
18 dealt with by the General Manager.
19 Q. Before you went to work in Bristol, you had worked in
20 the Frenchay Hospital. You had worked at King's College
21 Hospital in London, and you had also had a spell in
22 Holland?
23 A. That is correct.
24 Q. And also, I think, in Gloucester for a period?
25 A. Yes. I trained in Gloucester.
0005
1 Q. Can we look at page 13, please, of this first statement,
2 paragraph 34? In the 1980s and prior to that, you say:
3 "Consultant medical staff have always behaved and
4 been treated in a manner which would assume superiority
5 over the other health workers. This situation has
6 improved but not totally disappeared."
7 Is that something that you experienced in all the
8 hospitals you have worked in?
9 A. Yes, it was.
10 Q. What do you think has brought about what you
11 characterise as an "improvement"?
12 A. I think possibly -- I do not know. Most of the posts
13 that I originally came into, all the senior consultants
14 there had been there for many years. As younger
15 consultants seemed to come along, they seemed to have
16 a more easygoing approach; there is not so much of the
17 "old school" about them, really. I think that is
18 probably why, eventually, things have become easier to
19 deal with.
20 Q. When you went to the Bristol Royal Infirmary in 1984, of
21 the surgeons that this Inquiry is most concerned with in
22 terms of their work in paediatric cardiac surgery, one
23 of the surgeons had been there as a consultant for
24 getting on for a decade: Mr Wisheart?
25 A. Yes.
0006
1 Q. And the other one was on the point of being appointed
2 consultant when you began in 1984; is that right,
3 Mr Dhasmana? He was appointed shortly afterwards?
4 A. I cannot remember when he was appointed. He was
5 a senior registrar when I started in the unit.
6 Q. To what extent would you characterise each of those,
7 taking them in turn, as being of the "old school" as you
8 put it?
9 A. I would have said that I found it more difficult to
10 approach Mr Wisheart. Mr Dhasmana, I was used to
11 working with as a senior registrar, and therefore the
12 relationship very rarely changes once they become
13 a consultant.
14 Q. You mention your relationship with Mr Wisheart at
15 paragraph 40, page 15. You say an interesting sentence:
16 "We felt quite intimidated by him, although he is
17 very charming."
18 If he was not aggressive or overtly hostile,
19 indeed was charming, why did you feel intimidated by
20 him?
21 A. Because he was a charming person when he introduced
22 himself to you, or that would be the side that parents
23 et cetera would see of him, but he was someone that, if
24 you had a problem and you wished to discuss it with him,
25 he would go into periods of silence, be very
0007
1 disapproving. I myself find that sort of behaviour more
2 intimidating than someone who will confront me.
3 Q. So there would be no overt confrontation?
4 A. Not confrontation, no. I do not have a problem with
5 people who confront you with a problem; it is people
6 that can, as I say, give off a very intimidating air, as
7 if you should not have spoken, and they are not willing
8 to discuss the matter with you.
9 Q. Did you get the impression that you were seen as
10 speaking out of turn to Mr Wisheart?
11 A. Yes, I would.
12 Q. Why was that?
13 A. Because he would seem to disapprove of what was being
14 said to him, but he would not answer you or give you
15 a satisfactory answer; he would be more likely to walk
16 away.
17 Q. Was the disapproval because of what was being said
18 generally, or because of the fact that it was you that
19 was saying it, or both?
20 A. I guess a little of both.
21 Q. Mr Wisheart has responded to that paragraph. It is
22 WIT 132/68: he says simply, if we scan down a little:
23 "I am very disappointed at this comment as
24 I sought to create the opposite impression."
25 What you said at paragraph 40 about feeling
0008
1 intimidated, that obviously was your feeling?
2 A. Yes.
3 Q. To what extent were you aware that that feeling of
4 intimidation was felt by colleagues in similar positions
5 to your own?
6 A. I know that it was, because other members of staff would
7 comment as well, that they did not feel comfortable
8 questioning Mr Wisheart's decisions.
9 Q. How many G grade Sisters were there in the theatre at
10 the BRI?
11 A. Over which period?
12 Q. Over the period the Inquiry is concerned with, from the
13 mid-1980s through to 1995.
14 A. There was Angela Constance, Julie Lowe, Penny Waterson,
15 Penny James, myself, Mona Herborn, Carol Fairweather.
16 There was another girl, Patricia Carolan.
17 Q. And you would have known each other well?
18 A. I knew all of them well because I was there for the
19 whole period of that time.
20 Q. How many of them shared the impression you give at
21 paragraph 40, as far as you are aware?
22 A. Mona Herborn, certainly. Julie Lowe. I have to
23 confess, the other time is going back to 1984, and
24 I cannot remember, really.
25 Q. Do you remember any who took a different view?
0009
1 A. No.
2 Q. If we go back to page 13, where we started,
3 paragraph 34 --
4 THE CHAIRMAN: May I just ask one question of you, before
5 you leave that paragraph, which is whether anyone made
6 Mr Wisheart aware of the fact that others found him
7 intimidating?
8 A. I certainly did not. I do not know if anyone else did.
9 MR MACLEAN: Paragraph 34, the assumption of superiority
10 over other health workers that you refer to: would that
11 apply to medical and surgical staff, for example
12 cardiologists and surgeons?
13 A. I think it applies to any member of the medical
14 profession that was in a senior consultant job at that
15 time.
16 Q. If we go over the page to paragraph 36 on page 14, you
17 say the nature of theatre work makes it essential to
18 work well as a team.
19 It may be obvious, but why is that?
20 A. Because we need good communication skills in theatre.
21 We are all doing different jobs, but aiming towards the
22 same end, which is to get the operation done in a safe
23 manner, so therefore we do need to work well as a team.
24 Q. I think you do set out at some stage who is involved,
25 who was present at an operation.
0010
1 A. Yes.
2 Q. An open-heart operation. Would you briefly talk through
3 who those people are and what their jobs are during the
4 operation?
5 A. There would normally be the senior surgeon who was
6 operating with two assistants. There would be
7 a consultant anaesthetist plus registrar or senior
8 registrar anaesthetist. There would be two
9 perfusionists and then there would be an assistant nurse
10 or ODP to the anaesthetist, an assistant scrub nurse or
11 ODP to the surgeon, and a circulating person.
12 Q. Who would be available to give --
13 A. To give whatever was required to the scrub nurse.
14 Q. Just so that we have the nomenclature right, ODP stands
15 for --
16 A. Operating department practitioner.
17 Q. Through most of this period when you worked at the BRI,
18 these theatres would be doing cardiac operations on both
19 adults and children?
20 A. That is correct.
21 Q. To what extent did the line-up differ if it was
22 a paediatric operation?
23 A. It did not differ at all.
24 Q. To what extent did the job of the nurses involved in the
25 operation change when it was a child as opposed to an
0011
1 adult on the operating table?
2 A. Our job did not differ at all; the only thing would be
3 that we would normally not have relatives in the
4 anaesthetic room if it was an adult being operated on.
5 If it was a child, the parents were always present, but
6 there was usually either Helen Stratton or a ward nurse
7 present with those parents to take care of them.
8 Q. Once inside the operating theatre, as far as the nurses
9 on duty were concerned, it made no difference to the
10 actual job they were doing --
11 A. No.
12 Q. -- how old the patient was?
13 A. No.
14 Q. So there is no question of specific paediatric skills
15 for a theatre nurse in the same way there might be in
16 intensive care, for example?
17 A. No. I do not think there is.
18 Q. You talk in paragraph 36 about poor communication
19 skills, particularly from some of the members of the
20 surgical staff.
21 Two questions: first of all, how did those poor
22 communication skills manifest themselves?
23 A. It was usually in cases where the lists would get
24 altered around during the day and possibly the
25 anaesthetist had been informed but the theatre staff had
0012
1 not, so we would find out right at the very last minute
2 that we were doing the wrong case, or we were doing
3 a different case. So that can mean, for us, a different
4 setup, it could be a woman rather than a man, or
5 whatever, so that would alter our setup. So it is
6 important for us to know exactly which order the
7 patients are coming down in.
8 Q. You attribute these skills secondly to some members of
9 the surgical staff. Which members?
10 A. I am sorry, I do not ...
11 Q. You say there were poor communication skills,
12 particularly from some members of the surgical staff.
13 Which members of the surgical staff?
14 A. Both at consultant level, I think, and at senior
15 registrar level.
16 Q. So this was a general problem among surgical staff --
17 A. It was a general problem.
18 Q. -- so far as the nurses were concerned?
19 A. That is true.
20 Q. You say that it was a regular occurrence to be told at
21 the start of the day you would be cancelling a case
22 because of the lack of intensive care bed, and yet in
23 the event, carry out the operation later in the day.
24 Is that not explained by the point that
25 Mr Dhasmana makes at WIT 132/24? At the bottom of the
0013
1 page, Mr Dhasmana says:
2 "I would like to explain that members of medical
3 and nursing staff in the cardiac unit take postponement
4 and cancellation of operation very seriously and would
5 try their best to avoid it."
6 Was that your impression of the surgeons'
7 approach?
8 A. I think everybody would want to avoid a patient being
9 cancelled, yes.
10 Q. "So as a result, on many occasions, these decisions used
11 to be delayed to the last moment."
12 A. That is true.
13 Q. "Usually the cancellation would occur because of lack of
14 ITU beds and/or shortage of trained nurses in ITU or
15 operating theatres."
16 A. That is true.
17 Q. Your statement at paragraph 30 on page 35 -- this is
18 WIT 132/35 -- your second statement, you say there:
19 "Cases would sometimes have to be cancelled owing
20 to a shortage of ICU beds or alternatively the child not
21 being fit for surgery rather than unavailability of
22 theatre staff."
23 A. I think that is true.
24 Q. So that differs slightly, does it not, from the point
25 that Mr Dhasmana makes?
0014
1 A. I think Mr Dhasmana is using probably two examples that
2 I can think of in several years when we were cancelling
3 on a weekly basis. I do not really consider that to be
4 as relevant as the fact that it was more often due to
5 a lack of an ITU bed.
6 Q. So as far as you recall, the most common reason for
7 last-minute cancellation of an operation was a lack of
8 intensive care bed?
9 A. That is true. The other circumstance I can think of is
10 when the theatre staff would have been in during the
11 night and therefore we are required to have a period of
12 rest before we can come on duty again. In those
13 situations, what usually happened was the cases would be
14 staggered through the day and the second theatre would
15 start once those staff were able to come on duty. That
16 may be what he is referring to there.
17 Q. Let us have a look at your second statement, please, at
18 WIT 132/26, paragraph 3 on page 27.
19 You say in the second line that you first became
20 aware of differences in outcomes between the outcomes of
21 paediatric cardiac surgery at the BRI and other units in
22 1992 when Dr Bolsin showed you some data in respect of
23 the switch and AV canal operations.
24 Why did Dr Bolsin choose you to show the data to
25 you?
0015
1 A. He did not just choose me, he showed it to many people.
2 I am merely answering the question there that that is
3 when I became aware.
4 Q. Who else, to your knowledge, did he share the data with?
5 A. He would regularly share his work in the coffee room in
6 front of whoever may have been sat there at the time,
7 whoever was in theatre at the time. I would think there
8 were very few people working within the theatre
9 environment that had not seen those papers.
10 Q. So generally, the nurses who worked in theatre would
11 have been aware --
12 A. Would have known about his work, yes.
13 Q. What was your impression of what Dr Bolsin expected or
14 wanted you to do with this information he was giving
15 you?
16 A. I do not actually think Dr Bolsin expected us to do
17 anything with the information. I think he himself was
18 already going down that channel himself.
19 Q. Which channel?
20 A. Of actually trying to get something done about our
21 results. So by showing it to us, I do not think he
22 actually was asking us to do anything about it; I think
23 it was just a way of saying "Look at this: this is what
24 is happening. Do you realise this?" It was really
25 looking for approval rather than actually expecting us
0016
1 to do something about it. We were not in a position,
2 I do not feel, that we would have been listened to or
3 that there was anything we could do about it, but he
4 was, and he was doing that.
5 Q. Did he ever ask you to do anything? Did he ever say
6 "Look, Kay, I want you to go to X and say Y"?
7 A. No, he did not.
8 Q. You referred to the channel he was going down in terms
9 of trying to draw his data to the attention of with
10 whoever's attention it ought to be drawn to. Who
11 specifically did you understand Dr Bolsin to be
12 approaching with this data?
13 A. I am afraid I cannot really answer that question,
14 because I do not really know whom he was showing it to
15 at the time.
16 Q. Did you know Dr Black at all?
17 A. I know of Dr Black. I do not know him.
18 Q. Did he ever speak to you about the --
19 A. No, he did not.
20 Q. -- audit he and Dr Bolsin were carrying out?
21 A. He did not work within my department.
22 Q. Did any of the other anaesthetists either separately
23 raise these matters with you or, as far as you were
24 aware, ally themselves with Dr Bolsin?
25 A. The anaesthetists did not speak to me about this matter,
0017
1 the other anaesthetists. I am only aware from, again,
2 listening to conversations in coffee rooms that
3 I believe Dr Ian Davies supported Dr Bolsin. I do not
4 know who else did.
5 Q. And Dr Davies was one of the other anaesthetists?
6 A. Consultant anaesthetists.
7 Q. When you say it was your impression that Dr Bolsin was
8 really looking for approval from you and people like you
9 by giving this data, did you think he needed or wanted
10 approval, and if so, why did he need the approval of
11 theatre sisters?
12 A. "Approval" might be the wrong word to use, but he liked
13 to show his work to people whatever he was doing. It
14 did not have to be involved with these issues. Whatever
15 he was looking at at the time. He liked to show us what
16 he was doing.
17 Q. Was that being a bit of a show-off?
18 A. I guess he was. Yes, he was a bit of a show-off.
19 Q. Did that rub some people up the wrong way?
20 A. Yes.
21 Q. His was an uncommon attitude among the consultants in
22 that he would discuss what he was doing with nurses and
23 with whoever happened to be in the coffee room at the
24 time?
25 A. That is true.
0018
1 Q. Was there any other consultant, the anaesthetist or
2 otherwise, who took a similar approach?
3 A. No. I do not think there was.
4 Q. You refer over the page, at page 28, paragraph 6, to an
5 article which you think was in the BMJ --
6 A. I am not sure of that.
7 Q. -- referring to somebody called Marc de Leval, which
8 Dr Bolsin showed you?
9 A. Yes.
10 Q. Had you ever heard of Marc de Leval when he showed you
11 the article?
12 A. No, I had not.
13 Q. Can we look at PAR(1) 8/136.
14 If we just see the top of the page, the whole
15 page, do you remember, is that the article, "Analysis of
16 a cluster of surgical failures"? Perhaps if we blow up
17 the top paragraph, you will see that Mr de Leval reports
18 one death in the first 52 patients; then a series of
19 deaths; he then visited a low risk institution, and then
20 returned after patient number 68 died?
21 A. That was the content of the paper I looked at. I would
22 not recognise that that is definitely the same paper,
23 but certainly those were the facts that I was aware of.
24 That is the same story.
25 Q. If we go to WIT 132/30, paragraph 15, you say there that
0019
1 you now realise from your current experience that
2 children were being referred late for the switch
3 operation at 3 to 6 months rather than 2 to 4 weeks; the
4 same is true for many of the procedures coming out.
5 You now work with Mr Pawade at the Children's
6 Hospital?
7 A. That is correct.
8 Q. What is the typical age of switch patients for
9 Mr Pawade?
10 A. I would say approximately 10 days.
11 Q. Why should it have been, do you think, that patients
12 were referred late for switch operations? Was it
13 because, for example, that was the done thing at the
14 time, or is it your impression that patients were
15 referred later at Bristol than they were elsewhere?
16 A. I am not aware of at what point they would be referred
17 elsewhere and I can only assume that that was the time
18 that cardiologists thought it appropriate to refer them
19 to us at the BRI.
20 Q. The referral to the BRI would generally be from one or
21 other of the paediatric cardiologists at the Children's
22 Hospital; is that right?
23 A. Yes.
24 Q. They in turn might have referrals, if a baby was born in
25 the Maternity Hospital, from there, or was born
0020
1 elsewhere, from a centre more remote from Bristol?
2 A. That is true.
3 Q. So are you able to form a view as to where the delay in
4 the system was, whether it was with the cardiologists in
5 the Children's Hospital or whether it was further back
6 in the chain?
7 A. No, I am not, because as I said, at the time, I was not
8 aware that we would normally have been operating on them
9 earlier.
10 Q. How well did you know the paediatric cardiologists?
11 A. I did not really know them at all.
12 Q. Before you moved to the Children's Hospital, how many of
13 them had you worked with?
14 A. I had met Alison Hayes.
15 Q. In what circumstances?
16 A. She would occasionally come down when we had done
17 a repair, such as a VSD repair, and do an echo to check
18 the repair for the surgeon.
19 Q. At whose behest would she come to do that?
20 A. The surgeon's.
21 Q. And did both surgeons sometimes ask her to do so?
22 A. Yes, they did.
23 Q. What about the other paediatric cardiologists:
24 Dr Jordan, who retired, I think, in 1993; Dr Joffe;
25 Dr Martin?
0021
1 A. I had never met them before I went to the Children's
2 Hospital. However, occasionally Dr Peter Wilde, who is
3 one of the adult -- I do not think he is a cardiologist,
4 he is a radiologist -- he would come and do the echos
5 for us.
6 Q. You still do essentially the same job at the Children's
7 Hospital as you did at the BRI?
8 A. Yes.
9 Q. Do you see the cardiologists more often now? I do not
10 mean meet them in the coffee room: do you actually work
11 with them more often than you did at the BRI?
12 A. They still come to theatre to do the echos. I actually
13 have access now to the cardiology meeting, if I wish to
14 go on a Tuesday, which I did not previously, so I would
15 meet them there, but apart from that, only on the
16 occasions which they may be required to come to theatre
17 again to check a repair.
18 The other thing, we put in many more pacing boxes,
19 things in theatre now.
20 Q. What is discussed at the cardiology meetings on the
21 Tuesday that you got access to?
22 A. They discuss the forthcoming cases, so it gives an idea
23 to either the theatre staff or the perfusionist what
24 will be taking place in the next two or three weeks.
25 Q. Some of the same cardiologists are still working today
0022
1 as were working previously when surgery was carried out
2 at the BRI. Dr Joffe, I think, has fairly recently
3 retired?
4 A. Yes.
5 Q. And yet Mr Pawade's operations, for example, on the
6 switch, you have told us now take place at about 10 days
7 or thereabouts?
8 A. That is true.
9 Q. How has it come about that the referrals have now got to
10 the stage where the operations can take place so much
11 earlier?
12 A. I do not know. You would have to ask a cardiologist
13 that.
14 Q. But it is the same cardiologists?
15 A. Yes, it is.
16 Q. Tell me if you do not know the answer to this: to what
17 extent does the surgeon have the ability to influence
18 the time when the operation ought to take place for
19 a particular condition?
20 A. I am sorry, I do not really know.
21 Q. At paragraph 17, the bottom of the page there, you say
22 you were made aware in approximately 1992 of the fact
23 that they should be operating sooner, by a Registrar who
24 had experience in other centres.
25 Do you remember who this person was?
0023
1 A. Yes. I have remembered now. His name was Kevin
2 Waterson.
3 Q. And where did he work? Which other centres?
4 A. He had worked in Melbourne with someone called Roger
5 Mee, I think his name was, who was the same person
6 Mr Pawade worked with.
7 Q. And Mr Waterson was a Surgical Registrar?
8 A. Yes. In fact he had an overseas post. I do not know
9 what his exact title was.
10 Q. Did he only make you aware of this fact, or was it
11 something that he, rather like Dr Bolsin, was telling
12 you?
13 A. He was very outspoken, like Dr Bolsin. He would talk to
14 us in the coffee rooms.
15 Q. So again, his view that the operation was taking place
16 too late: the general run of staff in the BRI Cardiac
17 Unit would have known that was Mr Waterson's view, would
18 they not?
19 A. That is true.
20 Q. Do you know if he ever broached this view to the
21 surgeons?
22 A. No, I do not.
23 Q. Did you ever say to perhaps one of the consultant
24 anaesthetists at the end of an operation, "I hear we are
25 doing these operations much later than they do in some
0024
1 other centres"?
2 A. No, I did not.
3 Q. At page 37, paragraph 37 in the middle of the page, when
4 answering the question which I think is E11(c) in our
5 Issues List about complications that might be
6 encountered by the surgeon, you say that the paediatric
7 cardiac surgery team would know what operation was going
8 to be performed but when a child arrived in theatre, the
9 surgeon would quite frequently find an abnormality
10 present in the heart that had not been identified
11 previously in the cath' lab?
12 A. That is true.
13 Q. How frequent an occurrence was that?
14 A. It was quite frequent. I would not like to say
15 numbers. It would happen -- it happens on quite
16 a regular basis. It still does.
17 Q. Did the surgeons ever express surprise or annoyance --
18 A. They get very annoyed.
19 Q. Why? It may be obvious, but why?
20 A. Because, for example in the example I have given there,
21 it would change their technique for having to put that
22 child on to the bypass machine. If they had known about
23 there being an extra superior vena cava present, they
24 would be prepared for a totally different set up. So,
25 yes, they can change it, but it is just something that
0025
1 is annoying for them.
2 Q. How did the annoyance manifest itself? Did the surgeon
3 look at the patient and curse and swear, or --
4 A. Usually.
5 Q. Obviously they had to react to the situation as they
6 found it and get on with it and try to effect a repair?
7 A. Yes.
8 Q. Was the cardiologist ever called into the theatre during
9 the operation or subsequently on these occasions?
10 A. Sometimes they are called if we find something like an
11 extra ventricular septal defect present or something
12 like that which we were not expecting. They may well be
13 called to just check there is nothing else. So, yes,
14 they do occasionally get called to theatre.
15 Q. Was it your impression that when these unexpected
16 problems were discovered on the operating table for the
17 first time, that generally speaking the surgeons thought
18 these problems ought to be picked up sooner, or did they
19 accept that it was one of those things that can easily
20 have been missed?
21 A. No. Mostly they felt that it should have been picked
22 up.
23 Q. By ...
24 A. By the cardiologists.
25 Q. During either ...
0026
1 A. During their catheterisation, or echos, yes.
2 Q. If we go to -- it sits with this, perhaps -- page 38,
3 paragraph 39:
4 "All patients undergoing paediatric cardiac
5 surgery underwent cardiac catheterisation to assist
6 diagnosis."
7 That would be carried out during the split site
8 days at the Children's Hospital?
9 A. Yes.
10 Q. After 1987, I think when the new cath' lab opened?
11 A. I do not know where they were carried out. I have never
12 worked in the Cardiology Department.
13 Q. That whole paragraph, I take it, is dealing with
14 paediatric cardiac surgery, is it?
15 A. Yes -- I am sorry?
16 Q. The whole paragraph is dealing with paediatric cardiac
17 surgery?
18 A. Yes.
19 Q. At paragraph 54, page 42, you refer to the perfusionist,
20 Mr Caddy, who was replaced subsequently by Mr Downes
21 when Mr Caddy retired. You say that after Mr Downes'
22 appointment, the theatre staff and perfusionists worked
23 much better together as a team, which I assume you
24 considered to be a good thing?
25 A. That is correct.
0027
1 Q. What was the problem with Mr Caddy, then?
2 A. I do not think it was a problem with Mr Caddy; it was
3 purely that he and Richard had different ways of running
4 their department.
5 Q. In what ways were they different?
6 A. Mr Caddy would not ask for my advice on anything. There
7 was no reason why he should do. I know nothing about
8 perfusion. But Mr Downes will often come to me and we
9 will discuss cases together, so it just makes for
10 a better working relationship when you are in the same
11 environment all the time.
12 Q. So is it just that Mr Downes is a bit more sociable than
13 Mr Caddy was?
14 A. Well, sociable, but, yes, he is just more -- I just feel
15 I know what is going on more with the Perfusion
16 Department at the moment, whereas I did not before. But
17 that is not criticising Mr Caddy; it is just easier for
18 me.
19 Q. Let us look at paragraph 56, down the same page:
20 "Regarding the hours of work, these were and are
21 excessive ..."
22 Pausing there, is that a comment that you would
23 apply to the theatre nurses, first of all?
24 A. Yes, and to other members of staff working in the
25 theatre.
0028
1 Q. Then you say:
2 "I do not think that people under performed at
3 work because of the hours they were working."
4 If I was overtired or overstressed and unable to
5 cope, all of which are common ailments for me, I would
6 be under-performing at work.
7 Would one not expect under-performance if people
8 were working, regularly, hours that were excessive?
9 A. I think when you are regularly working long hours, yes,
10 you get tired, but in the job that we do, I do not think
11 you can be allowed to make mistakes. Therefore part of
12 my job is to monitor the theatre staff, that they are
13 not making mistakes and that they are performing well in
14 the case. If they are not, then I should pull them out.
15 Q. So it is not that working long hours does not lead to
16 under-performance; it is that there is a safety net to
17 prevent under-performance. Is that the point?
18 A. That is right. That is the point.
19 Q. How does that safety net operate?
20 A. There would always be someone like myself as a senior
21 member there, who is watching what is going on during
22 the case, monitoring people's performances.
23 Q. You would be monitoring whose performance? The nurses'
24 performance?
25 A. The nurses' performance, nobody else's.
0029
1 Q. You would not be monitoring the anaesthetists, the
2 perfusionists or the surgeons?
3 A. No, I would not have time to do that.
4 Q. I am not suggesting you should be, but you would not
5 be.
6 A. No.
7 Q. When I asked you whether this comment about
8 excessive hours of work applied to the nurses, you said
9 yes, it did, and to all the other staff in the operating
10 theatre?
11 A. If the nursing staff are there working, then, yes, it
12 stands to reason that the rest of the departments are
13 there as well, the perfusionists, the anaesthetists and
14 the surgical team.
15 Q. It may be implicit in what you have already said, but
16 there was no safety net in the theatre in place for the
17 anaesthetists or the surgeons in the same way that there
18 was for the nurses; is that right?
19 A. Well, the perfusionists have their own boss. Regarding
20 the medical staff, I do not know.
21 Q. What was your impression of the hours of work undertaken
22 by the paediatric cardiac surgeons that you worked with
23 at the BRI?
24 A. I think they were excessive.
25 Q. What is your evidence for that?
0030
1 A. They were regularly still in the hospital 10 o'clock,
2 12 o'clock at night.
3 Q. What time did they start in the morning?
4 A. 8 o'clock.
5 Q. Did that apply to Mr Wisheart?
6 A. Yes.
7 Q. Mr Dhasmana?
8 A. Mr Dhasmana worked very long hours as well, but I do not
9 think quite -- he was not late in the department quite
10 as much as Mr Wisheart was.
11 Q. Why was it, as far as you are aware, that Mr Wisheart
12 was there particularly lengthy hours?
13 A. I believe he did very lengthy ward rounds, or ITU
14 rounds, but I heard that from the ITU nurses.
15 Q. He was particularly thorough, was he?
16 A. Yes, that is another way of putting it.
17 Q. Another way of putting it might be that he was slow?
18 A. I cannot comment on that. I was not there.
19 Q. Did you ever have the impression that excessive work was
20 taking its toll on the surgeons?
21 A. I think occasionally, particularly with Mr Dhasmana,
22 I would know when he was tired because his temper would
23 deteriorate.
24 Q. I recognise that phenomenon!
25 A. But Mr Wisheart would often catnap in the coffee room
0031
1 between cases. He would often just have a small sleep
2 then, which I presume meant he was tired.
3 MR MACLEAN: Sir, I have dealt with the first two statements
4 from Mrs Armstrong. I have not yet dealt with the
5 third. I do not think I will be more than half an hour,
6 but it may be wise to have a break. The reason for that
7 is that whilst I have been on my feet I have been handed
8 a response by Mr Wisheart to the third statement of
9 Mrs Armstrong. No criticism of Mr Wisheart that it is
10 delivered at this stage because the statement itself is
11 only dated 6th October, yesterday. I do not suppose
12 Mrs Armstrong has had a chance to see these responses.
13 A. I have seen it.
14 Q. I am told you have not; it is a second set of responses
15 from Mr Wisheart. It may be wise for everyone else,
16 apart from Mrs Armstrong and I, to have a cup of tea and
17 for us to look at these comments from Mr Wisheart.
18 THE CHAIRMAN: For all of those reasons, we will take 15
19 minutes and reconvene at 10.45.
20 (10.30 am)
21 (A short break)
22 (10.45 am)
23 MR MACLEAN: Mrs Armstrong, we have dealt I think with your
24 first and second statements. I want to turn now,
25 please, to the third. That is WIT 132/54. It is your
0032
1 statement specifically concerned with Issue N in the
2 Inquiry's Issues List.
3 Can I take you to paragraph 8, page 56? You say
4 there that Dr Bolsin was concerned that too many
5 children had died and that was related to the length of
6 time the surgery was taking, the time on bypass and the
7 difficulties that caused with getting the child off
8 bypass?
9 A. Yes.
10 Q. In your second statement at page 43, paragraph 58, you
11 say that you were not aware of how Bristol compared
12 regarding the length of surgery with other units?
13 A. No. I was not. I was not aware whether other units
14 were taking the same length of time. What Dr Bolsin
15 said to me was that we were taking -- the cases were
16 taking too long and this was why the children were
17 dying, but I still did not know what the results were
18 like in other centres.
19 Q. But implicit in a suggestion that Bristol was taking too
20 long would be a suggestion that other places would do
21 them rather quicker, would it not?
22 A. Well -- yes, I guess you are right.
23 Q. You yourself did not have any knowledge of the length of
24 time that operations took elsewhere?
25 A. No. Only what Mr Waterston had told me regarding Mr Mee
0033
1 in Australia, that he was much quicker a surgeon, but
2 that was one surgeon being given as an example.
3 Q. You have been working for, what is it now, 4 and a bit
4 years with Mr Pawade, who I think started in May 1995?
5 A. I started in January 1996.
6 Q. You were off, I think, for a period in 1995 on maternity
7 leave?
8 A. That is correct.
9 Q. So you have been working with Mr Pawade for getting on
10 for four years now; is that right?
11 A. That is correct.
12 Q. Have you noticed any difference in the length of time
13 either of the operation as a whole or the time on bypass
14 since he has been surgeon?
15 A. Yes. He is much quicker.
16 Q. Does that shorter time on bypass make it easier, as far
17 as you are aware, to get the child off bypass?
18 A. It does seem to.
19 Q. Do you know why that is?
20 A. I am not really clinically trained to comment on that.
21 Q. We have mentioned the Surgical Registrar who had worked
22 in Melbourne, and we have mentioned Dr Bolsin's concerns
23 as expressed to you, showing you the data, and so on.
24 What other sources of information did you have
25 about alleged poor outcomes at Bristol other than
0034
1 Dr Bolsin and the people we have already discussed?
2 A. I do not think I did, at that time.
3 Q. Can I just show you page 62, please, paragraph 29? This
4 is your third statement. You mention there Helen
5 Stratton.
6 A. Yes, I do.
7 Q. She left the BRI before the children's surgery was
8 transferred to the Children's Hospital?
9 A. Yes, she did.
10 Q. Are you able to date these expressions or comments of
11 Helen Stratton to you?
12 A. No, I am not, because what she would say to us was done
13 when she was coming down to enquire for the parents how
14 an operation was going, and obviously when I said that
15 she expressed concern, what I was meaning there was that
16 it is obviously very distressful if the operation is not
17 going well. I do not recall her expressing any concern
18 regarding the surgeons themselves.
19 Q. So what was the specific nature of her comment?
20 A. A human response, that it is very sad to know that
21 something is not going as well as you would want it to.
22 That is very distressing.
23 Q. In your third statement at paragraph 10, page 57, you
24 say that between 1992 and 1994, Dr Bolsin's concerns
25 were "gathering momentum", as you put it.
0035
1 What do you mean by that? Do you mean he was
2 gathering more support to his cause, or that he was
3 expressing his concerns more loudly, or what?
4 A. We all felt that he did seem to be getting somewhere
5 with his efforts to stop us operating on children, which
6 was what his end aim was, I know that, because he did
7 tell me that.
8 Q. What was the evidence for that, that he was "getting
9 somewhere"?
10 A. He seemed to be meeting with various people and it
11 seemed to be under discussion, which it had not been
12 previously, and he did not seem to be willing to let
13 that drop, so we all felt that he was doing his best to
14 do something about it.
15 Q. Do you know who he was talking to, discussing it with?
16 A. I certainly know he discussed it with Professor
17 Angelini, who supported him. I believe he had spoken to
18 Dr Roylance. Several people he told me he had sent
19 letters to, but I am afraid I do not remember names
20 because I do not come into daily contact with these
21 people, so I do not remember their names.
22 Q. Professor Vann Jones?
23 A. I believe he did send a letter to Professor Vann Jones,
24 yes. But I may remember that from the inquest, I am
25 sorry.
0036
1 Q. You mean the GMC Inquiry?
2 A. Yes.
3 Q. You say in paragraph 10 that you dreaded seeing complex
4 paediatric cardiac surgery scheduled when you were due
5 to be the scrub nurse?
6 A. That is true.
7 Q. When did that feeling of dread set in?
8 A. I think it was for particular cases such as the switch
9 and cases like AV canals, which did appear to be the
10 ones that did not do very well in theatre. It was very
11 hard to have to scrub for those cases when you realised
12 that it may well end with the child dying at the end of
13 the case.
14 Q. In your statement to the GMC, which we need not go back
15 to, can I just read to you a sentence from it? You said
16 you had been concerned from around 1991 about the high
17 mortality and morbidity for switch operations carried
18 out on children in the Cardiac Unit at the BRI --
19 A. I am not sure that date is correct, actually. That was
20 the date that was given to me by the gentleman that was
21 taking my statement.
22 Q. I see. Taking your statement for the GMC?
23 A. Yes.
24 Q. As opposed to the statements for this Inquiry?
25 A. That is right, which I think I have explained, that
0037
1 I believe it was around 1992, but I am not absolutely
2 sure.
3 Q. So your best recollection is, notwithstanding what is in
4 the GMC statement which was suggested to you by somebody
5 else, that the beginning of your concerns was 1992,
6 which is when Dr Bolsin showed you his data; is that
7 right?
8 A. That is correct.
9 Q. Before Dr Bolsin showed you his data, did you have any
10 concerns of your own, gnawing away at the back of your
11 mind?
12 A. I did not realise at that time that the children could
13 possibly have done better in another centre. We always
14 have concerns. If a child does not do well, it is
15 a very distressing situation to be in, so, again, your
16 concern is a very human response to a child's death, but
17 that was what my job was at the time and that is what
18 I had to do, to scrub for those cases.
19 Q. You say again in that GMC statement that nursing staff
20 talked frequently amongst themselves about the concerns
21 they had. You touched on that earlier.
22 A. Regarding the children dying, yes.
23 Q. Would that nursing staff embrace theatre and intensive
24 care nursing staff?
25 A. We did not have a great deal of contact with the
0038
1 intensive care girls, really. We would take patients up
2 at the end of the case, hand over, but the nurses
3 themselves were then obviously very busy receiving that
4 patient into their care, so we would then have to go
5 back to theatre to prepare for either the next case or
6 to put the theatre ready for the next day.
7 So I did not have the opportunity to talk to the
8 intensive care nurses about this.
9 Q. So you do not remember discussing the concerns that you
10 had with Julia Thomas, for example, or her successor,
11 Fiona Thomas?
12 A. No, I am sure I never discussed it with Julia Thomas.
13 Q. Let us look further down this page, at the bottom of the
14 screen, paragraph 12. You say in the middle of that
15 paragraph that in the middle of 1994, you and other
16 theatre nurse colleagues stopped scrubbing for complex
17 paediatric cardiac surgery cases?
18 A. We took that choice ourselves; that we did not wish to
19 scrub for the complex cases any more.
20 Q. And with two exceptions: Alison Reed and Onyx Berwin?
21 A. Brewin. That is spelt wrong; her name is Brewin.
22 Q. What was the reaction of first of all the surgeons and
23 secondly the management of the hospital when 7 out of 9
24 members of staff said they were not doing it any more?
25 A. I think what I put in my statement is that we stopped
0039
1 scrubbing. We did not actually approach the surgeons or
2 take a stand against the surgeons and tell them we were
3 not willing to scrub. Those two people were willing to
4 do those cases, so it did not affect the throughput of
5 the children at that time.
6 Q. So the operations carried on as before?
7 A. They carried on and the surgeons and the management were
8 not aware of the fact of who was scrubbing for the
9 cases.
10 Q. So this was a kind of unnoticed protest, almost, in that
11 because there were two who were still willing to do the
12 job, life carried on as before as far as the surgeons
13 were concerned?
14 A. I cannot speak for the other girls who were not
15 scrubbing for the cases. I can only say for myself that
16 I could no longer bring myself to go and scrub for those
17 cases.
18 Q. Did you make this, if I use the word "protest",
19 "stand", if you like, known to the Nurse Adviser to the
20 Trust, or any of the more senior nurses in the Trust?
21 A. No.
22 Q. Margaret Maisey, I think, was ultimately the Nurse
23 Adviser to the Trust, was she not, and later the
24 Director of Nursing?
25 A. Was she?
0040
1 Q. Did you know that?
2 A. I know Margaret Maisey. I cannot recall what her titles
3 were. My only involvement with her was during the
4 grading, which was several years before.
5 Q. That was before the days of the Trust, in the late
6 1980s. I think she was Director of Operations and later
7 Director of Nursing. While she was Director of
8 Operations, I think I am right in saying she retained
9 a post as Nurse Adviser to the Trust.
10 A. Did she?
11 Q. Leaving her aside, you did not bring this stand that you
12 and your colleagues were taking to the attention of
13 anyone else in the managerial side of nursing in the
14 Trust?
15 A. No. I still say, I do not believe we were taking
16 a stand, because we did not do that. What we were doing
17 was saying that "We do not find it tolerable to scrub
18 for these cases", so any nurse in the department who
19 would tell me that she did not wish to scrub, then
20 I would certainly not make her scrub for one of those
21 cases.
22 Q. But why did not you bring it to the attention of some of
23 the management? After all, if all 9 members of staff
24 took the same view, then the system would have ground to
25 a halt, would it not?
0041
1 A. Because the other two members of staff were not willing
2 to do that. They were content to carry on scrubbing for
3 these cases.
4 Q. Happy or content?
5 A. I do not know. I cannot speak for them, really. They
6 did not want to stop doing them.
7 Q. Was this a state of affairs that had ever happened in
8 respect of any other operations, any other surgery you
9 had ever been involved with in your career, that scrub
10 nurses took it upon themselves no longer to scrub for
11 certain operations?
12 A. Not for operations. There are some scrub nurses that
13 perhaps would not want to scrub for certain surgeons,
14 but that is usually a personality clash and can be
15 avoided.
16 Q. You say in this paragraph, in the sentence we have been
17 looking at, that you and other theatre nurse colleagues
18 stopped scrubbing for complex paediatric cardiac cases.
19 A. That is correct.
20 Q. Did you still scrub for non-complex cases?
21 A. Some of the girls did, yes.
22 Q. Did you?
23 A. I was actually working as a surgeon's assistant at that
24 time, plus anaesthetic sister, so I was not really in
25 a position to have done it then.
0042
1 Q. How would you have decided whether a case was complex or
2 not complex?
3 A. This is just my opinion: my opinion of a non-complex
4 case is either an ASD or possibly some VSDs. Most other
5 congenital heart surgery is complex.
6 Q. You say at the end of that paragraph -- just bear with
7 me a second. I asked you whether you still scrubbed for
8 non-complex cases and you said some of the girls did?
9 A. That is true.
10 Q. I asked if you did, and you said you were working as
11 a surgeon's assistant at the time, as well as being the
12 anaesthetic sister. You said "So I was not really in
13 a position to have done it then". You mean --
14 A. I have probably not worded that very well. What I mean
15 is that the majority of my workload at that point would
16 have been in the anaesthetic room and working as
17 a surgeon's assistant. On my surgeon's assistant days
18 I would always be in with an adult because it was to
19 take veins out. Unless they were short of a scrub
20 nurse, at the time, being an anaesthetic sister, I would
21 be in the anaesthetic room.
22 Q. So your work had just taken you out of the potential
23 loop generally for being a scrub nurse?
24 A. I was still capable of scrubbing for the cases should
25 they be short of a scrub nurse, but at that point in
0043
1 time, it was not my usual routine.
2 Q. And you were not anxious to do so?
3 A. No.
4 Q. Can we go back to paragraph 12? Towards the bottom of
5 the paragraph you say:
6 "At some point during 1994, both Mr Wisheart and
7 Mr Dhasmana had been stopped from performing complex
8 heart surgery."
9 A. That is true.
10 Q. Who did you understand had stopped them?
11 A. We understood they had been stopped by the Department of
12 Health. I have seen Mr Wisheart's comment now.
13 Q. From where did you get that impression?
14 A. From Dr Bolsin.
15 Q. Let us look at what Mr Wisheart says. It is
16 WIT 132/69. You have seen this over the break, I think?
17 A. I have.
18 Q. This is the first page of three: Mr Wisheart's comments
19 on your third statement.
20 If we go to the next page, page 70, let us look at
21 the second comment on that page first, paragraph 3:
22 "Mrs Armstrong is mistaken in saying that such
23 a decision was made", in other words, a decision to stop
24 him and Mr Dhasmana performing complex heart surgery.
25 "The surgeons were not stopped from operating on
0044
1 complex neonatal cases in 1994, or stopped from
2 operating on any other type of case. In October 1993,
3 Mr Dhasmana himself stopped doing neonatal switch
4 operations. I did no correction of complete
5 atrioventricular septal defects after August 1994."
6 So the suggestion there is that the surgeons
7 themselves decided to desist respectively from neonatal
8 switches and complete AVSDs, rather than being stopped
9 from on high.
10 A. That was not the information I was given, but I wish
11 Mr Dhasmana and Mr Wisheart had informed us as the
12 theatre sisters of that decision themselves.
13 Q. So just to be clear, your impression was that the
14 Department of Health had stopped these two surgeons
15 operating on, what, all complex --
16 A. On complex cases.
17 Q. Paediatric cardiac cases?
18 A. Yes.
19 Q. Not just neonates?
20 A. I did not believe it to be neonates. We believed it was
21 to be all complex surgery, and certainly, the caseload
22 of complex surgery decreased dramatically after that.
23 Q. And you got that impression directly from Dr Bolsin?
24 A. Yes.
25 Q. From anyone else?
0045
1 A. I honestly cannot remember.
2 Q. When did you first become aware of the fact that the
3 children's surgery was going to move up the hill to the
4 Children's Hospital?
5 A. The first time I was made aware of it, I think was when
6 Dr Martin Elliott came down from London to look around
7 our facilities regarding taking up a professorial chair,
8 and the idea then was that he would be based at the
9 Children's Hospital, not at the BRI.
10 Q. Mr Wisheart says at the top of that page that at the
11 time, in 1994, when you said you and some of your
12 colleagues were refusing to scrub for the complex
13 paediatric cases, the decisions to appoint a new
14 surgeon, Mr Pawade as it comes out, and to move the work
15 to the Children's Hospital were being taken?
16 A. That is correct.
17 Q. You knew that?
18 A. I knew that. I think I have commented on that in my
19 statement, that we always thought this: that there was
20 a new surgeon being appointed and the work was being
21 moved to the Children's Hospital, but staff started to
22 get despondent when this all took such a long time.
23 Q. When I was touching on who you could have spoken to in
24 the nurse management side of the Trust about the
25 concerns which you had and the information you had been
0046
1 given by Dr Bolsin, I should perhaps have taken you back
2 to your first statement, page 12, paragraph 32.
3 You say at the end of that paragraph:
4 "The majority of staff", and I think that is
5 a reference to nursing staff, is it?
6 A. Yes.
7 Q. " -- were unwilling to make formal complaints because of
8 concern about job security. In this situation, all that
9 could be done was to accommodate that complaint and act
10 upon it as far as possible."
11 Where would the threat to job security come from
12 for a nurse making a complaint about clinical outcomes?
13 A. I think the problem is that nurses probably undervalue
14 themselves and you always feel that you will maybe not
15 be listened to should you make a complaint about
16 something, so it very rarely gets any further than
17 possibly the Sister or your first line manager level.
18 I think there is always the fear, as well as, that you
19 could end up being suspended or --
20 Q. Was anyone ever suspended for raising concern, so far as
21 you are aware?
22 A. No, I do not think so.
23 Q. So what was the basis for this concern that a nurse
24 might lose his or her job?
25 A. I think it is based on the fact that nurses have always
0047
1 felt in awe of the senior management and hospital
2 consultants. That is changing slowly now, but that has
3 been the case for many years.
4 Q. Was there a feeling that nurses concerned would not be
5 taken seriously by management?
6 A. Yes.
7 Q. And what was done in order, if anything, to encourage
8 nurses that that impression was false?
9 A. I think I can only talk from my own point of view.
10 I would certainly encourage anybody that wished to make
11 a statement or a complaint about anything to go to
12 a higher authority if necessary, but I do not feel that
13 I was in a position to force them to do so if they did
14 not feel they wanted to do that.
15 Q. Just going back to this business of stopping the
16 surgeons doing surgery, if Dr Bolsin had said to you
17 something like "The Department of Health have stopped
18 Mr Wisheart and Mr Dhasmana from doing complex
19 paediatric surgery", if that had been the case, there
20 would have been no more complex surgery at all, because
21 they were the only two paediatric cardiac surgeons?
22 A. That is true.
23 Q. But there was, throughout 1994, some complex paediatric
24 surgery being carried out?
25 A. Towards the end of the year, was there?
0048
1 Q. Was there, or was it your impression?
2 A. My impression was that the majority of my work -- my
3 memory may be failing me here, but I remember it that we
4 were doing quite a view VSDs and ASDs and we did some
5 total caval pulmonary connections which our results were
6 very good for, but I do not remember doing any AV canals
7 or -- I cannot remember doing any, actually. We may
8 have done, but I do not remember doing them.
9 Q. Because you were one of the seven or so who was not
10 scrubbing for complex paediatric cases?
11 A. That is true, but I was working in the department.
12 Q. If what Dr Bolsin said had been right, there would have
13 been no need for the seven or so nurses to refuse to
14 scrub for complex paediatric cases, because there would
15 have been none at all?
16 A. That decision came before the decision to stop us doing
17 complex surgery.
18 Q. So does that help us to date the information that the
19 Department of Health had, as you understood it, stopped
20 Mr Wisheart and Mr Dhasmana? Would that have been about
21 June or July of 1994?
22 A. I would be guessing. I really do not know.
23 Q. The decision which you and your colleagues took to stop
24 scrubbing for complex paediatric work you said was 1994?
25 A. I think it was -- yes, it was some time before that
0049
1 decision was made to do no more complex surgery.
2 Q. The operation on Joshua Loveday, which we are going to
3 come to, took place in January 1995?
4 A. That is true.
5 Q. So is this right: that the information you were given
6 about the Department of Health having stopped
7 Mr Wisheart and Mr Dhasmana from doing these operations
8 was some time between the decision to stop scrubbing and
9 the Loveday operation?
10 A. Yes, it was.
11 Q. Do you think you might be able, by looking back at
12 records, to more precisely date the decision to stop
13 scrubbing for the complex cases, if you were given some
14 more time to think about it?
15 A. I think the only way of finding that out would be to go
16 through the registers for that year and the names of the
17 scrub nurses will be beside the cases.
18 Q. So when we start seeing Reed and Brewin for the complex
19 paediatric cases, we will know that --
20 A. That was around the time. If it is their names that are
21 coming up consistently for those cases, then that would
22 be about the time, yes.
23 Q. Let us go to page 58 of your evidence. This is your
24 third statement. Paragraph 14. We turn now to the
25 Joshua Loveday operation.
0050
1 You at this time were training to be a surgeon's
2 assistant, which was an extended role from your usual
3 grade. Mona Herborn was another Sister in the
4 department. She came to see you a few weeks before the
5 operation was due to take place, confirming that the
6 operation was listed. You say, paraphrasing the
7 paragraph, that you spoke to Dr Bolsin, who seemed
8 surprised that the case was on the list?
9 A. That is correct.
10 Q. Was it your impression that Dr Bolsin knew nothing about
11 this planned operation until you had told him?
12 A. Yes, it was.
13 Q. What did he do? How did he react?
14 A. At the time he seemed to think that it would not be
15 a problem and that the child would definitely be
16 cancelled.
17 Q. If it was right that Mr Wisheart and Mr Dhasmana had
18 been stopped from carrying out complex paediatric
19 surgery already, then the operation should never have
20 been listed?
21 A. That is correct. That is why we were complaining.
22 Q. So Dr Bolsin might have realised at this stage that in
23 fact there had not been a complete cessation of these
24 operations ordered by the Department of Health?
25 A. I am sorry, what, prior to us talking to him, you mean?
0051
1 Q. Here is one listed, so it could not have been right
2 there was a cessation, because there was one planned?
3 A. My memory of that is that our main concern at that point
4 was to get that child taken off the list.
5 Q. In your statement to the GMC, when you dealt with this
6 point, you said you were very surprised and so were your
7 colleagues to see that this operation was planned?
8 A. Yes.
9 Q. Which colleagues shared your surprise at the planning of
10 this operation for January 1995?
11 A. Everybody I was working with: the perfusionists, as
12 I said Dr Bolsin, who was an anaesthetist.
13 Q. Why did you understand the operation had been listed?
14 Was it urgent? Did the patient need the operation in
15 a hurry?
16 A. I was not told why. Myself and Sister Herborn did speak
17 to Mr Dhasmana, but again, I cannot remember the exact
18 timing of that so it could have been the day, it could
19 have been the day before, to ask him why we were
20 operating on this switch. He said it was because it was
21 not a neonatal one; it was because of the child's age.
22 Q. Because, as Mr Wisheart has said in his comments on your
23 third statement, Mr Dhasmana had stopped doing neonatal
24 switches in October 1993?
25 A. I cannot remember the date he stopped doing them.
0052
1 Q. That is what Mr Wisheart says.
2 A. Yes.
3 Q. You have no reason to doubt that?
4 A. No.
5 Q. And neonates are essentially birth to 1 month of age,
6 and this patient for January 1995 was older than that?
7 A. Yes. I believe he was 13 months.
8 Q. So that is why it did not fall within Mr Dhasmana's
9 self-imposed moratorium on switches; but did he advance
10 a positive reason why the patient needed the operation
11 in January 1995 as opposed to February/March, or
12 May/June 1995, when there would be a new surgeon?
13 A. No.
14 Q. Did you know at the time this operation was planned that
15 Mr Pawade had been appointed?
16 A. Yes, I did.
17 Q. And you knew when he was going to take up his post?
18 A. Yes.
19 Q. And so, presumably, did Mr Dhasmana?
20 A. Yes.
21 Q. Did you say, "Well, why is this being listed now? Why
22 can it not wait for Mr Pawade?"
23 A. I did not say that to Mr Dhasmana. I did make that
24 comment to Dr Underwood, who was the anaesthetist.
25 Q. That is Sue Underwood, is it?
0053
1 A. Yes.
2 Q. She, as it turned out, was the anaesthetist for that
3 operation?
4 A. That is because she was the anaesthetist for that
5 operation.
6 Q. Can we look at the second page of your statement to the
7 GMC, GMC 14/23, the second paragraph on that page. You
8 say that on the Monday before the operation which was
9 scheduled for a Thursday, your colleague Sister Herborn
10 told you in the presence of Dr Masey -- she was an
11 anaesthetist as well -- "that I was the only scrub nurse
12 available to do that particular operation. Nurse
13 Herborn said that she would prefer if I didn't do it".
14 You said you would decline to act as a scrub nurse for
15 the operation?
16 A. That is correct.
17 Q. If we look at the next paragraph, Dr Masey went and got
18 the book showing he was off duty on the day of the
19 operation?
20 A. That statement is incorrect. I did say several times
21 that was incorrect. Dr Masey did not go and get the off
22 duty book. Mona Herborn already had the off duty book
23 in her hands.
24 Q. So would you take me through that part of the story?
25 A. At the time, Mona was asking me if I would be willing to
0054
1 scrub for the case because I was the only scrub nurse on
2 duty that could do a paediatric case. We were looking
3 down the people rota'd for that day at that time and
4 Dr Masey was stood with us. She pointed out the fact
5 that Alison Reed was on a day off that day, but may well
6 be willing to change her day off.
7 Q. She was one of the ones who had not taken part in the
8 self-imposed exile from complex paediatric cardiac
9 surgery that we discussed?
10 A. Yes.
11 Q. She and Onyx Brewin?
12 A. Yes.
13 Q. So did it turn out that Alison's shift was changed?
14 A. It was changed.
15 Q. So she was the scrub nurse?
16 A. She was the scrub nurse. I do not know who changed her
17 shift.
18 Q. Let us scroll down a little bit and tell me if anything
19 in this paragraph is inaccurate. There was no
20 anaesthetic nurse for the operation?
21 A. That is true.
22 Q. You were asked to do that job and you agreed. Why
23 should you agree to be the anaesthetic nurse and refuse
24 to be the scrub nurse?
25 A. I agreed to do anaesthetics that day, that is correct.
0055
1 I did not think, at the time, that that child was going
2 to come to theatre. That was how much we believed in
3 what Steve Bolsin was telling us, that that child would
4 not be coming to theatre. I really did not think he
5 would.
6 Q. Was there any pressure put on you to be the anaesthetic
7 nurse?
8 A. A comment was made, but I cannot remember exactly by
9 whom, therefore ... it was insinuated, I do not think
10 seriously, that with two anaesthetists present, did they
11 actually need an anaesthetic assistant? But I do not
12 know if it was a serious comment and I cannot remember
13 who made it, but the thought that they might carry on
14 without an anaesthetic assistant, in my view, the child
15 was better off with me acting as anaesthetic nurse on
16 that day.
17 Q. That type of suggestion would be likely to have come
18 from an anaesthetist, would it not?
19 A. Yes.
20 Q. A consultant anaesthetist?
21 A. I really do not remember who made that comment.
22 Q. So you agreed in those circumstances to be the
23 anaesthetic nurse, still not expecting the operation
24 actually to take place?
25 A. That is true.
0056
1 Q. Let us go, then, to your statement, WIT 132/59,
2 paragraph 17. The day of the operation came and the
3 case was still listed. The operation took place and, as
4 is well known and has been mentioned in various
5 broadcasts, media, about the events this Inquiry is
6 concerned with, the child died?
7 A. Yes.
8 Q. You say there that after the operation, Dr Underwood
9 told you that there would be no more, which you
10 understood to mean she would be no longer willing to
11 anaesthetise another child in these circumstances.
12 I asked you about the attitude of the other
13 consultant anaesthetists to Dr Bolsin's data and the
14 concerns that he had been expressing in 1992. You
15 suggested I think that Dr Davies was known at least to
16 you to be an ally, if you like, of Dr Bolsin.
17 By this time, was the attitude of all the
18 consultant anaesthetists that which Dr Bolsin had had
19 three years before?
20 A. At that point, I believe there were still two
21 anaesthetists who felt they would like to carry on with
22 paediatric work.
23 Q. With the same setup and the same surgeons and the same
24 cardiologists?
25 A. I think they themselves would have desired to have been
0057
1 transferred to the Children's Hospital to still carry on
2 doing the paediatric work when it went there.
3 Q. If we look down the page a little, please, to
4 paragraph 18, you say Dr Bolsin showed his work openly
5 to other people in the department, but you do not know
6 who saw it or when they might have seen it.
7 Mr Wisheart has made the comment at page 71, at
8 the top of the page, that Dr Bolsin may have shown his
9 work openly to some people, but he did not show it
10 openly to him, to Mr Dhasmana or to the paediatric
11 cardiologists.
12 Have you anything to gainsay that remark from
13 Mr Wisheart?
14 A. I certainly would not know about the cardiologists.
15 I would not be present if Dr Bolsin showing his work to
16 Mr Dhasmana, so that may well be a true statement. I am
17 sure it is.
18 Q. Dr Bolsin has made a comment as well on your statement,
19 page 72, by e-mail from Australia. He says, do you see
20 under N2, he was prepared to share his concerns about
21 the service with colleagues from medical and nursing
22 professions. He was aware that "there were doubts among
23 the theatre staff as to whether they should provide
24 nursing assistance to the paediatric cardiac surgeons."
25 I should say, he says some nice things about you
0058
1 above that.
2 Was there any express or implied suggestion from
3 Dr Bolsin that your reaction and that of your colleagues
4 to his showing you the data ought to be that you would
5 withdraw assistance at these operations; that that is
6 what he was expecting you to do?
7 A. If that was what he was expecting us to do, he certainly
8 did not voice that opinion.
9 Q. We are nearly through this statement, Mrs Armstrong.
10 Let us have a look at page 60, please. The very foot of
11 the page, paragraph 23. Mr Dhasmana's retraining. Just
12 before I come to that, I should deal with one point from
13 paragraph 21 which Mr Wisheart comments on. You refer
14 in paragraph 21 to having been told by Dr Bolsin that
15 there was a confrontation between himself and
16 Mr Wisheart and that Dr Bolsin was subdued for a while
17 after this.
18 Do you remember when that alleged confrontation
19 was?
20 A. I believe it was around about the time that there would
21 have been the discussions made for Martin Elliott coming
22 down.
23 Q. You have seen what Mr Wisheart says, I think. This is
24 page 71. There was only ever one heated discussion
25 between himself and Dr Bolsin when Dr Bolsin was not in
0059
1 the operating theatre when he should have been.
2 You were not present at the conversation
3 Mr Wisheart refers to, nor were you present at the one
4 Dr Bolsin reported to you?
5 A. No.
6 Q. So can you take this any further?
7 A. No. I can only believe both of their statements,
8 really.
9 Q. Let us go to page 60, paragraph 23. Mr Dhasmana went to
10 Birmingham for two days retraining. Did anyone go with
11 him?
12 A. Yes.
13 Q. Who?
14 A. I believe Sue Underwood went. There was certainly an
15 anaesthetist. I think it was Sue Underwood. I believe
16 Eamonn Nicholson went from the Perfusion Department and
17 nursing staff: Onyx Brewin and Alison Reed were the two
18 that went.
19 Q. Why did they go to Birmingham as opposed to London or
20 Newcastle?
21 A. I do not know. That was arranged by Mr Dhasmana,
22 perhaps because Birmingham was the closer centre to us
23 that was operating on the same sort of surgery.
24 Q. Just a couple of points to draw matters to
25 a conclusion. In your first statement at page 9,
0060
1 paragraph 24, and also at paragraph 37 on page 14, you
2 refer to the surgeons being late for surgery, for
3 theatre?
4 A. That is correct.
5 Q. You say that Mr Wisheart was the main offender?
6 A. That is correct.
7 Q. Mr Dhasmana would usually come when he was asked. You
8 say in this paragraph we are looking at now, four lines
9 from the bottom:
10 "They [the patient] would then be prepared for
11 surgery by the registrar ready for the consultant
12 surgeon to put them on bypass."
13 A. That is correct.
14 Q. So the drill was that the surgeon would be present
15 before the patient was put on bypass?
16 A. Yes.
17 Q. Is that right?
18 A. Yes.
19 Q. Was that always the position: the surgeon would be there
20 before the patient went on bypass?
21 A. Yes. I think so.
22 Q. You have seen Mr Wisheart's comment on this at page 67.
23 He deals quite rightly compendiously with paragraphs 24
24 and 37, which make the same point. He says:
25 "There is a practical problem in that the time
0061
1 taken to anaesthetise and place the patient on bypass
2 was extremely variable".
3 A. That is true.
4 Q. "And could range from a little over 1 hour up to
5 three hours."
6 If I have understood your evidence correctly, the
7 surgeon would be there before the patient was put on
8 bypass?
9 A. I am sorry, can I read that through again?
10 Q. Yes, do.
11 A. "There was a practical problem in that the time taken to
12 anaesthetise and place the patient on bypass was ...
13 variable."
14 Yes, well, the surgeon would be there before the
15 patient went on bypass, but the surgeon would not be
16 there, the consultant would not be there, when the
17 patient was brought into theatre.
18 Q. So what was the degree of variability in time?
19 A. The variability in time should have nothing to do with
20 it. The point is that we would never send for the
21 surgeons until we were ready for them to come. When we
22 sent, it was how quickly they responded to us sending
23 for them.
24 Q. But the variability, the length of time it took to put
25 the patient on bypass is completely irrelevant because
0062
1 the surgeon would always be there before the patient
2 began to go on bypass?
3 A. Yes, but not before -- when I say "put the patient on
4 bypass", there is a good half an hour's surgery that
5 takes place before that.
6 Q. I do not think we are at odds.
7 THE WITNESS (To the Panel): You understand, yes? So
8 someone else opens the patient up. Someone else may
9 well put the "purse strings" in. When we are at the
10 point when the heparin is being given and we are putting
11 the "purse strings" into the patient, then we would call
12 for Mr Wisheart or Mr Dhasmana to come to theatre to put
13 the patient on bypass.
14 Mr Dhasmana would always come straightaway, but
15 Mr Wisheart would take some time to come and we would
16 often need to call him two, maybe three times.
17 Q. Who would call the surgeon?
18 A. Whoever was the circulating nurse on that day.
19 Q. How much warning would a surgeon reasonably need, do you
20 think, to be told and able to get to the theatre and
21 change and get himself ready?
22 A. I would think they would need 10 to 15 minutes.
23 Q. So do you understand Mr Wisheart's comment there in the
24 first bullet point?
25 A. No. I do not feel that the time taken in the
0063
1 anaesthetic room is relevant because we would not send
2 for him until we were ready for him.
3 Q. He does say, over the page, page 68, that if this was
4 perceived to be a major issue, nobody told him that it
5 was a major issue?
6 A. It was brought up frequently at the meetings. We used
7 to have meetings where there was myself or Sister
8 Herborn, the theatre manager. There would be the chief
9 perfusionist and Mr Wisheart and punctuality was often
10 on the agenda.
11 Q. So he is wrong about that?
12 A. I believe him to be wrong about that.
13 Q. You have seen what Mr Dhasmana says about this point,
14 page 24?
15 A. I have.
16 Q. Have a look at paragraph 3 and tell me, once you have
17 read it, whether you accept what he says there.
18 (Pause).
19 A. He was always present in theatre if we had an emergency
20 such as a dissection or something like a TAVPD regarding
21 pulmonary. Our instructions were to bleep him when the
22 patient was brought into theatre. Those were always our
23 instructions. We would bleep him. He would respond to
24 his bleep, and then he would come to theatre. That
25 process would probably taken between 15 and 20 minutes.
0064
1 Q. Just a little longer than the time-frame you mentioned
2 a moment ago?
3 A. That is correct. I did say that Mr Dhasmana would
4 usually come when asked.
5 Q. You say Mr Wisheart was the chief offender?
6 A. That is correct.
7 Q. At page 8, paragraph 22 of your first statement, you say
8 that working with Mr Pawade is far less stressful.
9 Why is it far less stressful?
10 A. It is far less stressful because the cases go well. So
11 there is not that dread every time we go to the table
12 that the patient may not survive. Also, he is very
13 even-tempered -- that helps.
14 Q. I think you said in your statement to the GMC that you
15 never discussed your concerns with Mr Wisheart or
16 Mr Dhasmana?
17 A. No.
18 Q. Why not?
19 A. Probably because I was not brave enough.
20 Q. I think this is finally, unless somebody tells me
21 quickly otherwise: we were discussing a little earlier
22 the confrontation as you described it that Dr Bolsin
23 said he had with Mr Wisheart?
24 A. Yes.
25 Q. As you understood it, that confrontation had taken place
0065
1 about the time of Mr Elliott's visit when Mr Elliott was
2 contemplating taking the job of Professor of Paediatric
3 Cardiac Surgery?
4 A. That is true. I believe Mr Wisheart had taken exception
5 to a letter Dr Bolsin had written. That is what
6 Dr Bolsin told me.
7 Q. Is it that letter that helps you to date the
8 confrontation to Mr Elliott's visit?
9 A. No, it is not, actually.
10 Q. So why do you think that it was about that time the
11 confrontation took place?
12 A. Because there were some circumstances that happened at
13 that time that I just remember, being sat in the coffee
14 room, Dr Bolsin discussed that with me. Then I had
15 a conversation with Mr Dhasmana straight afterwards
16 regarding Martin Elliott. That is why I feel it was at
17 that time.
18 Q. Did Dr Bolsin enlighten you in any detail as to what the
19 subject matter of the confrontation was?
20 A. His letter had been about poor results. I do not know
21 what was said.
22 Q. So there was a letter, as you understood it from
23 Dr Bolsin to Mr Wisheart about --
24 A. I do not know if the letter went to Mr Wisheart. I do
25 not know who he sent the letter to, but I believe
0066
1 Mr Wisheart had taken exception to that letter. I do
2 not think it was to Mr Wisheart.
3 Q. Did you follow the course of the GMC proceedings against
4 Dr Roylance and Mr Wisheart, and Mr Dhasmana?
5 A. At the time when that was going on, my husband was
6 actually on intensive care, he was very ill, so I am
7 afraid at that point I was not really aware of what was
8 going on.
9 Q. So you were not following the detail of the evidence at
10 the GMC?
11 A. No.
12 MR MACLEAN: Mrs Armstrong, thank you very much for your
13 evidence. Those are all the questions I want to ask
14 you. The Panel may have some questions in a moment.
15 Before we come to the Panel, is there anything else you
16 want to say at this stage, anything I have not dealt
17 with properly or dealt with at all?
18 MRS ARMSTRONG: There was just one point. When we were
19 talking about communication skills and you were talking
20 about no staff wanting patients to be cancelled,
21 I thought you were wanting to question me about that but
22 you moved on. I would like to say I agree with
23 Mr Dhasmana that nobody wants to see patients being
24 cancelled but communicating any changes in the list is
25 very important for all who are concerned with looking
0067
1 after that patient that day, to make sure that no
2 mistakes are made.
3 MR MACLEAN: Thank you very much, Mrs Armstrong. Does the
4 Panel have any questions for this witness?
5 THE CHAIRMAN: Mrs Armstrong, first from Mrs Maclean
6 Examined by THE PANEL:
7 MRS MACLEAN: You were describing earlier on, page 29 in the
8 transcript, how it was your responsibility to look out
9 for under-performance amongst your nursing staff and
10 that you were able to pull people out if you felt that
11 they were overtired and not able to do their job?
12 A. That is correct.
13 Q. Did you ever actually have to do that, or was it just
14 something that was in reserve and a possibility?
15 A. No, we have regularly, particularly if a case had gone
16 on for a particularly long period of time, we have
17 certainly changed the scrub nurse, because I think there
18 is a limit as to how long you can expect somebody to
19 stand up, concentrate and perform to a high standard.
20 MRS MACLEAN: Thank you.
21 THE CHAIRMAN: Mrs Howard?
22 MRS HOWARD: Mrs Armstrong, you talked about the personal
23 choice you and your colleagues made about withdrawing
24 from scrubbing, and you also talked about professional
25 concerns in a very general way.
0068
1 Did you in any way consider approaching
2 professional organisations such as the Royal College of
3 Nursing to discuss your particular personal issues or
4 dilemmas?
5 A. No, we did not.
6 Q. May I enquire why?
7 A. I think the reason was that we also had such faith in
8 Dr Bolsin, we felt that he had taken this on as his
9 crusade and he was very determined to achieve a result
10 and we all had great hopes he would be successful. He
11 felt that he would be. We just felt that he could do so
12 much more than it would be possible for us to do.
13 MRS HOWARD: Thank you.
14 THE CHAIRMAN: Mrs Armstrong, thank you. Those are the
15 questions from the Panel. Mr Chambers?
16 MR CHAMBERS: Just one small point.
17 RE-EXAMINED BY MR CHAMBERS:
18 Q. It arises out of the question you have just been asked,
19 not going to the Royal College of Nursing. Did you in
20 fact, or would you in fact have had any facts and
21 figures that you could have presented to the Royal
22 College of Nursing, if, for example, you had spoken with
23 them?
24 A. Nothing in writing, no.
25 Q. Any other source of information, apart from what you had
0069
1 seen or heard from Dr Bolsin?
2 A. No. I had no facts about other centres, so, no.
3 MR CHAMBERS: Thank you very much.
4 THE CHAIRMAN: Thank you, Mr Chambers, that is helpful.
5 Mrs Armstrong, we have no further questions. May
6 I first of all thank you very much for coming this
7 morning. We found it very helpful to listen to you and
8 your evidence. Mr Maclean did raise one matter on which
9 you might be able to help us further, and if you are
10 able to do so, we would be very, very grateful.
11 Equally, if there is anything else that comes to your
12 mind that you would like to let us know, we would be
13 grateful to receive that. But for the moment, thank you
14 very much indeed.
15 MRS ARMSTRONG: Thank you.
16 (The witness withdrew)
17 MR MACLEAN: Sir, before we go any further, that took
18 slightly longer than I anticipated. I was shocked to
19 discover that it is 10 to 12. The next witness,
20 Mr Booth, will be relatively short and the one after
21 that, Professor Vann Jones, will be considerably
22 longer. It is really a matter for the Panel, whether
23 they want to have a lunchtime break now and then run
24 Mr Booth and Professor Vann Jones together in the
25 afternoon, or whether we start now with Mr Booth, or
0070
1 whether we have a very short break now, before we start
2 Mr Booth.
3 THE CHAIRMAN: Thank you for helping us, Mr Maclean.
4 I think, if we can, we perhaps should go on for another
5 half an hour and at that point have a half an hour break
6 for lunch, so let us proceed with Mr Booth until 12.30,
7 shall we?
8 MR MACLEAN: Yes. The next witness then is Mr William
9 Booth.
10 Mr Booth, could you stand up, please, to take the
11 oath?
12 MR WILLIAM BOOTH (SWORN):
13 Examined by MR MACLEAN:
14 Q. Your full name is William Booth?
15 A. That is right.
16 Q. Can we have a look, please, at WIT 309/1? We see from
17 that you are the Clinical Nurse Manager of the
18 paediatric Intensive Care Unit at the Bristol Children's
19 Hospital?
20 A. That is correct.
21 Q. And that is the first page of your formal written
22 statement to the Inquiry?
23 A. Yes.
24 Q. Page 27 is the final page of that same statement,
25 I think. That is your signature?
0071
1 A. It is.
2 Q. Have you read that statement through recently?
3 A. Yes, I have.
4 Q. And is there anything in it that you want to change
5 before we adopt that as part of your evidence to the
6 Inquiry?
7 A. No, there is not.
8 Q. I am not going to take you through that statement
9 paragraph by paragraph, or even page by page, because
10 the Panel have it and we have all read it. I simply
11 want to draw out one or two matters that arise from it.
12 You have also submitted some other materials by
13 way of annex to the statement, have you not?
14 A. Yes.
15 Q. I think your own curriculum vitae?
16 A. Yes.
17 Q. And a table showing nurse ratios and so on in different
18 hospitals?
19 A. Yes.
20 Q. And also the booklet -- this is 309/34 -- produced by
21 the Trust called "Remembering your Child, Parent's
22 Booklet", of which you were the main author?
23 A. That is right.
24 Q. I think you know that the Inquiry spent some time
25 recently dealing specifically with the issues of
0072
1 counselling and bereavement and how bad news was broken
2 and handled, and so on, and I hope you will forgive me
3 in those circumstances if I do not dwell today on that
4 booklet. As I say, the panel are fully aware of it and
5 will have read through it.
6 You began work in Bristol as a charge nurse in the
7 paediatric intensive care unit in the BCH in 1990?
8 A. That is correct.
9 Q. You worked in that post until 1995 with a very short
10 break in 1993 in the fair city of Glasgow?
11 A. That is right.
12 Q. And I will not ask you why you left there so quickly,
13 because it might upset me!
14 You became the Clinical Nurse Manager in April
15 1995?
16 A. That is correct.
17 Q. Back at the Children's Hospital?
18 A. Yes.
19 Q. At paragraph 11 of your statement, page 3, you refer to
20 a medically orientated model of management at the UBHT
21 which you believe was not dissimilar to other hospitals
22 at the time?
23 A. Yes.
24 Q. How did that manifest itself?
25 A. I came to Bristol after a short-term commission in the
0073
1 Royal Air Force and when I left the Radcliffe Infirmary
2 in Oxford, Trust status was not evident at that time.
3 After leaving the Air Force and returning to the
4 National Health Service, the UBHT was being created and
5 it was my impression that medical staff held all key
6 managerial posts within the Trust. I believe that was
7 not dissimilar to Trusts elsewhere.
8 Q. So UBHT was not out of the mainstream at that time?
9 A. I do not believe so, no.
10 Q. You say that this has changed over the last three to
11 four years?
12 A. Yes.
13 Q. And nursing is a heightened profile?
14 A. Yes.
15 Q. Is that again, that change, something that, as far as
16 you were aware, has been manifested throughout the NHS
17 generally?
18 A. Yes. I think so. The changes occurred three to four
19 years ago, which coincided with several new key
20 appointments, and particularly with a Director of
21 Nursing.
22 Q. And that would be Mrs Scott?
23 A. Yes, that is right.
24 Q. And she was appointed and also, about four years ago --
25 A. A new Chief Executive.
0074
1 Q. -- Mr Ross was appointed?
2 A. Yes.
3 Q. Were there any other key appointments?
4 A. Those were the key appointments that I think influenced
5 the profile of nursing in the UBHT.
6 Q. So how these two key appointments make their impact felt
7 at your level as being Clinical Nurse Manager in
8 intensive care?
9 A. It was my impression, and I was comparing UBHT with
10 Oxford when I left Oxford, Oxford enjoyed a very high
11 nursing profile, but I think that was quite unusual and
12 when I came to UBHT, I felt that nursing generally was
13 undervalued. With the appointment of Hugh Ross, and
14 then Lindsay Scott as the Director of Nursing, I felt
15 certainly over the last three to four years, as I have
16 stated, that nursing has enjoyed a much higher profile
17 and the contribution that nursing makes to the
18 organisation has been valued.
19 Q. You heard, I think, some of the evidence at least of
20 Mrs Armstrong this morning. I mentioned to her the fact
21 that Mrs Maisey was the Nurse Adviser to the Trust
22 whilst she held the post of Director of Operations
23 before she assumed the title of Director of Nursing
24 latterly?
25 A. Yes.
0075
1 Q. Mrs Armstrong did not seem to know about that.
2 A. I was not aware that she had assumed the title of
3 Director of Nursing.
4 Q. Were you aware that she was, before assuming that title,
5 the Nurse Adviser to the Trust?
6 A. Yes.
7 Q. I think she did have the title of Director of Nursing
8 for a relatively short time towards or perhaps just
9 after the end of the Inquiry's period of concern.
10 You have always worked at the Children's Hospital
11 in Bristol; you have never worked at the BRI?
12 A. That is correct.
13 Q. So under the Trust system, you would only ever have
14 worked within the Directorate of Children's Services?
15 A. That is right.
16 Q. And the General Managers were respectively, one after
17 the other, Marion Stoneham and Ian Barrington, who is
18 the Manager today?
19 A. Yes, that is right.
20 Q. And the Clinical Director of the Directorate was, for
21 a large part of the time, Dr Joffe?
22 A. Yes.
23 Q. He has now retired?
24 A. No, he is actually still a consultant paediatric
25 cardiologist.
0076
1 Q. And still the --
2 A. He is not the Clinical Director. That is now Dr David
3 Hughes.
4 Q. But until the period we are concerned with, it would be
5 Dr Joffe?
6 A. It would be Dr Joffe, yes.
7 Q. Paragraph 16 of your statement, Mr Booth, page 4. You
8 say that until paediatric cardiac surgery moved to the
9 Children's Hospital, the unit in the PICU was a small,
10 stable workforce, but once that work was moved to the
11 Children's Hospital, there was an increase in beds and
12 recruitment became an issue. Difficulties were
13 experienced recruiting qualified children's nurses with
14 additional intensive care qualifications.
15 The most relevant qualification would be ENB 415?
16 A. Yes, to have a qualification at ENB 415, they must be
17 children-trained as well.
18 Q. So that would be the ultimate specific qualification?
19 A. That would be the ideal, yes.
20 Q. Is there a reluctance among nurses to seek out that
21 qualification?
22 A. There is not a reluctance. Paediatric intensive care is
23 a very exacting speciality, an extremely stressful
24 environment to work in and it is not suited to all
25 children's nurses, so there are few children's nurses
0077
1 who would seek to work in a paediatric intensive care
2 unit.
3 Q. So most of those who obtain the Registered Sick
4 Children's Nurse qualification would not go on to
5 ENB 415?
6 A. No. I mean, it would be dependent upon, if they came to
7 work in the Intensive Care Unit and decided to make
8 paediatric intensive care their career, or for whatever
9 length of time, then they would undertake the ENB 415
10 course.
11 Q. Over two pages to page 6, you say at paragraph 26 that
12 from time to time there were people involved in the
13 support group for nursing staff. There were
14 professional counsellors and a psychologist?
15 A. Yes.
16 Q. And the Inquiry has heard about those previously.
17 "At the request of the staff, this no longer
18 happens. This is because by approximately a year after
19 primary nursing was introduced --", and that was in
20 1993?
21 A. Yes.
22 Q. "-- the nurses felt they had adequate support from their
23 peers within the primary nursing team."
24 You explain, if we look up the page to
25 paragraph 24, what primary nursing is. It is basically
0078
1 a group of teams, with each team being headed by a named
2 nurse, who was responsible for the co-ordination of the
3 care of a particular patient.
4 Is that the essence of it?
5 A. Yes.
6 Q. Is that too brief a summary?
7 A. Primary nursing was introduced in January 1993 as
8 a model of care delivery and to my knowledge, I think we
9 are probably one of the only paediatric intensive care
10 units in the country to have adopted that method of care
11 delivery.
12 I think previously in intensive care units nurses
13 have always been allocated on a sort of daily basis and
14 would care for a patient over the length of duty and the
15 difference between primary nursing and total patient
16 care as it is known is the continuity of care provided,
17 in that the child will be cared for by a small group of
18 nurses from their admission until discharge. Within
19 that group, one nurse would elect themselves as the
20 child's primary nurse or named nurse, and they would be
21 responsible for co-ordinating that child's care.
22 Q. Why does the institution of this system mean that the
23 nurses themselves feel they do not need the help from
24 counsellors and psychologists they needed in the past?
25 A. Previously when we practised total patient care and
0079
1 allocated nurses on a daily basis, the staff worked as
2 one team. Within primary nursing, we also introduced
3 a system where we split the nurses into several teams.
4 Usually each team composes around 12 nurses. They work
5 together all the time. They also have regular monthly
6 meetings to discuss issues within the team and about 12
7 months afterwards when they introduced primary nursing,
8 they felt they got peer support from each other, and we
9 encouraged that to the extent that each team would give
10 them a study day every year.
11 The team themselves decide on issues they wish to
12 discuss in the morning, usually clinical updates, then
13 in the afternoon, usually we spend the afternoon on team
14 building exercises, so we strengthen the team and
15 approximately, as I stated, 12 months after introducing
16 primary nursing, the nurses themselves felt they got
17 support from each other, and therefore chose themselves
18 to stop the more formal support meetings that we
19 previously had.
20 Q. If we go over the page, please, to paragraph 30, you say
21 you do not recall a key clinician who accepted overall
22 responsibility for the Intensive Care Unit?
23 A. That is right.
24 Q. What time period are you discussing there?
25 A. I think that was from my appointment in 1990, late 1990,
0080
1 up until about 1995, when several changes occurred on
2 the unit.
3 At one time Professor Peter Fleming did show
4 a particular interest in intensive care. That was quite
5 short-lived, if my memory serves me right, just a brief
6 period of time.
7 The paediatric anaesthetists in rotation, a weekly
8 rotation, accepted responsibility for the unit for that
9 period of time, but I do not recall one of them
10 accepting overall responsibility for the management of
11 the unit.
12 Q. What is the position now?
13 A. The position now has changed over the last five years
14 and we now have a Clinical Director of the Intensive
15 Care Unit.
16 Q. At whose behest was that change made?
17 A. Several changes occurred around 1995. Not only the move
18 of open-heart surgery from the Bristol Royal Infirmary
19 to the Children's Hospital, but two key reports were
20 also published at that time, one which is more commonly
21 known as the "Troop Report" which is a report to the
22 Chief Executive of the NHSE looking at the provision of
23 paediatric intensive care and making several key
24 recommendations, and at the same time there is a report
25 from the Chief Nursing Officers' Working Party looking
0081
1 at nursing standards, nurse education and workforce
2 planning in paediatric intensive care.
3 So there was a lot of activity at that time, and
4 at that time there were also other key appointments made
5 on the medical team, when cardiac surgery moved from the
6 Bristol Royal Infirmary to the Children's Hospital, in
7 that several new paediatric cardiac anaesthetists were
8 appointed and they also had a role on the Intensive Care
9 Unit.
10 Q. At paragraph 38, page 8, the bottom of the page, you
11 refer there to Mr Pawade, the paediatric cardiac surgeon
12 who is in post now, introducing protocols and guidelines
13 for open and closed procedures following his appointment
14 in May and the transfer of the work in October?
15 A. That is right.
16 Q. To what extent were those protocols and guidelines
17 a codification of past practice or a new development?
18 A. That was a new development. Previous to Mr Pawade's
19 appointment, we did not have any written protocols or
20 guidelines to care for children involving closed cardiac
21 surgery.
22 Q. What did those protocols provide for? What did they
23 say?
24 A. The protocols are very specific to the care of children
25 following both open and closed cardiac surgery. The
0082
1 children often have very complex problems
2 post-operatively, and within the protocols and
3 guidelines specific to some of those complications that
4 we often see post-operatively, they guide us through
5 certain clinical conditions that may appear. For
6 instance, when a child has had open-heart surgery,
7 particularly babies and young children, they can often
8 experience a transient phase of renal dysfunction and
9 may require peritoneal dialysis. So the protocols guide
10 us when we should start peritoneal dialysis and the
11 procedure that we should follow.
12 Q. So these are helpful or unhelpful?
13 A. Extremely helpful.
14 Q. Over the page, page 9, dealing with issue B.9 just above
15 paragraph 42, you say you are unable to comment on the
16 information available to referring clinicians and to
17 members of the public on the standards of treatment and
18 care attained at the BRI.
19 Did you, between 1990 when you started work and
20 1995, the end of the period we are concerned with, form
21 any impression of the quality of paediatric cardiac care
22 at the BRI?
23 A. The Children's Hospital functioned completely separate
24 to the Bristol Royal Infirmary and we did not have
25 access to any information that existed at that time on
0083
1 the results of surgery, so we were not aware of the
2 results of the Bristol Royal Infirmary.
3 Q. So you did not have access to any official data?
4 A. No.
5 Q. Did you have any unofficial sources of information?
6 A. Certainly I think towards the end of or during 1994, for
7 want of a better word to use, I sometimes heard sort of
8 gossip from colleagues, not from the Children's
9 Hospital, it was often some of the anaesthetists in
10 training who rotated to the Children's Hospital who
11 would sometimes talk about or express concern over
12 results of surgery at the Bristol Royal Infirmary.
13 But we were never able to substantiate those
14 comments, because we actually did not know what the
15 results were. We certainly did not know what the
16 results were compared with other centres in the country.
17 Q. Paragraph 51, page 13.
18 You refer there to the transfer of children from
19 the Children's Hospital down to the BRI.
20 A. Yes.
21 Q. And at paragraph 81, page 20, you refer to the transfer
22 of children in the other direction?
23 A. Yes.
24 Q. I do not know if you have had a chance to see the
25 transcript of Joyce Woodcraft's evidence on -- it seems
0084
1 like days ago but I think it was only Tuesday.
2 A. Yes, I have.
3 Q. You will have seen there she was asked about
4 a particular medical record. It is MR 722/63.
5 You see in the top of the sheet:
6 "Transferred from Ward 5", that is the BRI cardiac
7 ward?
8 A. Yes.
9 Q. "Arrived unannounced as usual". Joyce Woodcraft was
10 asked about that. Is that something, a state of affairs
11 that you are familiar with?
12 A. When I read this, it implies that a child just arrived
13 and we knew nothing about the child. What occasionally
14 happened is that we may know, we would obviously know
15 that a child was going to be transferred from Ward 5 to
16 the paediatric intensive care unit at the Children's
17 Hospital on a certain day. The transfer often is
18 reliant upon ambulance transport and the transfer would
19 not be an urgent transfer, it would be a routine
20 transfer. When we book transport, even now, today, we
21 are given either that the transport will be provided in
22 the morning or the afternoon and we are not given
23 a specific time.
24 So it did happen on occasion that we knew a child
25 was coming from Ward 5 in the morning or the afternoon,
0085
1 but the nursing staff on Ward 5 could not specify
2 a time.
3 What would be common practice is that the nurse on
4 Ward 5 would phone us to say that the child had left and
5 would be arriving at the Children's Hospital shortly
6 afterwards. Usually, one reason for transfer is when
7 Ward 5 was extremely busy and required another intensive
8 care bed, so on occasion they perhaps forgot to phone us
9 because they were busy preparing the bed for another
10 child, or adult case. So sometimes a child would arrive
11 and we did not know, they had left the Bristol Royal
12 Infirmary but we were expecting the transfer some time
13 that morning or after.
14 Q. It is the use of the words "as usual" that make this
15 record stand out. The usual position would be that the
16 Children's Hospital would know a child was coming rather
17 like a plumber, either morning or afternoon, but would
18 not know when specifically in the morning or afternoon?
19 A. We would know specifically it was in the morning or
20 afternoon, but not the time.
21 Q. You might then expect a phone call from the BRI saying
22 the child has just left at 10.30, and you would expect
23 them by a quarter to 11, or whatever time it took?
24 A. Yes.
25 Q. So it would not be usual for a child to show up at the
0086
1 Children's Hospital when the Children's Hospital did not
2 know that the child was coming that morning or that
3 afternoon?
4 A. I never experienced that. We always did know the child
5 was going to come in the morning or the afternoon.
6 Q. Let us look at paragraph 68 of your statement, which is
7 page 17. You refer there to an annex to your statement
8 which are the results of a summary of a survey of nurses
9 in paediatric intensive care prepared by the Department
10 of Health based on 1996 figures.
11 A. I am sorry, which paragraph?
12 Q. Paragraph 68.
13 A. Yes.
14 Q. If we look at page 52, tell me if that is the table that
15 you are referring to.
16 A. No.
17 Q. That is not my 52. Let us look at 32, then.
18 A. Yes, that is the table.
19 Q. Is that the one?
20 A. Yes.
21 Q. If we just turn that round, Bristol is at the bottom
22 entry there, at line Y, is it not?
23 A. Yes.
24 Q. If we look first of all at column 10, that shows
25 the percentage of children trained nurses in the
0087
1 Children's Hospital, the relevant paediatric intensive
2 care units?
3 A. Yes.
4 Q. And Bristol's percentage is 82 per cent?
5 A. Yes.
6 Q. Which is higher than some, and not as high as others?
7 A. That is right, although the national average at the
8 bottom being 84 per cent, so Bristol compared
9 favourably.
10 Q. Just a little under?
11 A. Just a little under at 82.
12 Q. Column 12 is the percentage of children and intensive
13 care nurses, so that is those who have both
14 qualifications?
15 A. Those are nurses who are sick children trained and also
16 in possession of an intensive care certificate.
17 Q. This shows Bristol at 48 per cent, which is bang on the
18 national average?
19 A. Yes.
20 Q. Then column 13 shows the agency or bank nurse staff who
21 were working on the particular day on which this data
22 was based?
23 A. Yes, that is right.
24 Q. Which was 22nd May 1996?
25 A. Yes.
0088
1 Q. And on that day in Bristol there were none?
2 A. That is right.
3 Q. So this table suggests, as you put it, that Bristol
4 compares pretty favourably with the national averages
5 for children with children trained nurses and paediatric
6 intensive care trained nurses in the Intensive Care
7 Unit?
8 A. Yes.
9 Q. But these figures are for 1996?
10 A. Yes.
11 Q. If we look at your statement at page 4, paragraph 15,
12 you see:
13 "Coinciding with the move of paediatric cardiac
14 surgery from the BRI to the Children's Hospital, the
15 nursing establishment was increased to accommodate three
16 additional beds, bringing the total number of open beds
17 to 8. Staff was actively recruited to fill vacancies.
18 They were required to be Registered Sick Children's
19 Nurses and it was desirable for them to have an
20 intensive care certificate."
21 A. Yes, that is right.
22 Q. In the process of recruiting additional nurses to meet
23 the demands of extra beds, did Bristol's percentage of
24 Registered Sick Children's Nurses or intensive care
25 nurses increase?
0089
1 A. We actively recruited nurses who were sick children's
2 trained, and as I state, it was desirable to have an
3 intensive care qualification. They are an extremely
4 rare commodity, and we were not always able to recruit
5 nurses with both those qualifications. More often than
6 not, we recruited nurses who were sick children trained.
7 The survey has been conducted annually since then,
8 and our percentage of sick children's trained nurses and
9 nurses with intensive care qualifications have increased
10 slightly, but generally remain static, although, having
11 said that, we have, this April, opened 10 or 12
12 intensive care beds, and although the percentage is very
13 similar, we actually have more nurses who are sick
14 children's trained and with an intensive care
15 qualification, because the percentage of the whole time
16 equivalents employed, you can sort of understand what
17 that -- so the reality is we do have more nurses, or the
18 percentage remains very similar.
19 Q. I know it is difficult to look back now so far in time,
20 but your impression is that this data that we have in
21 this table for 1996 does not show Bristol in any
22