Home Page Search Final Report Interim Report Evidence - Transcripts - Witness Statements - Submissions - CCNR Report and associated documents - Statistical Reports and associated documents - Background Papers - Expert Papers Inquiry Seminars About the Inquiry Help		Daily transcripts     Hearing summary 11th October 1999   The Bristol Royal Infirmary Inquiry oral hearings this week focus on concerns raised about the adequacy of paediatric cardiac surgery at the Bristol Royal Infirmary (BRI) and the subject of medical and clinical audit.   Today the Inquiry heard firstly from Professor Marc de Leval, Professor of Cardiothoracic Surgery, University of London. He was followed by Dr Stewart Hunter, Consultant Paediatric Cardiologist, Freeman Hospital, Newcastle Upon Tyne.   They described the visit they made, at the request of the management of the United Bristol Healthcare NHS Trust (UBHT), to the BRI in February 1995. The two doctors were asked to review the paediatric cardiothoracic surgery unit at the hospital and to draw conclusions about concerns which had been raised relating to above average mortality and morbidity figures for babies and children undergoing cardiothoracic surgery. Professor de Leval described the timetable of the visit and the information which was presented to him and Dr Hunter. They both concluded by commenting on their draft report and subsequent alterations made to that report, which was then presented to UBHT.

FULL TRANSCRIPT

   1                    Day 60, 11th October 1999
   2   (10.45 am)
   3   MISS GREY: Good morning, sir.
   4   THE CHAIRMAN: Good morning, Miss Grey. Good morning,
   5     everyone. I apologise that we are beginning slightly
   6     later than we should and that we announced but there are
   7     still, as regards those who travel from London,
   8     travelling difficulties which one hopes will correct
   9     themselves by the end of this week.
  10        May I also, while I am talking, Miss Grey, refer
  11     back to the letter which I mentioned I had received last
  12     week from the Permanent Secretary of the Department of
  13     Health. As it was addressed to me, I sought the
  14     Permanent Secretary's authority to make the letter
  15     public and this has been readily agreed so that letter
  16     will now be scanned into the public record.
  17        Miss Grey?
  18   MISS GREY: Sir, this morning we have the benefit of hearing
  19     again from Professor de Leval, who on this occasion will
  20     be giving evidence to the Inquiry of his investigation
  21     into the Paediatric Cardiac Surgery Unit there. So can
  22     I invite him to come forward and take the stand,
  23     please?
  24        Could you stand, please, Professor, to take the
  25     oath?

   1           PROFESSOR MARC DE LEVAL (SWORN):
   2             Examined by MISS GREY:
   3   Q. Professor, you have provided to the Inquiry a witness
   4     statement on this issue which can be found at WIT 319,
   5     please, page 1.
   6        Is that the first page of your witness statement
   7     on this issue?
   8   A. That is correct.
   9   Q. If we turn, please, to page 5, is that your signature on
  10     the bottom?
  11   A. Yes, it is.
  12   Q. Are the contents of this statement true to the best of
  13     your knowledge and belief?
  14   A. Yes, they are.
  15   Q. If we turn to one of the appendices to this witness
  16     statement, page 13, please, can you just explain to the
  17     Inquiry how these notes were generated and whether they
  18     are yours or that of your colleague, Mr Hunter?
  19   A. Those are the notes from Dr Hunter, so he had taken the
  20     handwritten notes and had them typed and sent to me so
  21     that we can use our notes to write the report.
  22   Q. We can see at the top there is a fax date of
  23     23rd February 1995.
  24   A. Yes.
  25   Q. That is when they were sent through by Dr Hunter to you;

   1     is that right?
   2   A. The fax, that is right, yes.
   3   Q. If we could start, please, by looking at UBHT 212/40,
   4     just as a matter of record, really, Professor, can we
   5     confirm, this is a letter sent by you to Mr Dhasmana
   6     which marked the beginning of your work on human factors
   7     in the switch operation, did it not, when you were
   8     obtaining the co-operation of colleagues in different
   9     units to participate in the study that you were planning
  10     at that stage?
  11        Do you want to scroll up through the letter?
  12   A. I would like to read it, because I forgot about this
  13     letter. (Pause). This is a letter which had been sent
  14     to all the cardiac surgeons in the UK to ask their
  15     participation to my study on the arterial switch
  16     operation which was being initiated at that particular
  17     time, that is correct.
  18   Q. Again, I think it is correct, is it not, that
  19     Mr Dhasmana agreed to participate in the study?
  20   A. He did, yes.
  21   Q. And to submit data from his switch series as part of it?
  22   A. He did, yes.
  23   Q. I think in the event, because of the cessation of the
  24     switch programme, he sent to you only details of two
  25     operations that fell within your terms of reference and

   1     the ongoing prospective participation fell to the part
   2     of Mr Pawade; is that correct?
   3   A. I cannot answer the question because the study was
   4     confidential, so I am myself unaware who sent data. The
   5     only thing I can say is that Mr Dhasmana discontinued
   6     his switch operation in early 1995, and therefore
   7     I expect that there were no patients of his in that
   8     survey.
   9   Q. If we go on then, please, to UBHT 61/337, this is the
  10     letter -- if we can scroll up a little further,
  11     please -- from Mr Wisheart to yourself?
  12   A. Yes.
  13   Q. First asking you to conduct an investigation into the
  14     field of paediatric cardiac surgery in the unit. Can
  15     I ask you, did he contact you solely by letter, or was
  16     there any conversation by phone between yourselves?
  17   A. No, I believe he phoned me to find out whether I would
  18     accept it, and then he put it in writing.
  19   Q. Did he describe to you at that stage the nature of the
  20     investigation?
  21   A. No.
  22   Q. So when you received this letter, you knew no more than
  23     is set out in this letter?
  24   A. That is correct, yes. Actually, the first information
  25     we had is when we met with the Chief Executive that

   1     particular day.
   2   Q. It is right that by that time Dr Hunter had been
   3     appointed as a paediatric cardiologist to assist you
   4     with this investigation?
   5   A. Yes. I believe he received a letter about a week later.
   6   Q. We can look at that if we look at JDW 3/312, please.
   7     There is the date, 30th January, at the top, and it is
   8     in effect, is it not, a repetition of the letter to
   9     yourself, save that it adds the information that
  10     Professor Marc de Leval has already agreed to act in
  11     this matter?
  12   A. I have not seen that before.
  13   Q. It may be that the Inquiry will hear from Dr Doyle of
  14     the Department of Health who was, you may recollect, the
  15     clinician who had been contacted at the Department of
  16     Health, the Medical Officer, by certain persons in the
  17     Trust and who had therefore been concerned in events at
  18     this stage, that he thought it would have been helpful
  19     to have included a statistician in your investigating
  20     team, if I may call it that.
  21        Do you think that would have been a helpful
  22     addition to your team?
  23   A. Yes. I think that the lack of statistician is
  24     a deficiency of the report. There is more than that.
  25     I think that first of all the data we were presented

   1     with were deficient themselves, and I think that
   2     a statistician is as good as the data you provide to the
   3     statistician. I think that the deficiency was the
   4     weakness of the data and the pressure of time which just
   5     made it impossible to have good data. I do not disagree
   6     that a statistician would have been much more demanding
   7     than we were to produce a report, and any competent
   8     statistician would have simply refused to comment on
   9     this, I think.
  10   Q. You mentioned there another pressure, the pressure of
  11     time constraints.
  12        Can you explain to us briefly what those were?
  13   A. When I was invited to go to Bristol, I indicated that
  14     I could do it after a holiday which I had booked the
  15     following month, and if they wanted me to come before,
  16     I could only spend a day to do so, and they opted for
  17     that proposal.
  18   Q. So that was the impetus which lay behind the time of
  19     a visit on 10th February?
  20   A. Yes, so there was a timing in terms of they wanted to
  21     have someone coming very soon, then the time we spent
  22     was, I think, short, and furthermore, they wanted
  23     a report rapidly following the visit, which also made
  24     a lot of pressure.
  25   Q. Because your holiday had been pre-booked before you were

   1     even invited to carry out this study?
   2   A. That is correct.
   3   Q. If we look, please, at UBHT 61/355, that is a timetable
   4     of your visit.
   5        First of all, if we scroll it down briefly, can we
   6     confirm that timetable conforms roughly to what in fact
   7     took place, that you saw the various individuals set out
   8     in that timetable?
   9   A. Yes. The only thing I think is that the afternoon
  10     session was to take place I think at the Children's
  11     Hospital, but we stayed in the Royal Infirmary, we did
  12     not go to the Children's Hospital.
  13   Q. At that stage I think you met Dr Hughes and
  14     Mr Barrington, but were you joined in your discussions
  15     by Dr Martin, Dr Hayes and Mr Dhasmana?
  16   A. Yes, we saw all of them, yes.
  17   Q. If we scroll up, please, again to the top of that
  18     timetable, we see there that you were scheduled to meet
  19     with Mr Dhasmana and Mr Wisheart initially, and then
  20     that you would be joined by Dr Martin and Dr Hayes, two
  21     consultant cardiologists.
  22        Do you think, perhaps with the benefit of
  23     hindsight, that it was suitable that your meeting with
  24     Mr Wisheart would have been joined by the cardiologists
  25     rather than with you being given an opportunity to see

   1     the cardiologists separately?
   2   A. I suppose that it is always useful to see people
   3     individually. We could also argue it would perhaps have
   4     been better to see Mr Dhasmana and Mr Wisheart
   5     individually, and then see them together. I think that
   6     the reason for our visit was very surgically oriented
   7     and I think complaints had been made about surgical
   8     results. I think that we probably made the error of not
   9     trying to see individual members of all the team as
  10     well, I suppose.
  11   Q. You talk about that as being an "error" at least with
  12     the benefit of hindsight. Did you get an impression at
  13     the time that the frankness of any discussions was
  14     impeded by the presence of other people in the room at
  15     any time?
  16   A. I think the meeting was quite open. Again, if
  17     I recollect it correctly, I suspect that we could have
  18     asked cardiologists specific questions about individual
  19     surgeons, for example, which we probably did not do at
  20     the time, although, as we discussed later, the surgeons
  21     themselves had provided data where they had
  22     individualised the surgeons. But it would have been
  23     useful to discuss with the cardiologists on the one
  24     hand, and similarly, it could have been useful to
  25     discuss with the surgeons the performance of the

   1     cardiologists.
   2   Q. As it was, did you have an opportunity to discuss either
   3     issue with either group?
   4   A. We did not discuss it specifically, but when we looked
   5     at the data, for example, the switch operations,
   6     a number of those patients had incomplete diagnosis or
   7     insufficient diagnosis, and if my memory is correct,
   8     I think one patient had an undiagnosed coarctation of
   9     the aorta, for example, so we did not specifically ask
  10     the surgeons what kind of service they had from the
  11     cardiologists, but from the data we received, it was
  12     evident that there were some weaknesses there as well.
  13   Q. And just to clarify, I think you implied earlier that
  14     you did not or were not able to ask the surgeons what
  15     input the cardiologists were making into post-operative
  16     care?
  17   A. No, but when we discussed the post-operative management
  18     of the patient it was quite clear that there was a great
  19     deal of disorganisation and lack of support between the
  20     various teams; and the cardiologists were not based
  21     where the operations took place. I think that their
  22     input into the post-operative management was
  23     insufficient.
  24   Q. Just perhaps for the sake of the record, Chairman, we
  25     might note the covering letter, please, at page 354, the

   1     covering letter for this programme, where we see the
   2     circulation list. One notes that it is not directly
   3     addressed but is copied to Professor Vann Jones, and
   4     furthermore, that Dr Joffe is not on the direct
   5     circulation list either.
   6        You did not meet with Dr Joffe during the course
   7     of the visit?
   8   A. No. I think he was out of town and he did apologise,
   9     I think, because he could not be there. He had
  10     a commitment the day we were there he could not cancel,
  11     I think.
  12   Q. If we go, then, to your report, the first version of the
  13     report, if I may call it that, appears at UBHT 52/262.
  14     This is the fax that sent the version through. It was
  15     addressed at that stage to Dr Roylance.
  16        Firstly, can I just ask you: how was the report
  17     prepared between yourself and Dr Hunter?
  18   A. The agreement was that I would summarise or have my
  19     notes taken in the meeting typed before I went on
  20     holiday, which I did. My secretary sent that to
  21     Dr Hunter while I was away. Then Dr Hunter sent his own
  22     comments and I believe a draft report and I sent him
  23     mine when I came back from my holiday and we realised
  24     that they were very, very similar, so we agreed that
  25     I would make some amendments to my report using his own

   1     report. This is the way it was done.
   2        So that particular report was sent by my Secretary
   3     but it had been seen, obviously, by Dr Hunter who had
   4     agreed with the amendments I had made.
   5   Q. If we look at page 266 of the report, we can see there
   6     the summary of the data that was displayed during the
   7     meeting.
   8        First of all, can I ask you, did you receive any
   9     data in advance of arrival at the UBHT?
  10   A. No. I had no data.
  11   Q. So you were required to assimilate the data during the
  12     course of the meetings and thereafter?
  13   A. Yes.
  14   Q. You speak first of all as to data produced by
  15     Dr Bolsin. Can I ask you first to look, please, just
  16     for the sake of identifying that data, at UBHT 61/80.
  17     Firstly, do you recognise this cover sheet?
  18   A. Yes.
  19   Q. That was part of the material given to you by Dr Bolsin;
  20     is that correct?
  21   A. Yes, that is correct, yes.
  22   Q. So if we turn over the page, page 81, that would be,
  23     again, part of the material that was presented.
  24     Page 82: similar.
  25   A. Yes.

   1   Q. Pages 83, 84, 85, 86.
   2        Do you recognise page 87?
   3   A. I do not recognise that page, no. I thought that the
   4     only data where surgeons had been individualised had
   5     been the data set produced by the surgeons themselves,
   6     so I do not recall this, having received it. I do not
   7     recall this.
   8   Q. So presumably the same comment would apply if we went
   9     over the page to page 88?
  10   A. Yes, the same comment.
  11   Q. If we can go please now to GMC 16/35, do you recognise
  12     this as being material provided to you?
  13   A. Yes.
  14   Q. If we go over the page and rotate, was the remainder of
  15     the data presented in this sort of format?
  16   A. We had the detail for the 13 switches -- are there 13
  17     switches?
  18   Q. I think that is correct, yes.
  19   A. Yes. We received that. Actually, we received the
  20     details of those 13 switches I think from both Dr Bolsin
  21     and from the surgeons.
  22   Q. I think this may be data of more than 13 switches here.
  23   A. We record the details of 13 switches, but not of the
  24     whole series, which was more than 13.
  25   Q. Dr Bolsin may say that he also gave to you data from an

   1     annual report produced from within the unit in 1990 to
   2     1991. Do you have any recollection of any further data?
   3   A. I have no recollection. I do not have them in my file,
   4     that is for sure, no.
   5   Q. And you have taken away the remainder of the data that
   6     he gave to you, have you?
   7   A. I thought I did, yes.
   8   Q. So the remaining material that I showed to you earlier
   9     is consistent with what you have in your file; is that
  10     correct?
  11   A. Yes, except for the surgeons being individualised.
  12     There are two tables. I do not have data.
  13   Q. That is the material you said you did not recognise?
  14   A. That is right.
  15   Q. If we go back, then, please, to page 266, you say in the
  16     second paragraph there that the second set of data was
  17     received from the cardiac surgeons and it may well be --
  18     were you told this -- that the cardiologists had
  19     participated in its preparation as well?
  20   A. I forgot the detail. What I know is that that had been
  21     done within a few days or the week which preceded our
  22     visit. I forgot who contributed to this.
  23   Q. That data covered the period from January 1992 to
  24     January 1995, a three-year period?
  25   A. Yes.

   1   Q. Was that what you had asked for in advance of the
   2     meetings?
   3   A. We had not asked any data beforehand.
   4   Q. So this was their initiative?
   5   A. Their initiative, yes.
   6   Q. And Mr Wisheart, I think, may say that it was on his
   7     initiative that the data had been broken down into
   8     a surgeon-specific form. Can you comment on that?
   9   A. I cannot. I mean, what I certainly said afterwards is
  10     that I congratulated the surgeons for having done that,
  11     and particularly Mr Wisheart, because obviously his
  12     results in particular for the AV canals was much worse
  13     than Mr Dhasmana's, and I thought it was very fair of
  14     him to do that.
  15   Q. In any event, if he says that it was produced on his
  16     initiative, it is certainly the case that it was not
  17     produced in response to a request from you --
  18   A. It was not, no.
  19   Q. -- and it therefore came in excess, as it were, of such
  20     a situation?
  21   A. As I said, we had no request because we did not know
  22     what the exact reason for the visit was. We knew there
  23     was a problem about results, but this is all we knew.
  24   Q. You received data from the surgeons in your visit with
  25     them, and data from Dr Bolsin later on during the day,

   1     because you saw him later; is that correct?
   2   A. I forgot the timing.
   3   Q. We can go back to the programme at UBHT 61/355. If we
   4     scroll down a little ... (Pause).
   5   A. Yes, we received this afterwards, yes.
   6   Q. Does it follow you were not able to discuss Dr Bolsin's
   7     data with the surgeons?
   8   A. We had, at the end of the day, a meeting where the
   9     surgeons and Dr Bolsin was there, so this is not exactly
  10     what the list of participants is. I am pretty sure at
  11     the end of the meeting where the surgeons and Dr Bolsin
  12     were present -- my recollection, I think, is based on
  13     the fact that we discussed the meeting which took place
  14     the night before the last switch was operated, and I am
  15     convinced that between that discussion the surgeons and
  16     Dr Bolsin were present.
  17   Q. Was there any discussion of Dr Bolsin's tabulation of
  18     data during that meeting that you can recollect?
  19   A. I do not recollect it, no.
  20   Q. One thing that appears from the data we have seen
  21     briefly is that with the exception of the switch
  22     operation data, which was common to both data sets,
  23     there appears to be little overlap in the time-scale of
  24     the two sets of data?
  25   A. That is correct, yes.

   1   Q. If we look at page 269 -- this is UBHT 52/269 -- this is
   2     the sole table I think that is appended to your report?
   3   A. Yes.
   4   Q. It deals with January 1992 to January 1995. Is it
   5     based, therefore, on the data you received from the
   6     surgeons?
   7   A. That is correct. Obviously we had no certainty that
   8     either set of data had been validated. We thought that
   9     it was important to have the data where surgeons had
  10     been individualised, and this is, I presume now, the
  11     reason for having used those data to comment on.
  12   Q. Did you make any use of Dr Bolsin's data in the event,
  13     then?
  14   A. I do not recollect whether we had used them or if --
  15     I do not think I can comment on this. Obviously we
  16     discussed those data with Dr Hunter, but whether we
  17     considered making two different tables with two sets of
  18     results, I have forgotten that.
  19   Q. One of the comments that you make in your witness
  20     statement is you say:
  21        "With hindsight, one could argue that it was
  22     unwise to produce a report based on such weak data."
  23        Can you summarise what you mean by "weak data"?
  24   A. I think that the data had not been validated. I think
  25     that at least the data that the surgeons had collected

   1     had been collected not prospectively; they went back to
   2     all the records, I presume, and we had no guarantee that
   3     some data had not been missed.
   4        We had no valid data to be compared with. I think
   5     the UK register itself is not validated; it does not
   6     individualise institutions or surgeons. And I think
   7     that any statistician would be very reluctant to draw
   8     firm conclusions from that type of analysis.
   9   Q. I think it would be a fair supposition that you
  10     appreciated those data weaknesses at the time of
  11     producing the report?
  12   A. Certainly, yes.
  13   Q. What were the factors, then, that led the report to be
  14     produced nonetheless?
  15   A. The report was produced as a confidential document to
  16     the Chief Executive which had been our brief by the
  17     Chief Executive when we met him. Unfortunately, the
  18     document became part of the public domain before the
  19     Chief Executive could see it, which was obviously not
  20     our intention, not expected. I think that if I had
  21     known that the document was going to be part of the
  22     public domain, I would have been more careful in the
  23     wording of the document. I think that it is totally
  24     unfair to say that a surgeon is a high risk surgeon with
  25     that type of data, and I think that it was irresponsible

   1     to say that with the data we had.
   2   Q. We will come on to that, if we may, in more detail, but
   3     I think it would be perhaps fair to summarise your
   4     report as saying that the reason why it was thought that
   5     it was acceptable to base it on data that was known to
   6     be weak was that it was intended merely as
   7     a confidential report to the Chief Executive?
   8   A. That is correct.
   9   Q. And perhaps I might add, one to be produced within
  10     a short time-scale?
  11   A. That is correct, yes.
  12   Q. Can we go then, please, to the meetings which you had on
  13     10th February, and firstly to the meeting with
  14     Dr Roylance as the first meeting which you had that day.
  15        Can you tell us, please, what the brief that
  16     Dr Roylance gave to you was to the extent that you have
  17     not covered it already?
  18   A. He first alluded to the difficulty of Mr Wisheart's
  19     position being on the one hand investigated in this
  20     particular problem, and at the same time, being Medical
  21     Director, at the time and implied that he wanted to have
  22     the report sent to him rather than the Medical Director
  23     for that particular reason.
  24        He explained to us that there had been complaints
  25     about the results of cardiac surgery and that he wanted

   1     to have an outside opinion, which was the reason for our
   2     visit, and asked again that report to be issued with the
   3     shortest possible delay, because of time, the pressure.
   4   Q. Did he say who would see the report?
   5   A. No. He asked the report to be sent to him, again,
   6     rather than the Clinical Director. My understanding is
   7     that the report would have been discussed by the Chief
   8     Executive with the different parties involved in cardiac
   9     surgery.
  10   Q. You say that he mentioned that there had been complaints
  11     about paediatric cardiac surgery. Did he give you any
  12     indication as to the nature of those complaints or how
  13     widely touched the unit was by such complaints?
  14   A. First of all, I am not sure he used the word
  15     "complaints", but it was what he meant. No, we did not
  16     know. We understood what the problem was, or started to
  17     have some idea what it was, when we received the
  18     calendar of events from Dr Bolsin. We started to have
  19     an idea of what the problem had been. Obviously the
  20     surgeons we saw first mentioned Dr Bolsin, but Dr Bolsin
  21     is the one who gave us the details of what had happened
  22     since 1989.
  23   Q. Dr Roylance may say that what he intended or put across
  24     to you when he met you and Dr Hunter was that firstly
  25     what might be described as a "quick and dirty" review

   1     was needed. Is that a phrase that you can recollect
   2     being used?
   3   A. I do not recollect the phrase, but he may have used it.
   4   Q. The sense of it: is that consistent with what you
   5     understood to be required?
   6   A. What we understood is that they wanted to have an
   7     outside opinion on the results so that they could go
   8     further in trying to solve the problems they were
   9     facing.
  10   Q. So because it was to be quick, it would not need to be
  11     unduly refined?
  12   A. Well, it is not because it is quick; the quality should
  13     have been good. I think that the time pressure did not
  14     allow us to, you know, request more investigations or to
  15     spend more time on it, but I think that the quality of
  16     the report was as good as we thought it could be
  17     following the information we had received.
  18   Q. Did he specifically ask for your opinion on three
  19     issues: the appointment of a new paediatric cardiac
  20     surgeon; the move up the hill to the Children's
  21     Hospital; and the issue of what interim surgery could be
  22     permitted to take place until Mr Pawade took up his post
  23     in May 1995?
  24   A. He did not ask us our opinion about a decision which had
  25     already been made, so the decision to concentrate the

   1     paediatric work on one site had been made. Mr Pawade
   2     had been appointed. The switch programme had been
   3     discontinued already when we went there. I think that
   4     there had been a directive from the Department of Health
   5     which was I think even wider than just the switch, if
   6     I am correct.
   7        So all these decisions had been taken already when
   8     we visited there, so we are not part of those decisions.
   9   Q. The fault is mine for phrasing my question badly. The
  10     question was whether Dr Roylance was asking for your
  11     opinion as to the adequacy of those steps to address any
  12     problems within paediatric cardiac surgery?
  13   A. No, he indicated that those steps had been taken and
  14     I suppose that he implied that he wanted to find out if
  15     we thought it was satisfactory in view of the problems
  16     we had been asked to give an opinion on.
  17   Q. If we turn, please, to WIT 319/13, these are Dr Hunter's
  18     notes of the meeting with Dr Roylance, amongst others.
  19     What is said there in the second line, is that
  20     Dr Roylance stated his concerns about the service --
  21     I think we have covered that, have we, on what he
  22     indicated were his concerns about the service? What did
  23     he say about that?
  24   A. The service is, I understood, the results of paediatric
  25     cardiac surgery. Whether he implied it includes in the

   1     service the actual facilities, I cannot comment on what
   2     he meant at the time.
   3   Q. But he stated some concerns about the service or its
   4     results?
   5   A. Yes.
   6   Q. The note then goes on to say he had stated also some
   7     concerns about professional loyalty in some members of
   8     staff involved in the dispute.
   9        What can you recollect about that?
  10   A. It is a question Dr Hunter maybe can answer better than
  11     me because it is his note. Whether he implied the
  12     conflicts between Dr Bolsin and the surgeons, I am not
  13     sure. I do not know if the words "professional loyalty"
  14     refer to Dr Bolsin or to the surgeons, I must say. That
  15     is quite vague to me and I just cannot comment on that.
  16   Q. Can you recollect any discussion of the professional
  17     loyalties of any member of staff?
  18   A. I do not recollect, but it does not mean it has not been
  19     mentioned; I do not recollect it.
  20   Q. Dr Bolsin for his part may have a concern that whatever
  21     briefing was given to you by Dr Roylance in some way
  22     influenced you, or possibly biased you, against him and
  23     his audit before you saw him, Dr Bolsin.
  24   A. That may be true. I am not sure. I do not think that
  25     it did influence us too much, or at all. I think that

   1     Dr Bolsin's interview and presentation was quite clear
   2     and he had the facts. I do not think that we could
   3     argue against or for what he had done, so I do not think
   4     that we had been influenced by what had been said in
   5     Dr Roylance's office in our report.
   6   Q. To put it crudely, Professor de Leval, can you remember
   7     any anti-Dr Bolsin "spin", as it were, on anything that
   8     Dr Roylance said to you?
   9   A. I do not think so. No, I do not recollect any comment.
  10   Q. Going on, you next met -- we see here you were joined by
  11     Mrs Ferris; is that correct?
  12   A. I must say, I have forgotten this.
  13   Q. There was, in any event, an outline of the changes that
  14     were to be put in hand in the service?
  15   A. I do not recall Mrs Ferris having joined him. I am sure
  16     she did, but I do not recall certainly what her
  17     contribution to that meeting was.
  18   Q. Turning over the page, we come to the first discussion
  19     with Mr Wisheart and Mr Dhasmana. We see there that in
  20     particular you reviewed the results from both neonatal
  21     and older switches with very detailed information and
  22     data on individual cases.
  23        Can you recollect, Professor, was that data in the
  24     form of a review of case notes or was it in the form of
  25     oral information presented to you by the surgeons?

   1   A. I do not recollect. I think we had details certainly
   2     for the 13 switches. Whether we had detailed
   3     information for the whole series, I forget, but we had
   4     details for the 13 switches and I think the surgeon went
   5     through each of them at the time.
   6   Q. When you say you had "details" of them, what details did
   7     you have?
   8   A. They were the diagnosis, the age of the patient, the
   9     coronary anatomy and the outcomes.
  10   Q. And you discussed that with the surgeons without
  11     carrying out any independent review yourself of the case
  12     notes?
  13   A. That is correct, yes. We did not go through any case
  14     notes.
  15   Q. We see later, if we turn over the page -- I am sorry,
  16     there is no note there of the fact that you were joined,
  17     I think, at some point in this discussion by Dr Martin
  18     and Dr Hayes. Can you remember that?
  19   A. Yes, we saw them after having seen the surgeons.
  20   Q. Did you have a discussion with them about the
  21     environment for children at the Children's Hospital as
  22     opposed to that at the Bristol Royal Infirmary?
  23   A. That was discussed on the day, the particular time of
  24     day I forget, but it was discussed.
  25   Q. Can you recollect what input or additions the

   1     cardiologists gave to you in their meeting with you?
   2   A. I think that we received a description of the staffing
   3     of the cardiac surgery department. I forget the details
   4     of that document, but I think we had a document from
   5     them summarising their activities and their working
   6     patterns and timetables.
   7   Q. Was there any discussion, then, of the question of the
   8     adequacy of the diagnosis that had been presented to the
   9     surgeons in any of these --
  10   A. I think they acknowledged the fact that those patients
  11     had not been diagnosed properly and there were some
  12     deficiencies or weakness there, yes.
  13   Q. Were you able to evaluate the quality of those
  14     deficiencies, whether those were to be expected, given
  15     the difficulties of diagnosing anatomy, or whether they
  16     represented mistakes that were perhaps more surprising?
  17   A. What I recollect, for example, is that coarctation -- it
  18     does happen, you can always miss something like
  19     a coarctation, but to miss a coarctation has major
  20     implications for the operation.
  21        To misdiagnose the type of coronary arteries you
  22     are dealing with may have some effect on the mental
  23     readiness of the surgeon, but the surgeon should be able
  24     to correct that during the operation. Although, still
  25     now, some surgeons in the UK would not undertake an

   1     intramural coronary artery repair, so they would be very
   2     demanding on the accuracy of the diagnosis. If you have
   3     an intramural coronary artery at the beginning of your
   4     switch experience, it is a very, very difficult
   5     situation because the risks are high, still high now.
   6     If I remember it correctly, I think there were two
   7     intramurals in that series of 13, which is very, very
   8     bad luck, but I do not think we can incriminate the
   9     cardiologists for not having diagnosed that in 1991,
  10     because I think that the accuracy of the echocardiograph
  11     diagnosis of the coronary arteries has improved a lot in
  12     the last few years. I would not consider that it is
  13     poor cardiology to have missed that pre-operatively.
  14     To miss a coarctation is more important.
  15   Q. I am not seeking, I hope, to incriminate anyone, but
  16     certainly to explore and from that point of view, you
  17     have mentioned obviously in your report the fact that
  18     the failures with the switch programme were likely to
  19     have been complex and dependent in large measure on the
  20     performance of the team rather than an individual
  21     surgeon.
  22        Were you able, do you think, on your visit to the
  23     BRI to get to the bottom of the contribution of the
  24     cardiologists to the success or otherwise of the switch
  25     programme?

   1   A. I think that it is certainly multi-factorial, and I am
   2     convinced that the differences between success and
   3     failure is in the small details in my recent study on
   4     human factors, to which I alluded when I was here some
   5     weeks ago, which confirms that what I have called "minor
   6     negative events" have a major impact on outcomes.
   7        I think that in any complex systems the variables
   8     you are dealing with are more or less important, and
   9     I think that those who work in the world of complexity
  10     would recognise that in any complex system, there are
  11     the so-called critical variables which are the most
  12     important ones, and I believe that in terms of the
  13     arterial switch operation, the surgeon is certainly one
  14     of the critical variables, if not the most important
  15     one, but a satisfactory pre-operative management is
  16     important.  An inter-operative team dealing with those
  17     patients regularly is also vital. We did not have the
  18     opportunity to go into the performance of the
  19     Anaesthetic Department during our visit, but this is
  20     very important. I think that patients with
  21     transpositions are very vulnerable to any major changes
  22     like aggression during the insertion of the catheters is
  23     very important, so I think that the induction of
  24     anaesthesia, the large insertion is very important.
  25        Then there is the operation where, again, I think

   1     that the perfusionists are very important. We did not
   2     go into this but the fact that those perfusionists were
   3     dealing most of the time with adults might be of some
   4     concern if they were not very familiar with children,
   5     but again, we had not investigated this at all.
   6        Then the post-operative management is absolutely
   7     vital for those patients. Many of them are quite sick
   8     afterwards and their survival depends on the very high
   9     quality of the post-operative care which again is a team
  10     effort which quite clearly did not exist there.
  11   Q. Returning then to the process of your investigation, you
  12     have listed a number of factors which you did not have
  13     an opportunity or time to investigate fully and you have
  14     mentioned, for instance, the anaesthetic contribution to
  15     success.
  16        How confident are you, or how happy are you, with
  17     the method of investigation that you were obliged to
  18     adopt as a means of reaching a conclusion upon the
  19     adequacy of care at the unit?
  20   A. I think that the report was carefully written. I think
  21     that the report indicated its weaknesses and the report
  22     mentioned the fact that the investigation should go well
  23     beyond the surgeons but through the systems. I think
  24     that was in the initial report. So I do not think that
  25     the report was misleading or that the report did not

   1     achieve what it had to do; I believe that the report
   2     provided some information which could have been useful
   3     for the Chief Executive to investigate further, to try
   4     to have a better understanding what was happening and
   5     what had to be done.
   6   Q. But there is a difference between producing the best
   7     report that you can, given the material available, and
   8     addressing that which I hope my question was seeking to
   9     explore: the limitations of the material with which you
  10     had to work?
  11   A. I think the material was insufficient. Again, the
  12     report was written four years ago, and I think that in
  13     four years, understanding of performance in health care
  14     has changed a lot as well. I think I certainly would be
  15     even more demanding now than I was five years ago to
  16     make comments or statements.
  17   Q. More demanding by seeking to explore further the
  18     contribution of other members of the team?
  19   A. That is correct, or to state that no conclusion could be
  20     drawn, for example, with the information that I had.
  21   Q. Next on the note from Dr Hunter is the record of the
  22     meeting with Dr Bolsin, if we can scroll up a little,
  23     please. There is a reference there, is there, to the
  24     calendar of events that he provided to you. He gave
  25     you, did he not, a list or an account of events

   1     described as a "calendar of events".
   2   A. Yes, he did.
   3   Q. It may be, again, that Dr Bolsin will give evidence to
   4     the Inquiry that he felt the manner in which he had been
   5     questioned by yourself and Dr Hunter was a hostile one.
   6        Do you have any comment to make on that
   7     suggestion?
   8   A. I think it is difficult to -- it is easy to say no, but
   9     I do not recollect. What I recollect is that during the
  10     meeting there was a sense of conflict which was present
  11     there and I think the way Dr Bolsin presented his data
  12     or the calendar of events was conflictual. Obviously it
  13     is difficult to blame someone, to adopt that attitude
  14     knowing what he had done for several years to try to
  15     solve the problem. Whether our reaction has been
  16     hostile or not, I cannot comment on this.
  17   Q. You say that his manner was "conflictual".
  18   A. Yes.
  19   Q. Can you help us a little by expanding on that?
  20   A. Obviously he felt there was a problem somewhere, and to
  21     start to audit the performance of another discipline --
  22     which was, I think, done without the knowledge,
  23     certainly not the co-operation or even the knowledge of
  24     the surgeon -- is conflictual, in my view. I think that
  25     the attitude to adopt in circumstances where there is

   1     a concern about performance is to make sure that the
   2     performers are aware of it, and then are asked to
   3     contribute to an assessment of an audit which would then
   4     take place.
   5        If our attitude was hostile, I suspect that it
   6     might be related to that feeling we had when we saw what
   7     had happened before. I am not sure.
   8   Q. Two things. Firstly, you have described the way in
   9     which Dr Bolsin had acted throughout the audit as being
  10     "conflictual", but earlier, you were commenting on his
  11     manner during the interview when you used the word
  12     "conflictual". Can you help us a little further on his
  13     manner to you at interview?
  14   A. The feeling one had is that he had adopted, himself,
  15     a hostile attitude towards the surgeon, because --
  16   Q. Is that "surgeon" or "surgeons"?
  17   A. "Surgeons". Well, I think "surgeons", yes -- and that
  18     this transpired while he was explaining what he had
  19     done. But again, I do not recollect if that has been
  20     the cause for us being hostile, or me or Dr Hunter.
  21     I do not recollect.
  22   Q. Dr Bolsin gave the results of his audit or discussed
  23     them with a number of figures within the UBHT, including
  24     at least figures within the anaesthetic department such
  25     as the Clinical Director of anaesthesia, Dr Monk.

   1        When you comment on the manner in which this audit
   2     was conducted and its secrecy, is it fair to suggest, in
   3     effect, that the responsibility for bringing this audit
   4     to the attention of the surgeons and seeking a joint
   5     solution lay upon Dr Bolsin rather than, say, other
   6     members of his department?
   7   A. I think that the surgical department should have been
   8     informed of this. I do not think it did happen until
   9     some time later. Whether the Director of Anaesthesia
  10     should have been more active or done something, it is
  11     hard to tell. I would like to say that the data should
  12     have done it, but if I try to take a situation which is
  13     current, for example, and try to see what would happen
  14     today, let us say, at Great Ormond Street, if a young
  15     anaesthetist who -- I think that Dr Bolsin had been
  16     appointed in 1989; is that right?
  17   Q. In 1988.
  18   A. So a junior anaesthetist coming to Great Ormond Street
  19     today who, for example, spent a year with Dr Bovey, who
  20     has the best results, or one of the best results, with
  21     a particular heart syndrome, and assuming that a young
  22     anaesthetist spent a year there, comes to Great Ormond
  23     Street and the mortality is twice as high, it is 100 per
  24     cent higher, let us suppose, and that anaesthetist,
  25     without telling us, starts taking notes about our

   1     performance and goes to see the chief of anaesthesia to
   2     tell him or her that the results are appalling, I am not
   3     sure that more reaction would take place, because we
   4     know the results; we are aware of the fact that our
   5     results are not as good, and I do not think that more
   6     action would take place today.
   7        So retrospectively, I am not sure that I expected
   8     more reaction, I must say.
   9   Q. So that depends, does it, on the surgical department
  10     already being aware of its results and being confident
  11     in its mind of having the proper explanations for any
  12     differences in outcomes that may be present between it
  13     and another unit?
  14   A. Yes, but though we are here in 1989 talking about the
  15     arterial switch operation, for example, which started
  16     about that year, and there was nothing to compare with,
  17     or very little to compare with at the time in the UK.
  18     We did not know what the results of the other units
  19     were. We still do not today. Obviously the surgeons
  20     were aware of those poor results. The question is
  21     whether it is acceptable or not. I must say, I have
  22     great difficulties in answering the question.
  23   Q. Going back, though, to the method of conducting the
  24     audit, if the junior anaesthetist that we are dealing
  25     with in your unit has raised it with the Clinical

   1     Director of Anaesthesia, has at least notified him or
   2     her that the audit is taking place, and perhaps a number
   3     of other figures around the hospital, does that not
   4     exonerate him, as it were, from the responsibility of
   5     bringing it to the attention of the surgeons?
   6   A. I must say, I cannot answer the question. There is
   7     a lack of openness somewhere along the line. I think
   8     the surgeon should have been informed, whether by the
   9     Director of Anaesthesia or by the person who carried out
  10     the audit, but if there is a feeling of sub-optimal
  11     performance, whatever the cause of it is, it should come
  12     into the open and be discussed.
  13   Q. In any event, a lack of openness was something that you
  14     took away, I think it is fair to say, very strongly from
  15     your visit to the UBHT that day?
  16   A. Yes.
  17   Q. If Dr Bolsin recollects giving you a summary of outcome
  18     data from an annual report dealing with the years of
  19     1990 to 1991, do you have any recollection of that data
  20     being given to you?
  21   A. No, I do not. I have already said that and I do not
  22     have it in my files, so either I forgot about it and
  23     I did not take the document with me -- I think if that
  24     document had been available, one of the two reports
  25     would have mentioned that. You can ask Dr Hunter later,

   1     but I do not recollect that at all.
   2   Q. So if Dr Bolsin recollects being questioned, he may say
   3     in a hostile fashion, about that data, would your answer
   4     be the same: that you have no recollection?
   5   A. If I have not seen the data, it is difficult to comment
   6     on those. I said that the hostile comment was about the
   7     way he interviewed, not specifically about this data in
   8     1991 which I have not seen, I suppose.
   9   MISS GREY: Sir, I am conscious of the time. I wonder
  10     whether this might be an appropriate moment to break for
  11     10 minutes or a quarter of an hour?
  12   THE CHAIRMAN: Yes. Shall we take 15 minutes, then, and
  13     reconvene at about 10 past 12?
  14   (11.50 am)
  15               (A short break)
  16   (12.10 pm)
  17   MISS GREY: Professor, we were looking at this minute
  18     provided by Dr Hunter before the break. If we could
  19     just scroll down the page a little, please, we will see
  20     that the last sentence on that line is Dr Bolsin's
  21     observation that the anaesthetist did not take part in
  22     the decision-making process at referral meetings, and
  23     therefore were presented with difficult problems
  24     post-operatively.
  25        First of all, can you recollect that comment being

   1     made by Dr Bolsin?
   2   A. I do not, but it does not mean he did not make it. I do
   3     not recollect it.
   4   Q. Out of your more general experience, can I ask you,
   5     first of all, would it be normal, in your experience,
   6     for anaesthetists to be present at referral meetings?
   7   A. It is not, but I think it is an important point. It is
   8     a point I have addressed to myself at Great Ormond
   9     Street on several occasions.
  10        I believe that if you have a critical mass of
  11     patients which can justify to have two or three
  12     anaesthetists mainly involved in paediatric cardiac
  13     surgery, those anaesthetists could be involved in the
  14     overall management of the patients, but by and large it
  15     is not the case in any institution in this country, and
  16     very few in the world, I believe, and most anaesthetists
  17     have lists in a number of specialties and cannot take
  18     part in discussions, but I believe it will be a step
  19     forward in the management of those patients if one could
  20     achieve that, but it is not the case.
  21   Q. What could the consultant anaesthetists add to those
  22     management meetings and take from them for future care?
  23   A. What happens, and I suspect it happened in Bristol as
  24     well, is that we review once a week the operations that
  25     we are going to do the following week with the

   1     cardiologists, the surgeons, and a number of patients
   2     may have different anaesthetic risks of which the
   3     anaesthetist could not be aware of. I think it is
   4     important, again, in terms of mental readiness to have
   5     the maximum of knowledge of the problems that you are
   6     going to tackle, and I think it is important to have the
   7     time to think about it, other than to face the problem
   8     as it is presented to you.
   9        What does happen is that the anaesthetists do see
  10     the patients, usually the night before the operation,
  11     but I think if they could be part of a multidisciplinary
  12     decision-making process, that would be good for the
  13     patients.
  14   Q. So you understand what Dr Bolsin is saying if he is
  15     saying, as is recorded in the minute, that the
  16     anaesthetist could be presented with difficult problems
  17     post-operatively, if there was not that pre-operative
  18     involvement?
  19   A. Yes, but in my experience, the obstacle is from the
  20     anaesthetists. There are those who do not want to do
  21     it. They say they cannot do it because their working
  22     pattern is different, and because by and large they
  23     refuse to spend their lives doing paediatric
  24     anaesthesia, because it is, according to them, more
  25     stressful than what they do and they do not want to do

   1     that only.
   2   Q. You mention, if it would be worthwhile reorganising to
   3     allow this sort of joint meeting to take place, if there
   4     were a "critical mass" of patients.
   5        What sort of numbers would be needed to
   6     generate --
   7   A. You must have also the agreement of the anaesthetists as
   8     a profession to accept, to become so specialised that
   9     they would do mainly paediatric cardiac surgery and that
  10     has not been agreed at all. But I would suggest --
  11     I have already mentioned that here -- that a centre
  12     doing 400 or 500 cases a year could justify having an
  13     anaesthetist who would be involved in the overall
  14     management of those patients, which is not only the
  15     operating theatre but also the cardiac catheterisation
  16     laboratory and also perhaps take part in the
  17     post-operative management. I personally believe that it
  18     is important for each member of those teams to have
  19     areas overlapping to facilitate interfaces, but again,
  20     there is a very serious obstruction from the
  21     anaesthetists with this.
  22   Q. 400 or 500 paediatric cases?
  23   A. That is correct, yes.
  24   Q. Before leaving the meeting with Dr Bolsin, can I ask
  25     you: was there any direct discussion with Dr Bolsin of

   1     the circulation of his audit data?
   2   A. I do not recollect that.
   3   Q. If we can move over the page, please, page 16, and
   4     scroll down the page, please, to the discussion with
   5     Sister Thomas, we see at the bottom there that she had
   6     worked for eight years in cardiothoracic surgery.
   7        If we turn over to page 17, there is there
   8     a record of Fiona Thomas setting out her views that
   9     there was still a considerable conflict between surgeons
  10     and anaesthetists, and she did not appear to be greatly
  11     enamoured at the way in which ITU was run for children.
  12        Can I ask you first, what impression do you
  13     recollect that Sister Thomas gave you as to potential or
  14     considerable conflicts between surgeons and
  15     anaesthetists?
  16   A. Evidently the decision-making was highly disorganised.
  17     I think that the surgeons and the junior surgical staff
  18     would first come in the morning to see the patient,
  19     write the orders; could be changed by the consultant
  20     surgeons; the anaesthetist could come at different
  21     times. There was a complete lack of cohesion in
  22     organisation in the management of those patients.
  23     Nobody knew who was in charge of the patients. It seems
  24     that the surgeons had the last word, but as it happens,
  25     very often the surgeons are not there necessarily when

   1     problems occur, so it was highly unsatisfactory.
   2   Q. Was that information that you got from Sister Thomas, or
   3     was that a more widespread view?
   4   A. I forget now. In the report I had used the word "highly
   5     disorganised" for the Intensive Care Unit. It was
   6     mainly from her interview, I think.
   7   Q. She is recorded as saying that she did not appear to be
   8     greatly enamoured of the way ITU was run for children.
   9        Did you pick up from her or from others
  10     information about the way in which the paediatric care
  11     was handled in ITU?
  12   A. Again, we did not go to the Intensive Care Unit, but my
  13     understanding is that those children were amongst the
  14     adults and that the staff there were more familiar with
  15     the treatment of adults than of children and that the
  16     junior doctor on duty was also not a paediatric expert,
  17     so more familiar with the adults. So I suspect what she
  18     means here is that they did not appear to be greatly
  19     enamoured to look after children.
  20   Q. If we scroll down, please, we see the record of the
  21     interview with Professor Angelini. Do you have anything
  22     to add from your recollection of that meeting, to that
  23     note?
  24   A. No. I had a feeling after that meeting that there was,
  25     again, probably a conflictual relationship between the

   1     Professor of Cardiac Surgery and the other two surgeons,
   2     but I did not go into the details of this. I do not
   3     know if it was a consequence of what had happened or if
   4     it started like this when Professor Angelini was
   5     appointed two and a half years before.
   6   Q. Is that something that you can specifically recollect
   7     arose out of your interviews at that time as opposed to,
   8     say, your subsequent knowledge of events, in, for
   9     instance --
  10   A. No, it was at that time, yes.
  11   Q. Further down the page, we see that Dr Monk's
  12     contribution is praised as being "lucid and logical".
  13     Is that an impression you took away as well?
  14   A. Yes.
  15   Q. He is recorded as saying that the results from surgery
  16     were "less than adequate". Can you explain what he said
  17     to you?
  18   A. I do not remember the details. I do not think he
  19     produced any figures or at least no comparative
  20     figures. It was just his clinical impression that the
  21     results were not good.
  22   Q. Was it related to specific procedures or was it
  23     a generalised comment?
  24   A. I am not sure. I think the switch was mentioned as
  25     a procedure, but I cannot be more specific on this.

   1   Q. He then goes on to say there had been unsatisfactory
   2     access to figures until quite recently. Did he say what
   3     access to figures he had been given, firstly by the
   4     surgeons?
   5   A. I think he alluded to the difficulties of obtaining
   6     figures from the surgeons until our visit took place.
   7     This is what he meant.
   8   Q. Did he discuss whether he had asked for figures from the
   9     surgeons?
  10   A. I do not recollect that.
  11   Q. So what you remember is a generalised comment that it
  12     had been difficult?
  13   A. That is right, yes.
  14   Q. But no more details?
  15   A. No more details no.
  16   Q. Or details in particular of whether or not he had
  17     actually asked for information?
  18   A. No. I do not recall what exactly he said at the time,
  19     but I think that there were many general comments that
  20     he made.
  21   Q. What about access to figures by Dr Bolsin? Was there
  22     any discussion of that?
  23   A. I do not think so. I do not think he commented on those
  24     figures, but I may not be right.
  25   Q. As Clinical Director of Anaesthesia, he would

   1     presumably, one might have thought, have the standing or
   2     authority to ask for figures from the surgeons concerned
   3     if there had been perceived to be a need for them?
   4   A. Possibly, but again, if I am trying to see what I would
   5     do, for example, if my Senior Registrar was complaining
   6     about an anaesthetist and was trying to audit the time
   7     it takes for an anaesthetist to prepare a patient for
   8     surgery, whether I would take action or not, I am not
   9     sure.
  10   Q. If you would not take action, why not?
  11   A. I think that I would probably initiate an open
  12     discussion to say that there is some concern, but
  13     I probably would not at that stage go to the figures.
  14     I just have a feeling that it is not the right attitude
  15     to start an audit exercise without the people who are
  16     investigated knowing about it. So I would use the
  17     opportunity to express some wishes to initiate an audit,
  18     ask them to do it, but I would certainly not use the
  19     figures at the time.
  20   Q. So you would bring it out into the open?
  21   A. That is right, yes.
  22   Q. And generate a discussion?
  23   A. Yes, to try to have a constructive attitude, rather than
  24     a conflict right from the start, yes.
  25   Q. And presumably, as part of that constructive attitude,

   1     you would seek to achieve some form of consensus on how
   2     the matter was then to be handled?
   3   A. Yes.
   4   Q. Whether one party or another would say, go forward with
   5     the figures, or whether that was the way forward at all?
   6   A. Yes.
   7   Q. You are nodding. I think that was a yes, was it, for
   8     the sake of the transcript?
   9   A. Probably, yes.
  10   Q. If it is a less than qualified yes, do say so.
  11   A. It is "Yes".
  12   Q. If we look back at your own witness statement and its
  13     account of the meeting with Dr Monk -- this is
  14     WIT 319/3, towards the bottom of the page, under the
  15     heading "other hospital staff", the last part of that
  16     paragraph mentions that he emphasised the poor results
  17     of the switch operation, which in his opinion did not
  18     only reflect on surgery but on the overall team
  19     management.
  20        Can you remember any of the elements in the
  21     judgment that he was making there?
  22   A. I do not, but my recollection is also that I had been
  23     impressed by Dr Monk, precisely because his overview of
  24     the problem, he was not considering his comments on the
  25     surgeons only but on the overall management of the

   1     patient, which was I think the most positive discussion
   2     we had during the day.
   3   Q. But you cannot remember the threads --
   4   A. I do not remember the details.
   5   Q. Looking up the page, the beginning of that paragraph,
   6     N7, Dr Pryn was concerned about the lack of hard data?
   7   A. Yes.
   8   Q. Did he make any comments on access to data?
   9   A. I do not recall. He probably made a similar comment
  10     that they had difficulties to get the data from the
  11     surgeons.
  12   Q. I think it may be if we look back at the minute we have
  13     just looked at, he was one of those who commented that
  14     they had only had the results on the preceding night;
  15     do you remember that?
  16   A. I do remember that. That was acknowledged by the
  17     surgeons as well.
  18   Q. He went on to point out a disparity between the
  19     expertise of the two surgeons. What was the contrast
  20     that he was drawing there?
  21   A. He was making the point that the results of the
  22     performance of one of the surgeons was less satisfactory
  23     than the other one. Whether he went into the details of
  24     the switches or the AV canals, I forget, but he
  25     indicated that there was a difference in the results,

   1     but without giving data.
   2   Q. So you are unable to help us as to which surgeon he was
   3     suggesting was more or less expert, or was he
   4     criticising both in relation to different procedures?
   5   A. No, he indicated the results of Mr Dhasmana were better
   6     than the results of Mr Wisheart.
   7   Q. Was that something that you eventually felt able to
   8     corroborate in any way, or to disagree with?
   9   A. Well, I think that I did agree with that and in the
  10     tables we sent with the report we indicated that the two
  11     surgeons had different results in terms of
  12     atrioventricular septal defect, certainly, and leaving
  13     aside the arterial switches, the results of Mr Dhasmana
  14     were satisfactory, in our opinion.
  15   Q. If we can go back to the report, please, UBHT 52/263, at
  16     the bottom of that page it sets out your judgment and
  17     that of Dr Hunter on post-operative management. You say
  18     there that it appears to be highly disorganised with
  19     conflicting decisions between the various parties
  20     involved.
  21        Is there anything further that you can assist the
  22     Inquiry with, because we have covered this in some
  23     measure already, as to the evidence upon which that
  24     judgment was based?
  25   A. No. It was mainly from Sister ...

   1   Q. Sister Thomas?
   2   A. Yes, who discussed the post-operative care. I do not
   3     think we had any other information than that. It says
   4     as she explained, what evidence, with the number of
   5     people coming to see the patients without any team
   6     effort and with the intensivists who are not on site all
   7     the time, and therefore provide a service which is
   8     intermittent.
   9   Q. Was that criticism not put to the surgeons or the
  10     anaesthetists concerned?
  11   A. Criticism? I do not think that the person who made
  12     those comments was criticising surgeons or
  13     anaesthetists, it was the fact that the post-operative
  14     management was disorganised.
  15   Q. It may have been a fact to her, but it might well be
  16     that the surgeons concerned and the anaesthetists and
  17     the surgical senior registrar and the SHO might have
  18     disputed it. Did any of them have an opportunity --
  19   A. No, we did not discuss specifically the post-operative
  20     management of either with either the surgeons, the
  21     cardiologists or the anaesthetists.
  22   Q. And it was not raised in the general discussion that
  23     rounded off the day, then?
  24   A. I do not think so.
  25   Q. So why is it that you say that that judgment which you

   1     felt confident enough to include in the report you sent
   2     to Dr Roylance, should not have been publicised without
   3     further investigation? I am looking there at WIT 319/1,
   4     please. This is your witness statement, at the bottom.
   5   A. I think that the comment about the post-operative care
   6     is based on information and data which are as weak or as
   7     strong as the data set we had received throughout the
   8     day. I think that if someone describes to me the way
   9     the patients are looked after post-operatively, saying
  10     that three or four different people come between
  11     8 o'clock and 10 o'clock and overrule their own orders,
  12     I think it would be very unlikely that the management of
  13     those patients is appropriate. I would confirm that
  14     today, as well.
  15   Q. But that implies that the judgment in the first report
  16     was accurate and fair --
  17   A. It was accurate.
  18   Q. -- and could have been publicised without further
  19     investigation?
  20   A. Well, again, this could apply to the data. I think that
  21     if someone tells that you a surgeon has done eight
  22     atrioventricular septal defects with seven deaths,
  23     I think I would again today say this surgeon is a high
  24     risk surgeon, but I would not like this to be published.
  25   Q. Because you would need to check the data?

   1   A. Absolutely, and not only that, make sure that they are
   2     validated, to see the risk stratification, exactly what
   3     the patients were, et cetera, yes.
   4   Q. If we can go back to the report, please, 52/264, you set
   5     out there the background of the current problem. Would
   6     I be right in thinking that the history of events there
   7     set out is taken primarily from Dr Bolsin's calendar of
   8     events?
   9   A. Yes.
  10   Q. And just for the sake of the record, if we look, please,
  11     at UBHT 61/49, please, is that the document that
  12     Dr Bolsin gave to you?
  13   A. Yes.
  14   Q. If we can go back to the report, one of the events that
  15     is set out there in the second paragraph, "Background of
  16     current problem" is the fact that in 1993 one paediatric
  17     cardiac surgeon went to the Children's Hospital in
  18     Birmingham to improve his technique on the switch
  19     operation. He went, I think as a matter of record,
  20     twice and on the second occasion, he took an
  21     anaesthetist, a perfusionist and two nurses along.
  22     On both occasions, I think again it is accurate to say,
  23     he watched operations being conducted by Mr Brawn.
  24        Are you able to help the Inquiry as to the
  25     appropriateness of that form of retraining, judged in

   1     the context of the standards of retraining or training
   2     at that time?
   3   A. He recognised the problem and he tried to solve it by
   4     visiting someone who was achieving better results.
   5     I have never found the definition of retraining. I have
   6     used the word in my paper on the "Cluster of Failures",
   7     and I still do not know what it means. Obviously
   8     retraining may indicate training to understand or try to
   9     pick up some technical details of a procedure or the
  10     management of the perfusion, the bypass, so I think that
  11     if you are facing failures, by definition you do not
  12     know exactly where the figure arises from. I think as
  13     surgeons we have a tendency, at least most of us, to
  14     incriminate the skill or the actual technical
  15     performance of the procedure, which I think is very
  16     shortsighted. We all make the mistake. So I think when
  17     you have a problem, you are in the dark and it is very
  18     difficult to decide whether it is appropriate, not
  19     knowing exactly what the cause of the failure was, and,
  20     for example in my own experience, I decided to retrain
  21     by doing the same, going to see Bill Brawn and having
  22     him to help me to do one or two switches, and
  23     I believed, when I started to do the switches myself,
  24     that I had learned some technical tricks.
  25        Five years later, I had realised that the way I do

   1     the switches is the way I did them before my "Cluster of
   2     Failures", not the way I learned it, and I am convinced
   3     that my retraining has given me back the confidence that
   4     I had lost and I think this is the most important point,
   5     to reach a state of mental readiness which is such that
   6     you cannot proceed with confidence and you have to
   7     regain it.
   8        Whether this is what Mr Dhasmana was looking for,
   9     I am not sure. I think that the word "retraining" here
  10     might not be appropriate because he had never achieved
  11     good results in the switches, so it was a question of
  12     training rather than retraining, which is slightly
  13     different, I believe. So it was the problem of
  14     initiating a new form of treatment, a strategy, the
  15     arterial switch operation having failed, while you start
  16     to implement that new strategy.
  17   Q. I think it is fair to record that the word "retraining"
  18     came from me and was no doubt inaccurate. The word you
  19     use in the report is "improvement": he went to
  20     Birmingham to improve his technique. Is that a better
  21     characterisation of what you understood to have been
  22     taking place?
  23   A. I think so.
  24   Q. But the difference between the form of study that you
  25     undertook and that Mr Dhasmana undertook in 1993 was

   1     that when he went to Birmingham, he watched operations,
   2     whereas I think you were assisted by Mr Brawn in
   3     carrying them out. Is that a material difference?
   4   A. I did both. If I am correct, I believe that Mr Dhasmana
   5     tried to have the same type of help as well, and that
   6     Mr Brawn did not find it possible for him to either go
   7     to Bristol or he did not have the time to do it --
   8     I have forgotten the details -- but I think that
   9     Mr Dhasmana was hoping to have that type of support.
  10   Q. We may hear that whatever he tried to achieve, he was in
  11     effect offered a choice between attending at Birmingham
  12     to see Mr Brawn in action and having Mr Sethia come to
  13     Bristol to assist in Bristol.
  14        If that was the choice presented by Mr Dhasmana,
  15     and clearly it is something that he either will or will
  16     not confirm to the Inquiry directly, do you have any
  17     critical comment on the choice that he did make to go to
  18     Birmingham?
  19   A. I think it is a very difficult question, on the one hand
  20     from the person who is receiving help and on the other
  21     hand from the person who is offering to help. I have
  22     helped lots of people or surgeons to do some operations,
  23     but it is a huge responsibility you are taking up to
  24     accept to help someone to perform a new operation and in
  25     a way, to have some responsibility in the outcomes, and

   1     I sometimes do not accept it because I do not feel that
   2     I like to take that responsibility.
   3        The choice between having Mr Sethia in Bristol or
   4     visiting Mr Brawn, I think it is a question of personal
   5     relationships which also, I think, is very important.
   6     It is, I think, not that easy for a senior surgeon to
   7     find another surgeon with whom you relate well, to learn
   8     something new or to solve a problem, and I think
   9     surgeons are not the easiest people to deal with, and we
  10     all have our weaknesses in personalities, and it is
  11     sometimes very difficult for two surgeons to work
  12     together.
  13   Q. You talk about personal relations. Is there anything
  14     about the school of surgery in which Mr Brawn and
  15     Mr Dhasmana were trained that might make it more natural
  16     for Mr Dhasmana to prefer to go and see Mr Brawn?
  17   A. I think so. I have never seen the individual results of
  18     Mr Brawn or Mr Sethia, but I believe that one of the
  19     most important schools of paediatric cardiac surgery has
  20     been the school of Castaneda in Boston, which has
  21     produced, I think, excellence which seems to be
  22     transmitted from one generation to the other. Mr Brawn
  23     was trained by Roger Mee, who was one of the first
  24     pupils of Aldo Castaneda.
  25        So I believe that in 1995, 1993, if I were,

   1     myself, to choose between the two surgeons, I probably
   2     would have taken someone coming from that school.
   3   Q. The next event recorded in that account of events after
   4     the approval of Professor Angelini is a joint meeting
   5     between the cardiac surgeons and the paediatric
   6     cardiologists and the cardiac anaesthetists, in which
   7     the surgeons reassured their colleagues that the results
   8     were improving.
   9        Firstly, were you given the impression that
  10     results were presented to this joint meeting?
  11   A. No, I do not think that any hard data had been produced
  12     for that meeting. This is my recollection.
  13   Q. If the surgeons reassured their colleagues that the
  14     results were improving, is that a statement that you
  15     would have expected to have been based on hard data?
  16   A. Well, I would have been reluctant to accept the
  17     statement without any hard data.
  18   Q. Were you yourself able to make any judgment on the basis
  19     of the data that you were presented with as to whether
  20     the results were improving by that time?
  21   A. I think that we had two periods in the results produced
  22     on that day and I think the second period went better
  23     than the first, but I have to go back to my ... I mean,
  24     this is in the tables we added to the first report.
  25   Q. We can look at page 269.

   1   A. No, that is only a single period, so we have no evidence
   2     of a trend here. But the meeting we are talking about
   3     took place in 1993, so presumably the surgeons were
   4     commenting on results obviously before 1993, which more
   5     or less precedes this era.
   6   Q. The data you were presented with by the surgeons?
   7   A. Yes.
   8   Q. Speaking of the data that was presented to you by the
   9     surgeons, you gave evidence I think earlier to the
  10     Inquiry that you did not yourself ask for any data prior
  11     to your visit to Bristol?
  12   A. That is correct.
  13   Q. Is that correct?
  14   A. Yes.
  15   Q. If Professor Angelini received the impression from
  16     whatever source -- he will have to help us on that
  17     source -- that you had asked whether before your visit
  18     or at some other time, for some ten years of data on
  19     operations by the cardiac surgeons, do you have any
  20     recollection of such a request?
  21   A. Not at all, and I suspect that I would have put it in
  22     writing, I think, if I had asked for that.
  23   Q. Just to clarify, when you say you did not ask for data
  24     in advance, you were then presented with data, is it
  25     also right to assume that you did not ask for any

   1     further data at the end of your visit?
   2   A. No.
   3   Q. If we turn back to page 264 --
   4   A. Incidentally, Dr Angelini had written -- shortly before
   5     the meeting -- a very short note to say that he was
   6     hoping that we would help them and indicated the task
   7     may not be easy but makes no comment about the data.
   8   Q. I think we can probably turn that up.
   9   THE CHAIRMAN: Can we see that, Miss Grey? .
  10   MISS GREY: If we look --
  11   THE CHAIRMAN: Shall we do it at the break and move on? We
  12     can come back to it. I am anxious that we do not refer
  13     to any material which is not available to everybody.
  14   THE WITNESS: I am afraid I do not have it here.
  15   MISS GREY: We can find that. I should have the reference
  16     at my fingertips, but I do not.
  17        If we go back, then, to the discussions on this
  18     page, we see that there is a reference there to a letter
  19     or a discussion between Professor Angelini and Professor
  20     Farndon on 24th July 1994. Were you ever given any
  21     document that might have underlined that event?
  22   A. I do not think so.
  23   Q. At the bottom of the page there is a reference to the
  24     non-infant switch and the discussion of that.
  25        As the record reads there, it says that an

   1     agreement was reached to proceed with the operation. It
   2     suggests that all parties concerned at the meeting
   3     agreed with that decision.
   4        Is that an accurate summary of events?
   5   A. Actually during the coffee break I tried to answer the
   6     question about hostility. I remember that the only
   7     comment I made which could have been taken as being
   8     hostile was precisely about this particular patient
   9     where we were told there was a unanimous decision to
  10     proceed, and Dr Bolsin did not agree with that; he
  11     disagreed with that statement. Then I think I am
  12     correct in saying he agreed that he had accepted to
  13     proceed on medical grounds, but not politically,
  14     "political" is the word he used, but there was
  15     a medical agreement. I suspect I may have shown some
  16     signs of irritation that that distinction was made.
  17     I think this is the only recollection I have of being
  18     perhaps seen as being hostile.
  19   Q. You yourself did not understand or did not sympathise
  20     with the distinction that was being made?
  21   A. No, I think that the purpose of the meeting was
  22     a medical decision and a full agreement had been reached
  23     to proceed on medical grounds. I did not see why
  24     a political reason could have been influential in the
  25     decision-making. Obviously, with hindsight, we could

   1     argue that the patient should not have been operated on
   2     I am not sure, having seen the details, but if the
   3     purpose of that meeting was to decide on medical
   4     grounds, they had reached agreement on this, I believe.
   5   Q. If we go on, please, to page 265, you set out then the
   6     forward steps that you understood had been already
   7     agreed upon, is that correct, within the Trust?
   8   A. Yes.
   9   Q. Going down the page, perhaps I could just fill in the
  10     reference now before we go on any further, thanks to the
  11     assistance of Mr Maclean: UBHT 61/338, please.
  12     (Pause).
  13   A. That is correct. There is no indication of having
  14     discussed data with me.
  15   Q. If we turn back to the report at 265, please, under the
  16     heading of "Perceptions ...", you speak there of the
  17     auditing activities of the surgical results by the
  18     anaesthetic department.
  19        Was it accurate to speak of the "Anaesthetic
  20     Department" on your understanding of events?
  21   A. I believe that we had been told in a meeting that it was
  22     Dr Bolsin with the assistance I think of Dr Black -- is
  23     it possible?
  24   Q. Yes.
  25   A. -- so this is why I used "Department" rather than

   1     "individual".
   2   Q. Why did you reach the conclusion that that lacked
   3     a collaborative attitude?
   4   A. Because as I said before, such an activity, to me,
   5     should have been done with at least the knowledge of the
   6     surgeons, which was not the case. So I think that
   7     should be done in the open, from the start.
   8   Q. You then go on, at paragraph 2, to talk about the
   9     surgeons' reticence to produce and analyse their own
  10     results.
  11        What was the judgment that the surgeons had been
  12     reticent in production of results based upon?
  13   A. It was quite clear from Dr Bolsin's interview and from
  14     the head of anaesthesiology, that they had great
  15     difficulties to obtain the results. It was, I think,
  16     clear also that when they met in 1993, the surgeons made
  17     a statement which was not supported by data and that the
  18     number of the people we had seen on that particular day
  19     in February had been presented the surgical results for
  20     the first time, so there was an obvious reticence from
  21     the surgeons, because even the first time they were
  22     informed of the audit in 1993, during the meeting they
  23     had, it was two years before, so I think that there was
  24     a reticence.
  25   Q. This question depends on my correct identification of

   1     the meeting in 1993, but it may well be that the Inquiry
   2     will hear that at that meeting Mr Wisheart put figures
   3     up on a blackboard and so, therefore, did present the
   4     results of the unit in the form of a sketch, data, on
   5     a blackboard.
   6        Does that alter your answer in any way?
   7   A. Again, I must say that if that scenario happened at
   8     Great Ormond Street at that particular time, even if we
   9     had done our very best to get the data, we would have
  10     found it very difficult to get accurate data. So it may
  11     be more than reticence to produce the data, it may be
  12     that it was not practically possible to do it.
  13   Q. What were the norms for data collection in your own unit
  14     during this period? Let us look first at the period
  15     from 1990 to 1993.
  16   A. It is highly unsatisfactory. What we had at Great
  17     Ormond Street, and still have, what we call a monthly
  18     death conference or mortality and morbidity conference,
  19     where the activity of the month is summarised in terms
  20     of name, age, diagnosis, outcomes, complications are not
  21     listed per patient, but sometimes summarised at the end
  22     of the report. Then there is a detailed summary of the
  23     patients who died.
  24        Those death conferences are printed and from them
  25     we extract the data which is sent to the UK register for

   1     the death conferences, but we do not have a database
   2     where all the patients are entered.
   3   Q. But was there ever any attempt to present not merely the
   4     month's figures but, say, an annual review --
   5   A. No.
   6   Q. -- or a review of series?
   7   A. No.
   8   Q. I asked you about the period from 1990 to 1993.
   9        By the time you came to Bristol in January 1995,
  10     had that position as you describe it changed in any way?
  11   A. At Great Ormond Street? No.
  12   Q. What about the process of making an annual report for
  13     either audit purposes or possibly at a time when the
  14     service was still designated as a supra-regional service
  15     to the Department of Health? Was there no data
  16     collection process for that purpose?
  17   A. All the data we have ever sent from Great Ormond Street
  18     were from those death conferences.
  19   Q. Going on, then, to paragraph 3, you describe there the
  20     process of channeling concerns upwards to the Department
  21     of Health before professional bodies as being
  22     "unfortunate".
  23        Can you tell us what your expectation as to the
  24     norms for tackling these sorts of concerns was at the
  25     time when you made the report?

   1   A. I would have hoped that the College of Surgeons, for
   2     example, could have been approached or the -- I am not
   3     sure if the British Paediatric Association was in
   4     existence in those days. I do not think they were; it
   5     was just the beginning. But the Society of Cardiac
   6     Surgery or Cardiology could have been approached as
   7     well, I think.
   8   Q. Why would that have been more acceptable or suitable
   9     than going to the Department of Health?
  10   A. I think that if a problem arises, I think first of all
  11     the people implicated should be fully aware of it and
  12     should contribute, do their best to understand and solve
  13     the problem. So the first step is in the institution of
  14     the department the problem arises from. And I believe
  15     that the profession should play a role in helping solve
  16     those problems before they call the Department of
  17     Health. Obviously, if the professional bodies are not
  18     of any help, one has to go further.
  19   Q. What legitimate interest or responsibility do you think
  20     that the Department of Health had in this matter?
  21   A. I think the Department of Health is ultimately
  22     responsible for health care and care provision in this
  23     country, so I think they should play a role there.
  24     Again, looking at the overall problem, I think that the
  25     fact that the cardiac surgery took place on two sites,

   1     for example, is a problem which goes well beyond the
   2     Department of Cardiac Surgery in Bristol, even in the
   3     Trust, I think.
   4   Q. Because it relates in part at least to funding issues?
   5   A. Yes, precisely.
   6   Q. But the Department, after these events had taken place,
   7     when the feeling was expressed to them that they were
   8     outsiders who should not have been approached until
   9     a later stage, replied that they saw themselves as being
  10     part and parcel of the family of health care providers.
  11     Why should they be the last port of call; health care
  12     professionals, other professionals, approached first?
  13   A. This is my view -- I do not think it is based on any
  14     form of legislation. I think that if we believe that
  15     professional self-regulation should play an important
  16     role in enhancing or improving health care or reaching
  17     excellence, that would be the way to proceed, to go to
  18     the profession first.
  19   Q. So paragraph 3 is ultimately based upon an
  20     understanding, in your view, of the importance of
  21     professional self-regulation?
  22   A. Yes.
  23   Q. Moving on to paragraph 4, then, you say at the bottom of
  24     that paragraph, the end of the paragraph, that there was
  25     no hard data on morbidity.

   1        Again, drawing on your experience of data
   2     collection at the time, would you have expected there to
   3     be such hard data?
   4   A. No. We have at Great Ormond Street some hard data on
   5     morbidity in the Intensive Care Unit only in the last 18
   6     months for the first time.
   7   Q. What was it that made data collection on morbidity
   8     relatively slow to start up and be collected?
   9   A. I think we already are behind that collection in terms
  10     of mortality. Morbidity is the next step.
  11   Q. When you say "we are already behind", whom do you mean
  12     by "we"?
  13   A. I think at least we at Great Ormond Street, but it
  14     applies to many other centres as well, I think, yes.
  15   Q. A related subject: there was no hard data on morbidity.
  16     Can I ask you, Professor, what your experience was of
  17     discussing the subject of morbidity with parents at the
  18     time of the terms of the Inquiry? If you go back to,
  19     say, 1990?
  20   A. In my own practice, I usually did not specify potential
  21     problems, other than chances of success or failure, so
  22     I would quote a risk of success which means survival
  23     without major or irreversible morbidity. This is what
  24     I mean. But I was never explicit in terms of going into
  25     the details of morbidity. For example, we, until recent

   1     years, never specified that there was a risk of brain
   2     damage after heart surgery.
   3   Q. But you have said that you define "success" to yourself
   4     as meaning not the difference between life or death, but
   5     the difference between life without major neurological
   6     complication, or death.
   7        Can you explain to us whether or not the meaning
   8     of "success" would have been explained to parents in
   9     those terms?
  10   A. It was not, no. It was just a global risk without being
  11     specific whether it was morbidity or mortality.
  12   Q. So was there any explicit discussion with them at that
  13     time of the risks of brain damage?
  14   A. No. Obviously some parents would question the
  15     complications and we would obviously answer the
  16     question, but we would not spontaneously bring out the
  17     topic of brain damage.
  18        I think there is a problem of culture and also of
  19     readiness of patients to accept this. At Great Ormond
  20     Street we often have at least one or two Senior
  21     Registrars who have completed their training in
  22     America. In many States the list of risks (not only of
  23     brain damage) has to be read to the family or to the
  24     patients. It was quite common, on the first week of
  25     July each year, when those residents came to work with

   1     us, to see parents in tears, totally distressed, because
   2     it was precisely indicated that their child could have
   3     brain damage the following day.
   4        So I think there is a problem of culture which has
   5     changed quite a lot in the last few years, and obviously
   6     now, even if we distress the parents, we would mention
   7     that, but it was not specifically mentioned at the time.
   8   Q. When did your practice change, roughly?
   9   A. I think it has changed. I became involved in court
  10     cases where patients had suffered brain damage and the
  11     first question that the legal expert would always ask
  12     is: "Did you tell the family? If you did, it is fine.
  13     If you did not, it is not fine at all". So this is when
  14     I started to do it, but I must say, with reluctance,
  15     because of the impact on the families. I have a feeling
  16     that very often the families actually are aware of this
  17     because they have discussed open-heart surgery, but to
  18     spell it out seems to be very traumatic.
  19   Q. You told us of events, the pressure of litigation. Can
  20     you date that in chronological terms at all, within the
  21     last --
  22   A. I think that nowadays I have always a witness with me.
  23     I mention the neurological risks and I write it down,
  24     and this is for the last two years -- the last two or
  25     three years.

   1   Q. You have talked of a change in medical culture: doctors
   2     now changing their practice. What about the
   3     acceptability of that information for parents? Has
   4     their reaction to this sort of data changed in any way?
   5   A. I think so. I think in the past the majority of the
   6     patients had established a relationship of trust and
   7     they were aware of risks without being willing for those
   8     to be specified, knowing that everything possible was
   9     done for their child and I think that attitude has
  10     changed. Patients and parents are more demanding. They
  11     want to know more precisely what the potential risks
  12     are, which is obviously correct, and the doctors not
  13     only are more open about the risks of failure, but also
  14     are more aware of their own risks of litigation. So it
  15     is a combination of a number of issues which has changed
  16     the practice.
  17   Q. I have taken you away from the report to discuss that
  18     issue. If we go back, please, to paragraph 5, you talk
  19     about the tension that has arisen from this long saga
  20     creating an atmosphere of distrust and lack of
  21     confidence and then you add that that has made the
  22     working conditions for the surgeons "nearly untenable."
  23        What was that perception based upon?
  24   A. It is based upon personal feeling that if I had been
  25     asked to operate a high risk patient in Bristol in

   1     February 1995, I would have refused. I would have been
   2     unable to do it because I felt that it was not a team
   3     effort, that I was watched for the worst and that the
   4     pressure would have been such that my performance would
   5     have suffered from it. So it is a personal statement.
   6   Q. If we look at the statement of Dr Hunter on this matter,
   7     he comments at WIT 322, please, page 6, under the
   8     heading "Conclusion" that "The visitors sensed a lack of
   9     communication between the various parties involved and
  10     felt that this was at the root of the problem facing the
  11     Trust."
  12        Firstly, would you agree with that as an
  13     observation?
  14   A. Yes.
  15   Q. If you go on, he then goes on to say:
  16        "Those who initiated the audit activities gave the
  17     impression that they were intent on policing the
  18     surgical activities rather than working together to see
  19     a solution."
  20        Again, is that a comment that you would agree
  21     with?
  22   A. Yes.
  23   Q. What would you understand the word "policing" to mean in
  24     that context?
  25   A. I think that it was not a cost-effective way to improve

   1     a situation. It was an activity to demonstrate failure,
   2     which I think it is important. But not done in
   3     a constructive way, basically. So it is a good
   4     intention, but poorly conducted.
   5   Q. The last sentence of that paragraph:
   6        "There was in general a lack of understanding of
   7     the problems of paediatric cardiac surgery."
   8   A. I am sure you can ask Dr Hunter what exactly he meant by
   9     this sentence later. The way I understand it is that
  10     they were not, in a specialised environment, at all
  11     levels where there was enough knowledge to deal with the
  12     children on the same site.
  13   Q. What about the working conditions of the anaesthetists
  14     in this setup, and in particular, that of Dr Bolsin?
  15     Did you consider the attitude or regard in which he was
  16     held by the other members of his department?
  17   A. No. I do not have a feeling for this. I cannot answer
  18     your question.
  19   Q. Because it might be said on Dr Bolsin's behalf that it
  20     was he who felt that he had to leave the unit ultimately
  21     because of the way in which he was treated?
  22   A. Well, I have no knowledge of the reasons for his leaving
  23     and the possible problems within the department. I am
  24     not aware of it.
  25   Q. It was not an issue at any rate that you picked up at

   1     the time you visited?
   2   A. Not at all, no.
   3   Q. If we go back, please, to the report, UBHT 52/264, and
   4     turn over the page, to page 266, you then go on to deal
   5     with data analysis.
   6        Firstly, can I ask, what comparative data was your
   7     analysis based on? Was it the Cardiac Surgical
   8     Register?
   9   A. I believe so. I think that they had produced some data
  10     from the register at the time, yes. The report is based
  11     on data we received at the time of the visit, nothing
  12     else. We did not look at any other data at the time.
  13   Q. Including the Cardiac Surgical Register, then?
  14   A. You mentioned a register of 1991, which I have not seen,
  15     as I said already before twice.
  16   Q. I think that was intended to be a Bristol document
  17     rather than --
  18   A. Yes, but I have not consulted that document to write
  19     this report. Again, Dr Hunter may remember about the
  20     register, but I am not aware of it.
  21   Q. Did you consult the CSR to write this report, or was
  22     your knowledge of comparative figures based on your own
  23     experience and knowledge?
  24   A. No, I did not use any of my own experience, I used only
  25     the data which had been given to us at the time.

   1   MISS GREY: Sir, I am coming to the conclusions of the
   2     report and then to its treatment. I wonder whether this
   3     might be an appropriate moment to break for perhaps
   4     three-quarters of an hour so that we might resume at
   5     2.00?
   6   THE CHAIRMAN: Yes, shall we do that, then?
   7   (1.15 pm)
   8            (Adjourned until 2.00 pm)
   9   (2.00 pm)
  10   MISS GREY: Could we scroll up, please, to page 266,
  11     where you say, towards the bottom of the page, that
  12     consultant 2 has a mortality of 0 per cent for VSDs,
  13     0 per cent for tetralogy of Fallot and 8.6 per cent for
  14     AV canal and as a result of that data, you say that
  15     consultant would certainly compare very favourably with
  16     the best UK institutions.
  17        Consultant 2 was the consultant concerned with the
  18     arterial switch operation; is that not right?
  19   A. That is right, yes.
  20   Q. So in making your judgment on comparisons, that was
  21     excluding the switch series; is that right?
  22   A. Yes. That was specified in the report somewhere, that
  23     the comments were leaving the switches aside.
  24   Q. If we go over the page, we see more generally your
  25     conclusions about standards.

   1        Perhaps we should go back first to the previous
   2     page, 266, please. You had been saying, in discussing
   3     them, in effect that a number of the cases were "high
   4     risk", is that right, or had complicating factors?
   5   A. That is what the switch is. I indicated that one had an
   6     undiagnosed coarctation of the aorta; two had the whole
   7     coronary system arising from one sinus; and one of them
   8     an intramural pathway. I said earlier two today, but it
   9     is only one.
  10   Q. On the next page you talk about multifactorial reasons
  11     for failure for those particular results.
  12        If we turn down the page, when you say that the
  13     results of the neonatal arterial switch should improve,
  14     that you were not able to determine the cause of those
  15     poor results; is that correct?
  16   A. That is correct, yes.
  17   Q. And you say it is most likely to be a multifactorial and
  18     multidisciplinary problem. What were you getting at in
  19     that conclusion?
  20   A. I indicated earlier that the diagnosis of the coronary
  21     arterial pattern was not as good as could have been;
  22     that coarctation was not diagnosed in those patients.
  23     We already discussed the post-operative management of
  24     those patients, which is the reason for using the words
  25     "multidisciplinary" and "multifactorial".

   1   Q. What about the non-neonatal switch series? Where were
   2     your conclusions or judgments on that to be found?
   3   A. I did not comment very much on this because it is very,
   4     very difficult to comment on those switches. If they
   5     are older it means usually they have additional lesions
   6     and therefore that they are actually technically higher
   7     risk patients, and I think each of them has to be taken
   8     individually.
   9        The fact that the older switches which probably
  10     were more complex had better results than the neonatal
  11     switches to me would indicate that there was a problem
  12     about doing open-heart surgery in new-born infants
  13     there, because they had better results with older
  14     patients.
  15        I alluded to that problem when I was here a few
  16     weeks ago, that many centres have progressed by lowering
  17     the age of the patients on which they were doing
  18     surgery. What Castaneda has done -- we mentioned him
  19     earlier -- was he decided that those patients should be
  20     operated on as neonates and set up a system which was
  21     proficient at dealing with neonates. The problem with
  22     some centres such as Bristol, or actually Great Ormond
  23     Street, is that we have lowered the age and for quite
  24     some time we felt that the risk of surgery in a bigger
  25     patient was lower than in the younger infant, which is

   1     not the case if you have a system which is efficient in
   2     dealing with small babies.
   3   Q. The immediate trigger for the investigation you were
   4     conducting had been a non-neonatal death in the switch
   5     series. Do you think in the circumstances it was
   6     adequate to produce a report without a clear guidance or
   7     judgment on the problems or difficulties or results in
   8     the non-neonatal switch series?
   9   A. Well, two points. The first one is that we had not
  10     received the details of the non-neonatal switches, so
  11     far as I recall; I think we had seen only the details of
  12     the 13 patients, and I do not believe that it is
  13     possible to make a statement on the older ones without
  14     more details for each single patient. I think each
  15     single note should be reviewed.
  16   Q. You said two points; were those them?
  17   A. I think they were, yes.
  18   Q. If we turn to page 268, we see at paragraph 8 that you
  19     believe that it would be inappropriate to do neonatal
  20     arterial switch operations before the new appointee took
  21     up his position, but then you went on to say that you
  22     had no reason to believe that Mr Dhasmana should not
  23     continue to carry out operations on other conditions.
  24        In what status did that recommendation leave the
  25     position of non-neonatal switches?

   1   A. I do not think that sentence was a sentence which
   2     indicates he could carry on the older switches. I think
   3     we had identified a problem with the neonatal switches
   4     and the comment is dealing with that particular subset
   5     of patients; it does not mean that we think he could
   6     continue to do the older ones.
   7   Q. So your interpretation of how you intended your results
   8     to be read was that all arterial switches should cease;
   9     is that correct?
  10   A. Well, I do not specifically comment on the older ones.
  11     I think we were presented with a problem with the
  12     neonatal ones. For that particular group of patients,
  13     we thought it was inappropriate to continue.
  14   Q. Does that mean the older arterial switches could
  15     continue, or not?
  16   A. I do not think I had an intention to comment on those
  17     patients precisely because, first of all, it is very
  18     uncommon to have to do a non-neonatal switch. It is
  19     a very rare thing to do. I suspect some of those
  20     patients had been banded in the past and it was an
  21     operation which was no longer done for transposition.
  22     So I think that the subset of non-neonatal switches is
  23     very small in that group of patients.
  24   Q. What do we take out of paragraphs 8 and 9? Do we take
  25     out of them the fact that non-neonatal switches were

   1     envisaged as continuing if such a case should present
   2     itself, or not?
   3   A. No, I have not commented on the non-neonatal switches,
   4     and I think, as I say, it is a group of patients which
   5     are very, very rare, and I do not feel I should comment
   6     on those patients more than any other patients.
   7   Q. It was a crisis relating to a non-neonatal switch which
   8     had been the trigger for your review. Is it
   9     satisfactory to complete a review without offering
  10     guidance on that situation should it present itself
  11     again?
  12   A. I think that most of the discussion was about the
  13     neonatal switches. The switch is an operation which is
  14     done in neonates, in more than 90, 95 per cent of the
  15     cases, and although I agree that the visit was triggered
  16     by a death following a switch which happened to be
  17     a non-neonatal switch, I do not think that I wanted to
  18     comment specifically on those patients who are older
  19     than one month of age to complete the report.
  20   Q. Can we go back to the preceding page where you discuss
  21     the results for consultant 1. Perhaps to give it
  22     a context, we should first look back at page 266.
  23        If we scroll down, we can see consultant 1 has
  24     a mortality of 0 per cent for ventricular septal
  25     defects.

   1        Does that judgment imply a discard of the results
   2     that Dr Bolsin had given you for that particular type of
   3     lesion?
   4   A. I think that those were the data for the periods
   5     January 1992 to January 1995, produced by the surgeons.
   6   Q. So when you said then that consultant 1 would be amongst
   7     the higher risk surgeons, on what was that judgment
   8     based?
   9   A. On the AV canals, and I think tetralogy of Fallot as
  10     well, in those days most centres, I think, I am not
  11     sure, had lower mortality than that. But I am not
  12     certain.
  13   Q. Having made that judgment on consultant 1, you then went
  14     on to make conclusions which we have looked at, if we go
  15     back to page 268, which related to the cessation of
  16     arterial switch operations, or neonatal arterial switch
  17     operations before the new consultant took place, but you
  18     did not make any comment as to what the position of the
  19     first consultant would be until Mr Pawade came. Why was
  20     that?
  21   A. I think that the appointment of Mr Pawade had been made
  22     and his coming was imminent, and surgeon number 1 had
  23     already indicated that he would step down, so he is
  24     a paediatric surgeon.
  25   Q. Were you told when Mr Pawade would be coming?

   1   A. I think we were told, but I have forgotten what the date
   2     was, I must say.
   3   Q. I think the date was to be May 1995, so at least two
   4     months from the date at which you were reporting. Was
   5     there not a need to offer advice on the position of
   6     Mr Wisheart in the interim?
   7   A. I do not think I would have gone so far with the data
   8     I had been presented with on that day. I think that
   9     maybe you could have said that we should investigate
  10     further the actual performance of Mr Wisheart to decide
  11     what he should do while waiting for Mr Pawade to start,
  12     but I do not think that I would have, on the data
  13     available on that day, made such a recommendation.
  14   Q. You said that you might have recommended that there was
  15     a need for further investigation?
  16   A. Yes.
  17   Q. Why do we not find that in the report, then?
  18   A. Because I think that that report, as I said earlier, was
  19     to be given to the Chief Executive who had then to use
  20     it as an indication of what the next step should be,
  21     which, in my view, would have been for them to
  22     investigate the overall problem, including the
  23     performance of Mr Wisheart.
  24   Q. But we do not see anywhere in your final conclusions
  25     that further investigations of Mr Wisheart's position

   1     would have been desirable.
   2   A. No. The report says that Mr Wisheart had agreed to step
   3     down in the near future, which was, as you indicate, two
   4     or three months later, and we qualify him as a high risk
   5     surgeon, so I thought those two comments were sufficient
   6     for the Chief Executive to decide what the next step
   7     should be.
   8   Q. If we go back to page 267, to the top there, you make
   9     comments at paragraphs 2 and 3 about the absence of any
  10     data to provide definitive national benchmarks against
  11     which the performance of the surgeon can be set. We
  12     discussed the availability of the Cardiac Surgical
  13     Register. That is one benchmark, is it not?
  14   A. It is, but it gives the UK figures which are not
  15     validated on the one hand, so we do not know what the
  16     performance of each individual unit or individual
  17     surgeon is, which I think is very, very important. Let
  18     us assume, which I think is the case, that there are in
  19     the UK maybe three centres doing more than 400 or
  20     perhaps 500 cases per year, and then that there are
  21     10 or 15 units doing a very small number. If the three
  22     large units have good results, the average of the UK
  23     register will be probably a lot higher than those who
  24     are the poorer performers.
  25        So I think it is very, very difficult to say that

   1     in terms of number of surgeons, the two surgeons at
   2     Bristol, one was below the average performance of other
   3     surgeons in the UK at the time.
   4   Q. What about other sources of data that would have been
   5     available to practitioners at the time: papers, for
   6     instance, commenting on performance?
   7   A. By and large, people like to publish their good results,
   8     not their bad results. You could rely on those results
   9     to establish a benchmark if you decide that the
  10     benchmark should be based on the best published results.
  11     That is fair enough, but you cannot consider that it
  12     represents what goes on in the field at the time.
  13   Q. If you are trying to judge what is going on in the
  14     field, what about the informal discussions that one has
  15     with colleagues, other people in what is a relatively
  16     small field? Is that not a way of finding out what the
  17     experience of other institutions is?
  18   A. I do not believe so. I think that people have
  19     a tendency to either exaggerate or forget their
  20     problems, and unless you have hard data, it is
  21     impossible to compare.
  22   Q. Looking at the picture overall, would you say it was
  23     not possible, then, to set parameters against which
  24     acceptable performance could be judged?
  25   A. Certainly not at that time, and even today I would have

   1     some difficulties in telling you what we should do to
   2     compare the performance with.
   3   Q. We have looked at the report that you produced, and we
   4     have seen that it was faxed through to Dr Roylance on
   5     23rd February. You say in your statement that
   6     unfortunately there was nobody there to receive it,
   7     despite having enquired, so as to hopefully ensure that
   8     that would take place.
   9        Can you tell us, Professor, what was the status,
  10     as you understood it, of the report that had been faxed
  11     through to Dr Roylance?
  12   A. It was a document which was sent to him to help him
  13     understand the problem, find out if there was a problem
  14     or not and help him to solve it to take action.
  15   Q. Was it a completed report, or was it a draft on which
  16     you expected further discussion and comment?
  17   A. We have used the word "draft" to justify that document.
  18     The main reason for changing the document was that we
  19     did not expect this document to be part of the public
  20     domain as it stood.
  21   Q. But when you say that you used the word "draft" to
  22     justify it, are you saying, therefore, that you apply
  23     that word because it was intended to be confidential and
  24     therefore the analysis was not, perhaps, particularly
  25     robust, as opposed to using the word to describe

   1     a document upon which you expected comment, criticism,
   2     further feedback, and expected to revise it in the light
   3     of, say, comments from clinicians?
   4   A. I think that the truth is that I did not expect to have
   5     to change the document if it had remained within the
   6     knowledge of the Chief Executive.
   7        The reason for changing it is that the nature of
   8     the document had changed, in my view, after it had been
   9     sent to the Chief Executive.
  10   Q. Because we learned that it was seen by other clinicians
  11     in a semi-open meeting?
  12   A. Yes, that is correct.
  13   Q. What were you told about what had happened to it? Can
  14     you tell us firstly, who reported back to you on this?
  15   A. I think, but I am not sure, it was Mr Wisheart or, is it
  16     Mr Nix who was at the time the Deputy Chief Executive?
  17   Q. That is correct, he was Deputy Chief Executive.
  18   A. Because Dr Roylance was on leave of absence, so I am
  19     pretty sure that Mr Wisheart had telephoned me and
  20     I think Mr Nix as well, and explained to me what had
  21     happened. The document had been read at a meeting and
  22     therefore was now a public document.
  23   Q. Was any comment made to you about the advisability or
  24     otherwise of releasing or publishing the document as it
  25     first stood, by either of them?

   1   A. I think that both of them indicated that in the wording
   2     of some of the sentences, it was not appropriate --
   3     I forget the word they used -- or we did not have enough
   4     data to support them for a public document.
   5   Q. Can you recollect the phrase "legally inadvisable" being
   6     used to you?
   7   A. No, I do not recall that.
   8   Q. Or any suggestion that there had been legal advice
   9     taken?
  10   A. I did. When I realised that the document had been
  11     displayed publicly, I went to see my own Chief Executive
  12     to find out what I should do, and he advised me to take
  13     advice to the hospital legal adviser who asked me
  14     whether I had indicated on the document that it was
  15     confidential and I said "No". He said "In that case you
  16     cannot say that it was confidential".
  17   Q. People who contacted you -- Mr Wisheart, Mr Nix -- so
  18     far as you can recollect, were suggesting that various
  19     amendments might need to be made to the report?
  20   A. Yes.
  21   Q. Did those suggestions come from both of them, or either
  22     one or other of them?
  23   A. I forget the details. The only thing I recollect is
  24     that I refused to change the actual content of the
  25     report, but I was prepared to change part of the

   1     wording, if it had been somewhat too strong, but the
   2     nature of the content was to be the same.
   3   Q. Can you remember who it was who was suggesting
   4     amendments in the draft to you?
   5   A. No. I mean, as I say, I spoke to both of them and
   6     I have forgotten the details of the discussions.
   7   Q. Did anybody ever fax to you, or send to you, any
   8     comments in written form on your draft? Or was this all
   9     done over the telephone?
  10   A. No, I do not recollect receiving -- and I went through
  11     my records; I do not recall receiving any fax.
  12   Q. So if I showed you, for instance, UBHT 61/370, where we
  13     see at the top the response to the document and then the
  14     response is said to summarise conclusions of Dr Joffe,
  15     Dr Monk, Professor Vann Jones, is that the first time
  16     you have seen that?
  17   A. Yes, the first time. I have not seen that, no.
  18   Q. Let us take it down, then, and go back to the final
  19     version that was completed.
  20        First of all, can you help us on the date when it
  21     was completed? If we look, please, at PAR(2) 1/105,
  22     this, I think, is the final version of the document;
  23     is that right? The double-spaced version. (Pause).
  24   A. From my records here, the last word on page 1 appears to
  25     be --

   1   Q. We can look at various versions it. If we look at
   2     PAR(1) 5/130, this is a slightly better copy. Do you
   3     see at the bottom of the page what you were looking
   4     for? It simply says "currently provided ..."
   5        If we turn over the page, please, you see there at
   6     the bottom of that paragraph the discussion of the
   7     post-operative care:
   8        "The overall post-operative management at the
   9     Royal Infirmary appears to be less organised with
  10     multiple decision-making processes."
  11